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Complaint Investigation

The Orchards At Three Rivers

Inspection Date: October 30, 2025
Total Violations 10
Facility ID 235354
Location Three Rivers, MI
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Inspection Findings

F-Tag F0558

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0558 during a complaint investigation conducted on 2025-10-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0605

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Immediate Jeopardy

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0605 during a complaint investigation conducted on 2025-10-30.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-10-31.

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F-Tag F0679

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0679 during a complaint investigation conducted on 2025-10-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide activities to meet all resident's needs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0730

Nursing and Physician Services Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0730 during a complaint investigation conducted on 2025-10-30.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Observe each nurse aide's job performance and give regular training.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0744

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0744 during a complaint investigation conducted on 2025-10-30.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0842

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-10-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0865

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0865 during a complaint investigation conducted on 2025-10-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Have a plan that describes the process for conducting QAPI and QAA activities.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0868

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0868 during a complaint investigation conducted on 2025-10-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0940

Administration Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0940 during a complaint investigation conducted on 2025-10-30.

Category: Administration Deficiencies

The facility was found deficient in the following area: Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

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F-Tag F0947

Nursing and Physician Services Deficiencies
Harm Level: Potential for More Than Minimal Harm

Federal health inspectors cited Edgewood Health and Rehabilitation in Three Rivers, MI for a deficiency under regulatory tag F-F0947 during a complaint investigation conducted on 2025-10-30.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 10 deficiencies cited during this inspection of Edgewood Health and Rehabilitation.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-11-20.

📋 Inspection Summary

The Orchards at Three Rivers in Three Rivers, MI inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Three Rivers, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Orchards at Three Rivers or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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