Riverview Health and Rehab Center North

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 05/05/2026 at 8:48 AM an interview with Dietary Manager (DM) I regarding date marking found food items should have a receive, discard, and open date on them. On 05/05/2026 at 8:49 AM observed an opened package of sliced turkey with a facility marked receive date of 4/30 and a facility marked discard date of 6/1 in the walk in cooler. DM I stated that is not right and indicated it should have an open date. On 05/05/2026 at 8:52 AM observed a plastic bag containing sliced cheese with a discard date of 05/03/2026 in the walk in cooler. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the water management plan was implemented and that appropriate infection control practices were followed for two residents (R129 and R71) out of two residents reviewed for infection control and prevention, resulting in the potential for spread of infection among residents in the facility.

Inspectors wroteBased on observation, and interview, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies, resulting in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 05/05/2026 at 12:48 PM observed a section of wall covering cut out with two protruding utility lines extending from the wall in the third floor common area outside of the dining room. The lines were left uncapped and a paper towel was found pressed inside one of them. On 05/05/2026 at 1:28 PM observed an approximate four by two foot area of floor tiles missing under the clean linen rack in the first floor east transitional rehabilitation room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean and homelike environment for one resident (R20) out of one resident reviewed for safe, clean, homelike environment resulting in resident dissatisfaction with living conditions.

Inspectors wroteBased on interview, observation, and record review, the facility failed to assist with discharge planning for one resident (R74) of two residents reviewed for discharge planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure tube feeding nourishment was dated for two residents (R13 and R129) of three residents reviewed for tube feeding management.

Inspectors wroteThis citation pertains to intake 2632800. Based on interview and record review the facility failed to report an allegation of physical abuse from a staff member to the State Agency in the required timeframe for one (R101) of four sampled residents reviewed for abuse resulting in an unreported allegation of abuse and the potential for more allegations of abuse to go unreported.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Properly date-label food stored in the walk-in freezer and walk-in cooler, 2. Ensure food past the use-by-date was not stored with active food stock; 3. Ensure two commercial ice machines were cleaned in a timely manner; and 4. Effectively clean surfaces in the kitchen. These deficient practices had the potential to affect all the residents who consumed food from the kitchen and consumed ice from the ice machines, resulting in the potential for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document and ensure resident's activity preferences were honored for one resident (R61) out of two residents reviewed for activities, resulting in resident frustration and boredom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for one resident (R287) out of two residents reviewed for food preferences, resulting in the resident's dissatisfaction with the dining experience.

Inspectors wroteThis citation pertains to intake MI00149358. Based on interview and record review, the facility failed to ensure staff reported an injury of unknown origin to the abuse coordinator for one resident (R401) out of four residents reviewed for injuries of unknown origin.

Inspectors wroteThis citation pertains to intake MI00149358. Based on interview, and record review the facility failed to update/revise/review a care plan in a timely manner for one resident (R401) out of four residents reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify and discuss a room change with a resident and their responsible party for one resident (R801) of one residents reviewed for room changes, resulting in R801 being moved to a new room without approval of the responsible party and the increased potential for transfer trauma (physical, behavioral, and emotional reaction to a sudden change in ones surroundings).

Inspectors wroteBased on observation, interview, and record review the facility failed to develop or implement a person-centered behavior care plan for one (R801) of three residents reviewed for care planning resulting in R801 not having a care plan for behaviors of wandering and the potential for psychosocial needs to go unmet.

Inspectors wroteThis citation pertains to intake MI00145652. Based on interview and record review the facility failed to review the Plan of Care (POC) and ensure adequate assistance when providing care for one resident (R4) out of four residents reviewed for falls, resulting in a fractured pelvis and hematoma to the head.

Inspectors wroteThis citation pertains to intake MI00143701. Based on interview and record review the facility failed to readmit one resident (R609) to the facility upon discharge from a hospital.

Inspectors wroteThis citation contains two deficient practice statements: DPS#1 This citation pertains to intakes MI00142304 and MI00142542. Based on interview and record review the facility failed to provide adequate supervision and follow elopement protocol for one resident (R12) who left the facility at an unknown time to staff. R12 was determined to be missing at 8:15 AM on 1/23/24. A moderately cognitively impaired resident with a BIMS of 8 left the facility with a recorded temperature of that day of 33 degrees Fahrenheit and raining. The facility was made aware R12 was at a city hospital at 11:23 AM. This resulted in the likelihood of serious injury, serious harm, serious impairment or death related to being struck by a motor vehicle and/or injury related to inclement weather. [...]

Inspectors wroteThis citation pertains to intake MI00134838. Based on observation, interview, and record review, the facility failed to ensure unrestricted, 24-hour visitation for all 141 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain food service equipment in a clean and sanitary manner; 2. Ensure walls in areas where food was prepared were clean; 3. Store the ice scoop in a clean and sanitary manner; 4. Ensure food items past the use-by-date were not stored with active food stock; 5. Properly date-label food; and, 6. Maintain cleanable surfaces (knife storage area and floor underneath the can opener). These deficient practices have the potential to affect all residents who eat food served from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure that the Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI-program aimed on improving processes involved in health care delivery and resident quality of life) meetings quarterly, resulting in the potential for impaired resolution of identified issues or decreased quality of care with the potential to affect all 141 residents that reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to initiate and/or accurately complete residents' advance directives in a timely manner for five residents (R41, R43, R46, R67, and R105) of thirteen reviewed for resident's rights, resulting in the potential for resident wishes to not be honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop comprehensive individualized care plans for four residents (R43, R104, R120, and R20) out thirty-eight residents reviewed for care plan interventions, resulting in the potential of unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that five out of five (FF, MM, NN, OO, and PP ) certified nurse aides (CNA) whose in-service files were reviewed, had the required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for staff incompetency and/or harm to resident's well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure certified nurse aides (CNAs) fulfilled the requirement to complete 12 hours of in-service education annually for five of five certified nurse aides (FF, MM, NN, OO, and PP) resulting in the potential for care performance concerns.

Inspectors wroteThis citation has three deficient practice statements. DPS#1 Based on observation, interview, and record review the facility failed to follow infection control practices for five residents (R40, R43, R47, R97, and R104) out of five residents reviewed for respiratory care, resulting in improper storage of nebulizer tubing and the potential for cross-contamination.

Inspectors wroteBased on observation and interview the facility failed to ensure hand sinks were in good repair to be easily cleaned and sanitized in four rooms (1039,1040,1041, and 1044) out of fifteen rooms located on Trans East Nursing Station, resulting in the potential for harmful growth of microorganisms and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignified dining for one resident (R17) of one resident reviewed for eating assistance while in room, resulting in the potential for feelings of being ignored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was within reach of one (R92) of one resident reviewed for accommodation of needs, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide showers as desired for one resident (R103) of two residents reviewed for choices, resulting in resident dissatisfaction.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean and comfortable environment for two residents (R40 and R79) out of two residents reviewed for safe, clean, homelike environment resulting in resident dissatisfaction and discomfort with living conditions.

Inspectors wroteBased on interview and record review the facility failed to file a report with the state of Michigan within a 24-hour period concerning an allegation of staff to resident abuse for one resident (R115) of 10 residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure a Pre-admission Screening and Annual Resident Review (PASARR-determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability [ID/DD] meets the criteria for a nursing home and their needs are met) Level I (3877) was completed for three sampled resident's (R93, R97, and R89) from a total sample of 38 resulting in the potential for unmet mental health care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate Activities of Daily Living (ADL) care for one resident (R101) out of nine residents reviewed for hygiene, resulting in a dependent residents nail care not being performed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide vision services for one of one resident (R120) reviewed for vision concerns, resulting in inadequate accommodations of vision needs and potential for further deterioration of vision.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate foot care for one resident (R101) out of nine residents reviewed for Activities of Daily Living (ADLS), resulting in R101 having overgrown toenails with debris. Findings Include: During an interview on 2/11/24 at 2:03 PM, R101 reported that foot and nail care had not been provided. An observation of bilateral feet revealed resident's toenails were greenish in color and had had debris underneath. Nails were thick and had grown passed the end of toes and had started curving outwards. R101 further reported, It would be nice if they could be cut. Record review of R101's electronic medical record revealed admission into the facility on 6/7/23 with a pertinent diagnosis of hemiplegia and hemiparesis (paralysis on one side of body). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow therapy recommendations to initiate restorative services to maintain range of motion (ROM) and mobility for one resident (R98) of six residents reviewed for ROM, out of a total of 28 sampled residents resulting in the potential for a decline in range of motion, and mobility and worsening of contractures.

Inspectors wroteThis citation pertains to intake MI00141655. Based on observation, interview, and record review the facility failed to ensure that a foley catheter (urine drainage system) was properly secured to the resident's leg, for one resident (R27) out of two residents reviewed for catheter care, resulting in the potential for injury.

Inspectors wroteBased on record review and interview the facility failed to respond to a pharmacy recommendation for one resident (R3) of two residents reviewed for medication and medication regimen, resulting in a lack of follow-up for possible needed changes.

Inspectors wroteBased on observation, interview and record review, the facility failed to justify the use of three medications for one resident (R3) of two residents reviewed for medication and medication regimen, resulting in potential ineffective resident care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical equipment in safe operating condition.