Inspection Reports for Golden Orchards Assisted Living and Memory Care

2464 55th St, Fennville, MI 49408, USA, MI, 49408

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 1.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

75% better than Michigan average
Michigan average: 5.2 deficiencies/year

Deficiencies per year

4 3 2 1 0
2020
2023
2025

Census

Latest occupancy rate 20% occupied

Based on a March 2025 inspection.

Census over time

0 7 14 21 28 Jun 2023 Mar 2025

Inspection Report

Renewal
Census: 4 Capacity: 20 Deficiencies: 0 Date: Mar 25, 2025

Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with licensing statutes and rules for the facility's license renewal.

Findings
The onsite inspection found the facility in compliance with all applicable rules and statutes. The licensing consultant recommended issuance of a 2-year regular adult foster care license with a capacity of 20.

Report Facts
Capacity: 20 Residents observed: 4 Staff observed: 3

Employees mentioned
NameTitleContext
Adam SchlueterAdministratorNamed as licensee/licensee designee and administrator
Megan AukermanLicensing ConsultantConducted inspection and signed report

Inspection Report

Renewal
Census: 4 Capacity: 20 Deficiencies: 1 Date: Jun 7, 2023

Visit Reason
The inspection was conducted as part of the renewal licensing study to verify implementation and compliance with the corrective action plan addressing prior violations.

Findings
The facility was found to be in non-compliance with the rule regarding the use of assistive devices, specifically a bedrail assistive device not identified in a resident's written assessment plan. An acceptable corrective action plan was submitted and approved.

Deficiencies (1)
Resident A’s bed was equipped with a bedrail assistive device that was not identified in Resident A’s written assessment plan.
Report Facts
Number of staff interviewed and/or observed: 4 Number of residents interviewed and/or observed: 4 Facility capacity: 20

Employees mentioned
NameTitleContext
Eli DeLeonLicensing ConsultantAuthor of the report and signatory
Marcia CurtissLicensee/Licensee DesigneeNamed as licensee in report
Natalie BustillosAdministratorNamed as facility administrator

Inspection Report

Complaint Investigation
Capacity: 20 Deficiencies: 3 Date: Apr 4, 2023

Visit Reason
The investigation was initiated due to a complaint alleging that direct care staff did not seek medical attention upon a change in Resident A's health status, which allegedly led to Resident A's death.

Complaint Details
The complaint alleged that Resident A was taken to the hospital on 07/26/2022 after being unresponsive and with unstable vitals, but that staff failed to identify the change in condition earlier. The complaint was substantiated with violation established.
Findings
The investigation found that Resident A experienced a decline in physical condition over several days without medical attention being sought by staff or the administrator. Resident A was eventually sent to the hospital unresponsive and later died. Additional violations included failure to complete a new assessment plan and resident care agreement upon Resident A's admission to the attached memory care facility.

Deficiencies (3)
Direct care staff did not seek medical attention upon a change in Resident A’s health status.
Failure to complete a new Assessment Plan for AFC Residents upon admission to Golden Orchards II.
Failure to complete a new Resident Care Agreement upon admission to Golden Orchards II.
Report Facts
Capacity: 20 Complaint Receipt Date: Mar 28, 2023 Investigation Initiation Date: Mar 28, 2023 Report Due Date: May 27, 2023

Employees mentioned
NameTitleContext
Natalie BustillosAdministratorNamed in investigation findings and statements regarding Resident A's care
Marcia CurtissLicensee DesigneeNamed in investigation findings and correspondence
Jessica WellsClinical ManagerNamed in investigation findings and interviews regarding Resident A's condition
Moses GonzalezDirect Care StaffInterviewed regarding Resident A's care
Abbigail CrippsDirect Care StaffInterviewed regarding Resident A's care
Ellie Garcia MoralesDirect Care StaffInterviewed regarding Resident A's care
Roseanne ChattersonDirect Care StaffInterviewed regarding Resident A's care
Kyle SchumacherAMR ParamedicInterviewed regarding ambulance response to Resident A

Inspection Report

Original Licensing
Capacity: 20 Deficiencies: 0 Date: Dec 17, 2020

Visit Reason
The visit was conducted as an original licensing study for the facility Golden Orchards II to determine compliance with applicable licensing statutes and administrative rules.

Findings
The facility was found to be in substantial compliance with licensing requirements, including physical facility standards, staffing, and program descriptions. A temporary license with a maximum capacity of 20 residents was recommended and issued.

Report Facts
Capacity: 20 Staffing ratio: 2 License term: 6

Employees mentioned
NameTitleContext
Marcia CurtissLicensee DesigneeHandles corporate and management details; meets licensing requirements
Natalie BustillosAdministratorOn-site administrator handling day-to-day operations; meets licensing requirements
Ian TschirhartLicensing ConsultantConducted the licensing study and recommended issuance of temporary license
Jerry HendrickArea ManagerApproved the licensing recommendation

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