Michigan ›Three Rivers

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St, Three Rivers, MI 49093 · St. Joseph County · 100 certified beds · avg 81 residents/day · certified since Jan 22, 1979

Abuse citation flag (CMS)

Part of chain: OPTALIS HEALTH & REHABILITATION (36 facilities, chain avg rating 2.4★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
4
Serious findings on record
$40,700
Fines, last 3 years
3.21
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Jun 30, 2026 · F-0627 · triggered by a complaint

The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.

Why it matters: A rushed or poorly planned move can leave a resident somewhere that can't meet their needs.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 27, 2026 (Deficient, Provider has plan of correction)

▲ Actual harm, one-off · Oct 22, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 31, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Oct 8, 2025 · F-0627 · triggered by a complaint

The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.

Why it matters: A rushed or poorly planned move can leave a resident somewhere that can't meet their needs.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 31, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Feb 21, 2025 · F-0604 · triggered by a complaint

The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.

Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 18, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (77)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 30, 2026▲ G · Actual harm, one-offThe facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
Jun 30, 2026D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Jun 30, 2026D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Jun 30, 2026D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
Apr 2, 2026F · Potential for harm, facility-wideThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Apr 2, 2026D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Apr 2, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Apr 2, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Dec 3, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 3, 2025F · Potential for harm, facility-wideThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Dec 3, 2025E · Potential for harm, repeatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Dec 3, 2025E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Dec 3, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Dec 3, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Dec 3, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Dec 3, 2025D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Dec 3, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 3, 2025D · Potential for harm, one-offThe facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive.
Dec 3, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Dec 3, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Dec 3, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 3, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · from a complaint
Oct 22, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 22, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Oct 8, 2025▲ G · Actual harm, one-offThe facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
Oct 8, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Oct 8, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Oct 8, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Oct 8, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Oct 8, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Oct 8, 2025D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
Oct 8, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jul 29, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jul 29, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jul 29, 2025D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
Feb 21, 2025▲ G · Actual harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Feb 21, 2025D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Feb 21, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Feb 21, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Feb 21, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Oct 24, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Oct 1, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 1, 2024E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Oct 1, 2024E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Oct 1, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Oct 1, 2024E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required.
Oct 1, 2024E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Oct 1, 2024E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Oct 1, 2024E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Oct 1, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Oct 1, 2024D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Oct 1, 2024D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint
Oct 1, 2024D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential. · from a complaint
Oct 1, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Oct 1, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 1, 2024D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Oct 1, 2024D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Oct 1, 2024D · Potential for harm, one-offThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
May 30, 2024E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint
May 30, 2024D · Potential for harm, one-offThe facility did not honor residents' right to manage their own money and financial affairs. · from a complaint
May 30, 2024D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Jan 4, 2024E · Potential for harm, repeatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jan 4, 2024E · Potential for harm, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 4, 2024E · Potential for harm, repeatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Aug 2, 2023F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 2, 2023E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Aug 2, 2023E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 2, 2023D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Aug 2, 2023D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Aug 2, 2023D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Aug 2, 2023D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Aug 2, 2023D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Aug 2, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 2, 2023D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Aug 2, 2023D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Aug 2, 2023D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Aug 2, 2023D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (16 → 14).

YearCitationsSerious (G–L)Worst severity that year
2023130F
2024240F
2025323G ▲
202681G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $40,700, plus 1 Medicare payment denial period.

DateTypeAmount / length
Oct 8, 2025Fine$14,015
Oct 8, 2025Fine$26,685
Feb 21, 2025Payment Denial26 days from Mar 20, 2025

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMichigan avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.214.323.95bottom 3% in Michigan; bottom 22% in the U.S.
Registered Nurse hours0.660.840.69bottom 35% in Michigan; top 41% in the U.S.
Weekend total nurse staffing2.943.793.50bottom 5% in Michigan; bottom 28% in the U.S.
Weekend RN hours (not acuity-adjusted)0.490.490.48top 38% in Michigan; top 34% in the U.S.
Total nursing staff turnover (%)47.744.145.8bottom 37% in Michigan; bottom 43% in the U.S.
RN turnover (%)52.639.242.9bottom 25% in Michigan; bottom 32% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.02, RN 0.62, weekend 2.77. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5

Who owns this facility

For profit - Corporation

Owner / managerTypeRoleStakeSince
Om Holdco 5 LLCOrganization5% or Greater Direct Ownership Interest100%04/07/2023
Optalis LP Investors 5 LLCOrganization5% or Greater Indirect Ownership Interest10%04/07/2025
Optum Management Solutions. INCOrganizationIndirect Ownership InterestNOT APPLICABLE04/07/2023
SNW LLCOrganization5% or Greater Indirect Ownership Interest30%04/07/2023
Cliftonlarsonallen LLPOrganizationADP of the SNFNOT APPLICABLE01/01/2025
Conner, MarianneIndividualADP of the SNFNOT APPLICABLE05/13/2024
Dorsey, JasmineIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2025
Dorsey, JasmineIndividualADP of the SNFNOT APPLICABLE11/28/2025
Dunn, CharlesIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE11/28/2025
Keith, AngieIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2025
Keith, AngieIndividualADP of the SNFNOT APPLICABLE12/19/2025
Nona Morgan, Charity ReneeIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2025
Optum Management Solutions. INCOrganizationOperational/Managerial ControlNOT APPLICABLE04/07/2023
Optum Management Solutions. INCOrganizationADP of the SNFNOT APPLICABLE11/28/2025
Patel, RajanIndividualManaging Control - Governing BodyNOT APPLICABLE04/07/2023
Patel, RajanIndividualOperational/Managerial ControlNOT APPLICABLE04/07/2023
Schlaupitz MadhavanOrganizationADP of the SNFNOT APPLICABLE01/01/2025
Shah, HemantIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE11/28/2025
Sharon, RobertIndividualManaging Control - Governing BodyNOT APPLICABLE05/13/2024
Sharon, RobertIndividualOperational/Managerial ControlNOT APPLICABLE05/13/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
The Orchards at Three Rivers4.0 miThree Rivers, MI★☆☆☆☆1/5SFF
Fairview Nursing and Rehabilitation Community6.4 miCentreville, MI★★★★☆3/5
Froh Community Home15.5 miSturgis, MI★★★☆☆3/5
Medilodge of Portage18.7 miPortage, MI★★★☆☆2/5

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Facility data as of CMS processing date 2026-08-01. CCN 235395.