Rivergate Terrace

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 14, 2024

  This citation pertains to intake MI00142660. Based on observation, interview, and record review, the facility failed to implement appropriate safety interventions for two residents (R579, R44) out of 10 residents reviewed for accidents, resulting in a fall with injury (traumatic cerebral hemorrhage and subsequent death) and oxygen equipment not stored safely. Findings include: It was reported to the State Agency that a resident fell out of bed, sustained a head injury, and not long after passed away. On 3/12/24 at 9:07 AM, the family member/guardian for Resident #579 (R579) said R579 passed away on 1/22/24 from a brain bleed that resulted from a fall at the facility. […]

• Actual harm, isolatedF684Oct 19, 2021

  This citation pertains to intake MI 193. Based on observation, interview, and record review, the facility failed to: 1.) identify, assess, monitor, and implement timely and consistent wound care treatments for 2 of 6 residents (R#45, #47), and 2.) ensure weekly skin assessments were consistently completed on 4 of 6 residents (R#s 45, 46, 47, 48) reviewed for quality of care, resulting in delay in the identification and worsening of a wound, dried dressing adhering to resident's skin, resident pain and anxiety, the potential for delay in wound healing and development of wound infection, and the potential for other care needs to go undetected. […]

• Actual harm, isolatedF684Feb 18, 2021

  This citation pertains to MI 543. Based on interview and record review, the facility failed to properly assess and implement timely care and medical interventions for one resident (#201) reviewed for quality of care, resulting in acute [CONDITION(S)] and emergency hospital admission. Findings include: The complainant reported to the State Agency that a resident was not provided proper assessment, diagnoses, and treatment in a timely manner upon his change in condition, resulting in hospitalization and death. The complainant stated the resident of concern died three days after his hospitalization . A review of the clinical record for Resident #201 (R201) documented an admitted [DATE]. R201 was discharged to the hospital on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Mar 14, 2024

  This citation pertains to Intake MI00142807. Based on interview and record review, the facility failed to adequately provide infection control surveillance for all residents resulting in missed opportunities to decrease the potential risk of the spread of infections. Findings Include: Record review of the facility's Infection Control Book revealed no completed documentation of infection surveillance for January 2024 and February 2024. There was no evidence that data was compiled and monitored in a timely manner during those months to provide an overview of the facility's infection control practices. […]

• No harm, potential for more than minimal, widespreadF925Mar 14, 2024

  Based 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 219 residents. Findings include: On 3/13/24 at 10:42 AM, thirty live ants were observed in the kitchen's dry storage room. Upon observation the surveyor inquired with Dietary Director, staff A, on the current state of the insects in this area to which they responded, I'll have someone clean this up. At this time the surveyor observed staff A asking Dietary Aide, staff D, to clean the area. […]