Rivergate Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 06/02/2026 at 8:52 AM observed missing paint from the front edge of the wire rack leaving exposed metal in the two door prep refrigerator in the kitchen. On 06/02/2026 at 9:00 AM observed the three compartment sink drain lines for the wash, rinse, and sanitize basins all connect to a common drain line leading into the grease trap and discharged into the floor with no air gap. On 06/02/2026 at 9:00 AM observed the cap missing from the atmospheric vacuum breaker (AVB) on the water faucet connected by a hose to a chemical dispensing system in the kitchen. [...]

Inspectors wroteBased on observation, and interview the facility failed to maintain general cleanliness and repair of the premises and ensure appropriate backflow prevention was installed at plumbing fixtures. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 06/02/2026 at 2:07 PM an interview was conducted regarding cleaning. Director of Housekeeping and Laundry Services (DHLS) B indicated housekeeping staff clean shower rooms twice a day, and shower equipment is cleaned by Certified Nursing Assistant (CNA). On 06/02/2026 at 2:10 PM observed a floor tile cracked and chipped and the adjacent floor tile missing near the sink in the station one east soiled linen room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medical supplies (topical lubricating jelly) from the active inventory in the Station 2 medication storage room.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a Level II PASARR (Pre-admission Screening and Resident Review) for one (R16) resident reviewed for PASARRs. This resulted in the potential for care needs being unmet due to the lack of a comprehensive evaluation by the state designated authority.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative services as recommended to maintain range of motion and mobility for one resident (R152) of two residents reviewed for range of motion.

Inspectors wroteBased on interview and record review, the facility failed to accurately identify incidents of physical harm as abuse by a Resident Representative (RR), for one resident (R501) of three residents reviewed for abuse, resulting in the potential for continued physical harm.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly implement an abuse policy for incidents of physical harm of one resident (R501) by a Resident Representative (RR), for one of three residents reviewed for abuse, resulting in the potential for continued physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to report to the State Agency incidents of physical harm for one resident (R501) by a Resident Representative (RR), for one of three residents reviewed for abuse, resulting in unreported incidents of physical harm.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly conduct and document an investigation of incidents of physical harm of one resident (R501) by a Resident Representative (RR), for one of three residents reviewed for abuse, resulting in the potential for continued physical harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of loose medications were conducted for three medication carts (3 West, 2 [NAME] and 2 East) out of four medication carts observed for medication storage.

Inspectors wroteThis citation pertains to Intake: MI00151131 Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring to prevent an elopement for one resident (R600) who had severe cognitive impairment and was assessed and care planned as an elopement risk. R600 left a secured unit on the second floor and exited the front door during the time a staff member left the lobby unsecured. R600 exited the building while following an unknown visitor on 03/01/2025 at approximately 6:37 PM, unbeknownst to facility staff. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 03/01/2025 and the immediacy was removed 04/04/2025 per review of the facility's responding interventions as verified on 4/17/2025. The IJ was identified on 04/17/2025 during an abbreviated survey. [...]

Inspectors wroteThis citation pertains to intake MI00147167. Based on interview and record review, the facility failed to confirm and document the timely notification of resident representative for one resident (R101), out of four residents reviewed for change of condition, resulting in missed opportunities to participate in medical decisions regarding care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure facility staff followed the care plan for transfer assistance for one (R401) of three residents reviewed for falls, resulting in a fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 172 residents who receive meal services.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 172 residents and its staff resulting in an increased potential for harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests, resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 172 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a resident (R52) for self-administration of medications resulting in medications left at the resident's bedside. Findings Include: During an observation on 5/29/24 at 10:50 AM, upon entering R52's room, two medications were seen in a clear medicine cup on the resident's bedside table. During an interview on 5/29/24 at 10:51 AM, it was reported by R52 that the nurses sometimes leave the medications on the table if I am sleeping, and I take them when I wake up. Record review of R52's electronic medical record (EMR) revealed no assessment or physician's order to self- administer medications. Further review of R52's EMR revealed admission to facility on 12/6/22 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the Pre-admission Screening and Resident Review (PASSARR) Level I determination (DCH-3877 and/or DCH-3878) was reviewed, revised, and sent to the Local Community Mental Health Services Program (CMHSP) for a Level II OBRA (Omnibus Budget Reconciliation Act) evaluation for one resident (R150) of five residents reviewed for PASSARR, resulting in the potential for unmet mental health services.

Inspectors wroteThis citation pertains to intake MI00142899. Based on interview and record review the facility failed to prevent the use of inappropriate language during care to one resident (R916) out of three residents reviewed for abuse.

Inspectors wroteThis citation has two deficient practice statements. Deficient Practice Statement #1. This citation pertains to intake MI00142978. Based on interview and record review the facility failed to develop/implement a care plan for one resident (R917) out of three residents reviewed for care interventions for psychotropic medications. Findings Include: Record review of R917's electronic medical records revealed admission into the facility on 8/25/23 with a pertinent diagnosis of dementia. According to the Minimum Data Set (MDS) dated [DATE], R917 had impaired cognition and required assistance with Activities of Daily Living (ADLS). Record review of Physician orders documented, Seroquel Oral Tablet 25 MG (antipsychotic) Give 0.5 tablet by mouth at bedtime for mood disorder. Start date 8/16/23. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure complete and accurate documentation was maintained in an Electronic Health Record (EHR) for one resident (R916) of three residents reviewed for accurate medical records resulting in inaccurate and incomplete medical records with inadequate care delivery.