Michigan ›Three Rivers

The Orchards at Three Rivers

55378 Wilbur Rd, Three Rivers, MI 49093 · St. Joseph County · 87 certified beds · avg 75 residents/day · certified since Jan 1, 1978

SFF Candidate

Part of chain: THE ORCHARDS MICHIGAN (15 facilities, chain avg rating 1.9★)

1/5
Health inspection rating (on-site)
3
Serious findings on record
$137,535
Fines, last 3 years
3.74
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)

▲ Immediate jeopardy, one-off · Oct 30, 2025 · F-0605 · triggered by a complaint

The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.

Why it matters: Using sedating drugs as a 'chemical restraint' can rob residents of alertness and mobility and increases risks of falls and death, especially in people with dementia.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

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

▲ Actual harm, one-off · Nov 25, 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: Nov 26, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Mar 21, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

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: Apr 9, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (70)

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
Mar 5, 2026F · Potential for harm, facility-wideThe 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.
Mar 5, 2026E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Mar 5, 2026E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 5, 2026E · Potential for harm, repeatedThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Mar 5, 2026D · 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.
Mar 5, 2026D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Mar 5, 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).
Mar 5, 2026D · 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.
Mar 5, 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.
Mar 5, 2026D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Mar 5, 2026D · 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.
Mar 5, 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.
Mar 5, 2026D · 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.
Dec 23, 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. · from a complaint
Dec 23, 2025F · Potential for harm, facility-wideThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Dec 23, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Dec 23, 2025E · 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
Dec 23, 2025E · 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
Dec 23, 2025E · Potential for harm, repeatedThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
Dec 23, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Dec 23, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
Dec 23, 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
Nov 25, 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
Nov 25, 2025E · 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
Nov 25, 2025E · 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
Nov 25, 2025E · Potential for harm, repeatedThe facility did not have enough staff with the right skills to meet the mental and behavioral health needs of its residents, such as those living with dementia or depression. · from a complaint
Nov 25, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Nov 25, 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
Nov 25, 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
Oct 30, 2025▲ J · Immediate jeopardy, one-offThe facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. · from a complaint
Oct 30, 2025F · Potential for harm, facility-wideThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint
Oct 30, 2025F · Potential for harm, facility-wideThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint
Oct 30, 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. · from a complaint
Oct 30, 2025F · Potential for harm, facility-wideThe facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint
Oct 30, 2025F · Potential for harm, facility-wideThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint
Oct 30, 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. · from a complaint
Oct 30, 2025D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint
Oct 30, 2025D · Potential for harm, one-offThe facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint
Oct 30, 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
Aug 4, 2025E · Potential for harm, repeatedThe 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. · from a complaint
Aug 4, 2025E · Potential for harm, repeatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint
Aug 4, 2025E · Potential for harm, repeatedThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Aug 4, 2025D · 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. · from a complaint
Aug 4, 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
Aug 4, 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. · from a complaint
Apr 3, 2025F · Potential for harm, facility-wideThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint
Apr 3, 2025F · Potential for harm, facility-wideThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
Apr 3, 2025F · Potential for harm, facility-wideThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. · from a complaint
Apr 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. · from a complaint
Apr 3, 2025D · 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 3, 2025D · 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. · from a complaint
Apr 3, 2025D · 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. · from a complaint
Apr 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. · from a complaint
Nov 15, 2024F · Potential for harm, facility-wideThe 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.
Nov 15, 2024F · Potential for harm, facility-wideThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Nov 15, 2024F · Potential for harm, facility-wideThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Nov 15, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Nov 15, 2024D · 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.
Nov 15, 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.
Nov 15, 2024D · 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.
Nov 15, 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.
Nov 15, 2024D · Potential for harm, one-offThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs.
Jun 13, 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
Jun 13, 2024D · 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
Jun 13, 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. · from a complaint
Mar 21, 2024▲ G · Actual 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
Oct 4, 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.
Oct 4, 2023D · 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 4, 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.
Oct 4, 2023D · 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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (9 → 13).

YearCitationsSerious (G–L)Worst severity that year
202340D
2024131G ▲
2025402J ▲
2026130F

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)

1 fine totaling $137,535, plus 1 Medicare payment denial period.

DateTypeAmount / length
Oct 30, 2025Fine$137,535
Oct 30, 2025Payment Denial48 days from Dec 3, 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)3.744.323.95bottom 24% in Michigan; bottom 49% in the U.S.
Registered Nurse hours0.500.840.69bottom 19% in Michigan; bottom 38% in the U.S.
Weekend total nurse staffing3.373.793.50bottom 30% in Michigan; top 49% in the U.S.
Weekend RN hours (not acuity-adjusted)0.300.490.48bottom 28% in Michigan; bottom 33% in the U.S.
Total nursing staff turnover (%)48.144.145.8bottom 36% in Michigan; bottom 42% in the U.S.
RN turnover (%)72.239.242.9bottom 5% in Michigan; bottom 10% 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 3.38, RN 0.46, weekend 3.04. 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: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation · changed ownership in the last 12 months

Owner / managerTypeRoleStakeSince
Kornfeld, RobertIndividual5% or Greater Indirect Ownership Interest10%11/01/2025
Gutman, IsaacIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Gutman, IsaacIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2025
Gutman, IsaacIndividualADP of the SNFNOT APPLICABLE11/01/2025
Hoffman, AlexanderIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Hoffman, AlexanderIndividualADP of the SNFNOT APPLICABLE11/01/2025
Kornfeld, RobertIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Kornfeld, RobertIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2025
Kornfeld, RobertIndividualADP of the SNFNOT APPLICABLE11/01/2025
Roberts, RandyIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2025
Roberts, RandyIndividualADP of the SNFNOT APPLICABLE11/01/2025
Smith, GarrettIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2025
Smith, GarrettIndividualADP of the SNFNOT APPLICABLE11/01/2025
Taub, JacobIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Taub, JacobIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2025
Taub, JacobIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE03/16/2026
Taub, JacobIndividualADP of the SNFNOT APPLICABLE11/01/2025
Teeple, MelissaIndividualOperational/Managerial ControlNOT APPLICABLE11/01/2025
Teeple, MelissaIndividualADP of the SNFNOT APPLICABLE11/01/2025
White Lake Healthcare LLCOrganizationOperational/Managerial ControlNOT APPLICABLE11/01/2025

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
Optalis Health and Rehabilitation of Three Rivers4.0 miThree Rivers, MI★☆☆☆☆1/5abuse
Fairview Nursing and Rehabilitation Community7.6 miCentreville, MI★★★★☆3/5
Medilodge of Portage14.7 miPortage, MI★★★☆☆2/5
Froh Community Home17.8 miSturgis, MI★★★☆☆3/5
Bronson Commons18.5 miMattawan, MI★★★☆☆2/5
Harold and Grace Upjohn Community Care Center19.2 miKalamazoo, MI★☆☆☆☆1/5
Medilodge of Kalamazoo19.4 miKalamazoo, MI★★☆☆☆2/5

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Facility data as of CMS processing date 2026-08-01. CCN 235354.