Inspection Reports for
LakeHouse Three Rivers
1215 N. Elm Street, Three Rivers, MI, 49093
Back to Facility Profile6 Reports
Inspection Report — Aug 20, 2025
Renewal
Date: Aug 20, 2025
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The home was found in non-compliance with 5 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (5)
R 325.1932 Resident medications: Resident A’s morning medications were placed in applesauce and/or yogurt contrary to physician orders which required administration with water. The A-Hallway medication cart was found unlocked with no staff present, making medications easily accessible.
R 325.1970 Water supply systems: No records or documentation were found to show that hot water plumbing fixtures used by residents were tested to ensure water temperature was tempered between 105 to 120 degrees Fahrenheit.
R 325.1972 Solid wastes: Multiple garbage or rubbish containers in common areas lacked tight-fitting lids, risking cross-contamination.
R 325.1976 Kitchen and dietary: Multiple food items in the employee lounge and activities room were unlabeled with no appropriate open date, making it unclear if they were safe for consumption.
R 325.1979 General maintenance and storage: Hazardous and toxic chemicals along with sharps were stored in unlocked cabinets in the activities room, accessible to anyone and posing a risk to residents with impaired cognition or function.
Report Facts
Corrective action plan due: 15
Inspection Report — Sep 27, 2023
Renewal
Date: Sep 27, 2023
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The home was found in non-compliance with 5 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (5)
R 325.1922 Admission and retention of residents: Resident A’s tuberculosis screening could not be found and Resident B’s screening was not completed within 12 months before admission.
R 325.1923 Employee's health: Employee A’s tuberculosis screening was completed the same day as occupational exposure and Employee B’s screening was completed after occupational exposure.
R 325.1932 Resident Medications: Resident A’s medication administration record was blank for Tramadol at 8:00pm on 8/15/23 with no documentation of medication refusal, creating uncertainty if medication was given as prescribed.
R 325.1954 Meal and food records: The home did not maintain a record of the meal census and amount of food used for the preceding 3-month period.
R 325.1979 General maintenance and storage: Industrial chemicals were easily accessible under the sink of the common area kitchenette, posing a risk to residents with impaired cognition.
Report Facts
Corrective action plan due: 15
Inspection Report — Aug 29, 2023
Date: Aug 29, 2023
Visit Reason
Addendum to original licensing study report to change the facility name from Bowman Place to LakeHouse Three Rivers.
Findings
The facility name change was requested and approved following an onsite visit and receipt of updated documentation.
Inspection Report — Aug 14, 2023
Complaint Investigation
Date: Aug 14, 2023
Visit Reason
Investigation of a complaint received on 2023-08-09 about staffing, medication administration, and resident falls.
Complaint Details
Facility accepts residents not appropriate: not established. Residents left wet and not cared for: established. Employees sleep while working: established. Facility roof leaking: not established. Additional findings: failure to notify department of name change — established.
Findings
Three violations were established related to residents left wet and unattended, employees sleeping while working, and failure to notify the department of a facility name change. Two allegations were not established, including acceptance of inappropriate residents and facility roof leaking.
Deficiencies (3)
R 325.1931 Employees; general provisions: residents were left wet and unattended, and caregiver checklists showed scheduled assistance was not consistently provided.
R 325.1931 Employees; general provisions: employee SP6 was found sleeping while working multiple times despite disciplinary actions.
R 325.1913 Licenses and permits; general provisions: the facility changed its name to Lakehouse Three Rivers without providing written notice to the department within 5 business days.
Report Facts
Corrective action plan due: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SP6 | Third shift worker | Named in the sleeping while working violation |
Inspection Report — Jul 11, 2023
Complaint Investigation
Date: Jul 11, 2023
Visit Reason
Investigation of a complaint received on 2023-07-06 about medication administration and other concerns.
Complaint Details
Resident fall interventions: not established. Facility staffing: not established. Medication Administration Record incomplete: established. Residents do not receive showers: not established. Facility is dirty: not established. Additional findings: not established.
Findings
One rule violation was established related to incomplete medication administration records; all other allegations were not established.
Deficiencies (1)
R 325.1932 Resident medications: multiple instances were found where the medication technician did not initial that medication was administered on the MAR.
Report Facts
Corrective action plan due: 15
Inspection Report — Mar 22, 2017
Original Licensing
Date: Mar 22, 2017
Visit Reason
Original license application for a home for the aged facility.
Findings
The facility was found in substantial compliance with the home for the aged public health code and administrative rules.
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