Rivergate Health Care Center

In the surveyor’s words

From the most serious findings on record at Rivergate Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 17, 2025

  This 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. […]

• Immediate jeopardy, isolatedF689Aug 3, 2021

  This citation pertains to MI 270. Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 6 sampled residents (Resident #1) reviewed for supervision, resulting in an Immediate Jeopardy when on [DATE] at approximately 12:10 AM, Resident #1, who was known to wander about the housing unit and try to take food from other residents and from the nurses station and who was on a pureed diet due to dysphagia, obtained a peanut butter sandwich from the nursing station which was left unsupervised and unlocked. Resident #1 aspirated the sandwich, asphyxiated, lost consciousness, sustained an [CONDITION(S)] [CONDITION(S)] and died . […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based 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… […]

• No harm, potential for more than minimal, widespreadF921Jun 4, 2026

  Based 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.On 06/02/2026 at 2:23 PM observed a… […]

• No harm, potential for more than minimal, widespreadF812May 31, 2024

  Based 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. Findings include: 1. On 5/30/24 between 10:12 AM, and 10:40 AM, the following non-food contact surfaces in the kitchen were observed soiled and with visible debris on their surfaces: On the ventilation filters above the fryer. On the grates of the flat top grill. On the sides of the oven On the oven's stainless steel backsplash. […]