The Orchards at Three Rivers: Seizure Medication Missed - MI
The inspection, conducted December 23, 2025, found that on the morning of December 22, the River Unit, which the facility's own Director of Nursing identified as requiring three CNAs due to the complexity of its residents' needs, had just one.
DON B told the inspector she had been notified of the situation that same morning, December 23, the day the inspector arrived.
The facility's stated minimum for any unit on day shift is two CNAs. The River Unit's higher threshold exists because its residents need more care, not less. On December 22, it had neither.
Administrator A and DON B said they were aware of the staffing concerns and were in the process of addressing them. Administrator A said the facility was monitoring staffing levels to ensure they met required state minimums. The inspection report does not indicate those minimums were being met.
The staffing finding was not the only concern inspectors documented. Residents had missed showers. Food complaints had accumulated. Administrator A said he fills out concern forms and takes them directly to the Dietary Manager and her supervisor, a process he described as his response to the problem. The kitchen had been outsourced to a contracted company on November 1, less than two months before the inspection.
Three separate issues, all of them known to leadership, all of them unresolved on the day inspectors walked in. The River Unit's residents spent part of December 22 with one person responsible for all of them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Three Rivers from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
The Orchards at Three Rivers in Three Rivers, MI was cited for violations during a health inspection on December 23, 2025.
DON B told the inspector she had been notified of the situation that same morning, December 23, the day the inspector arrived.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.