The Rivers Health & Rehabilitation Center of Gross

In the surveyor’s words

From the most serious findings on record at The Rivers Health & Rehabilitation Center of Gross, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 10, 2021

  This citation pertains to intake # MI 666. Based on observation, interview and record review, the facility failed to complete and/or document ordered wound care treatments for two residents (Resident # 703 and Resident #708) of two reviewed for wound care, resulting in the worsening of a pressure ulcer, and the likelihood of the continued worsening of a wound and unnecessary pain. Findings include: Resident #703 On 08/09/2021 at 09:51 AM, Confidential Witness A was interviewed via telephone. According to Confidential Witness A, Resident #703 had developed a wound within the facility. Confidential Witness A stated, We (the family) had no idea how bad that wound was. When we got to the hospital, we seen it. I was horrified. […]

• No harm, potential for more than minimal, widespreadF812Aug 22, 2024

  Based on observation, interview, and record review, the facility failed to maintain the dish machine to ensure dishware was sanitized. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/20/24 at 8:55 AM, dietary staff was observed cleaning soiled dishware in the facility's dish machine. At that time, a plate simulating dishwasher tester was sent through the dish machine to check the sanitizing properties of the facility's high temperature dish machine. The maximum temperature recorded on the plate simulator was noted to be 124 degrees Fahrenheit. The plate simulating dishwasher tester was sent through the dish machine a second time, and the maximum temperature was noted to be 125 degrees Fahrenheit. […]

• No harm, potential for more than minimal, widespreadF761Dec 8, 2021

  Based on observation, interview, and record review the facility failed to ensure medication storage per professional standards of practice for one medication cart, resulting in an unlocked and unattended medication cart on the first floor hall, with several medications in plain view, with the potential for medication diversion. Findings include: On 2/15/2022 at 8:32 AM, during a tour of the 1st floor, an unlocked and unattended medication cart was observed with approximately 17 pre-packed medications labeled with the type of medication and resident names. An unidentified staff member walked past the medication cart and was asked if they knew where the assigned nurse to that cart was located. […]

• No harm, potential for more than minimal, widespreadF806Dec 8, 2021

  This citation pertains to MI 968. Based on observation interview and record review, the facility failed to offer a dignified dining experience for three sampled residents (R901, R14 and R35) of three reviewed for food preferences and non sampled residents (R7, R13, R16, R17, R24, R25, R27, R53 and R68) resulting in the use of foam take out style containers for meals, plastic utensils and resident dissatisfaction with the dining experience. Findings include: Resident #14 (R14) On 12/08/21 at 8:49 AM, R14 was observed to be served their breakfast food in a white foam take out style clamshell. R14 reported the food had been served that way for the last few months. […]

• No harm, potential for more than minimal, patternF550Jul 12, 2023

  This citation pertains to Intake MI00137133. Based on observation, interview, and record review, the facility failed to promote a dignified existence and value residents' private living space, for three residents (R29, R36, and R272), and potentially affecting all residents residing on the first floor, resulting in resident feelings of frustration and disrespect and the potential for diminished quality of life. Findings include: Resident #29 On 7/11/23 at 10:37 AM, Certified Nursing Assistant (CNA) K was observed to walk into R29's room. CNA K did not knock or announce herself before entering. […]