Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverview Estates during CMS and state inspections, most recent first.
Two residents with significant cognitive and physical impairments were subjected to verbal and mental abuse by CNAs during personal care, including derogatory remarks about incontinence and threats to prolong care. These actions caused embarrassment and humiliation, violating the facility's abuse prevention policy and resulting in psychosocial harm.
A resident with a history of sepsis experienced a significant decline, including hypotension, tachycardia, labored breathing, and unresponsiveness. Despite a physician's order to send the resident to the ER if her condition worsened, nursing staff did not escalate care or notify the physician as required. The resident was later found without vital signs, and documentation showed missed assessments and lack of follow-up on abnormal findings.
Surveyors found that opened bags of frozen vegetables, potato items, and hamburger patties in kitchen freezers were not labeled with open or expiration dates, and some packaging was left open to the air. Dietary staff confirmed the lack of proper labeling and sealing, noting that the marker used for labeling was ineffective. This was not in accordance with the facility's food storage policy.
A licensed nurse failed to properly don required PPE, initially wearing only gloves instead of both gloves and a gown, when entering the room of a resident on droplet and contact precautions for Influenza A. Signage on the resident's door did not clearly indicate the need for a gown, and staff demonstrated uncertainty about the correct PPE requirements, resulting in a lapse in infection control practices.
The facility allowed four employees, including CNAs, housekeeping, and maintenance staff, to begin working with residents before their criminal background checks were completed and verified, contrary to facility policy. This failure meant the facility did not know if these staff had histories of abuse, neglect, exploitation, or related offenses before granting them resident access.
The facility did not offer or document consent, declination, or contraindication for the pneumococcal PCV20 vaccine for several residents, and lacked a system to determine vaccine eligibility or track vaccination status, resulting in missed assessments and offers of the vaccine as required by policy.
Staff failed to notify a resident's physician or family after observing an abnormal abdominal bulge and did not document further assessment. The resident later experienced significant deterioration, including labored respirations and unresponsiveness, without timely physician notification or emergency intervention, contrary to care plan and facility policy.
A resident with a urinary catheter was not provided with a securement device as required by facility policy and care plan, resulting in the catheter tubing rubbing against the skin and causing two open sores on the penis. Staff confirmed that no risk agreement was in place to refuse the device, and documentation linked the skin breakdown to the lack of catheter securement.
A resident with severe cognitive impairment and multiple diagnoses was receiving hospice services, but the facility's care plan did not include specific instructions or coordination with the hospice provider's plan of care. The care plan lacked details on hospice visit frequency, supplies, medications, and contact information, resulting in uncoordinated care between the facility and hospice.
Failure to Prevent Verbal and Mental Abuse by CNAs
Penalty
Summary
The facility failed to protect two residents from verbal and mental abuse by certified nurse aides (CNAs), resulting in psychosocial harm. One resident with multiple sclerosis, severe contractures, and bowel incontinence was subjected to repeated derogatory remarks by a CNA during personal care. The CNA made comments about the resident's incontinence, such as suggesting the resident should clean or buy new shoes for the staff, and expressed frustration about the resident's bowel movements in front of other staff. The resident reported feeling embarrassed and humiliated by these remarks, which were corroborated by witness statements from other CNAs present during the incident. Another resident with Alzheimer's disease, dementia, and major depressive disorder, who was non-ambulatory and required maximum assistance for activities of daily living, was verbally abused by a CNA during peri-care. The CNA told the resident to "shut up" and stated she would prolong care to upset the resident. This incident was witnessed by another CNA, who reported the occurrence to a licensed nurse. The resident was known to become agitated during care but could be redirected with appropriate interventions, as outlined in her care plan. Both incidents involved staff disregarding the residents' care plans, which emphasized the need for a calm environment, clear communication, and respect for the residents' dignity during care. The CNAs' actions were in direct violation of the facility's policy prohibiting abuse, neglect, and exploitation. The facility's documentation and witness statements confirmed that the residents experienced embarrassment, humiliation, and impaired psychosocial well-being as a result of the staff's behavior.
Failure to Timely Assess and Escalate Care for Resident with Sepsis History
Penalty
Summary
Staff failed to prevent neglect of a resident with a known history of sepsis by not timely and competently assessing and providing care during a significant change in condition. The resident exhibited symptoms including struggling to talk and drink, hypotension, tachycardia, and later shallow, labored respirations with pale, moist skin. Despite these symptoms and a physician's order to send the resident to the emergency room if her condition did not improve or worsened, the nurse did not contact the physician or arrange for emergency care when the resident's condition deteriorated. The resident's care plan required staff to notify the physician of any changes in condition and to monitor and report signs of respiratory distress. Documentation showed that the resident became increasingly lethargic, had abnormal vital signs, and required oxygen supplementation. At one point, the resident was unresponsive to verbal stimuli and refused fluids, yet no further assessment or escalation of care was documented until the resident was found without a pulse or respirations several hours later. Additionally, a previously noted abdominal bulge was not further assessed or followed up by staff. The facility's policies required nurses to notify supervisors and physicians of immediate needs and to assess and document findings related to potential neglect. These protocols were not followed, resulting in the resident's death and the determination that the facility failed to protect the resident from neglect.
Removal Plan
- Immediate education regarding F600 began and was completed.
- Nursing staff were not allowed to work until they were educated on the policy and clinical protocols for assessing residents and notification to the physician upon changes in condition.
- An onsite verified the completion of the corrective actions to remove the immediacy.
Failure to Properly Date and Seal Opened Food Items in Kitchen Storage
Penalty
Summary
During an inspection of the facility's kitchen cold storage, surveyors observed that several opened bags of frozen vegetables and potato items in one upright freezer, as well as an opened box of hamburger patties in another freezer, were not labeled with either the open date or expiration date. The plastic bag containing the hamburger patties was also left open to the air. Dietary staff confirmed that the bags were undated or the dates were not readable, and explained that the marker used for labeling was not appropriate, as the ink rubbed off. The facility's Food Receiving and Storage policy required all foods stored in the refrigerator or freezer to be covered, labeled, and dated with a use-by date, and for opened containers to be dated and sealed or covered during storage. These practices were not followed, resulting in a failure to properly date and seal opened bags of food.
Failure to Adhere to Infection Control Precautions for Resident with Influenza A
Penalty
Summary
A deficiency occurred when a licensed nurse entered the room of a resident who was on droplet and contact precautions for Influenza A, but failed to don the required personal protective equipment (PPE) as indicated by facility policy and posted signage. The nurse initially wore only gloves upon entering the resident's room, despite instructions on the door for PPE use, and engaged in conversation with the resident for approximately eight minutes before being informed by another nurse that a gown was also required. Only after this reminder did the nurse don a gown and continue interacting with the resident. Further review revealed inconsistencies in the signage posted on the resident's door, which did not clearly indicate the need for a gown, despite the resident's diagnosis and the facility's infection control protocols. Administrative staff confirmed that the signage instructed staff to wear gloves and a mask, but did not specify gown use. There was also a lack of clarity among staff regarding the appropriate PPE required for droplet and contact precautions, as evidenced by administrative nurses needing to consult infection control protocols and CDC guidelines to verify the correct procedures. The facility's policies outlined the use of enhanced barrier precautions (EBP) and transmission-based precautions, including the use of gowns and gloves during high-contact care activities and when caring for residents with infections such as Influenza A. However, the failure of staff to consistently apply these precautions, as well as unclear signage and staff uncertainty, led to a lapse in infection control practices for the resident in question.
Failure to Complete Background Checks Prior to Staff Access to Residents
Penalty
Summary
The facility failed to perform required criminal background checks for four employees prior to allowing them to work with or around residents. Specifically, records showed that a Certified Nurse Aide, another CNA, a housekeeping staff member, and a maintenance staff member all began employment and had access to residents before their background checks were completed and verified. Administrative staff confirmed that the facility did not have evidence of completed background checks for these individuals before they started working. The facility's policy required human resources personnel to check the state website for background check results and to track the date of the check, the result, and when the result was recorded. However, this process was not followed, as evidenced by the delayed verification of background checks for the four staff members. This lapse meant that the facility could not confirm whether these employees had any history of abuse, neglect, exploitation, misappropriation of property, or mistreatment prior to their interaction with residents.
Failure to Offer and Document Pneumococcal Vaccination per CDC Guidance
Penalty
Summary
The facility failed to offer, obtain informed declination, or secure physician-documented contraindications for the pneumococcal PCV20 vaccination in accordance with the latest CDC guidance. Record reviews for seven residents revealed that several had not been offered the pneumococcal vaccine since admission, and there was no evidence of consent, informed declination, or documentation of contraindication in their medical records. Specifically, two residents had not been offered or received the pneumococcal vaccine since admission, and five residents' records lacked evidence of consent or declination for the vaccine. Interviews with administrative nursing staff confirmed that the facility did not have a definitive system in place to determine resident eligibility for the PCV20 vaccine, nor a process to track which residents had been offered, accepted, or declined the vaccination. The facility's existing policy required assessment and offering of the vaccine within thirty days of admission, with documentation of education, consent, or refusal, but this was not followed. As a result, eligible residents were not properly assessed or offered the pneumococcal vaccination as required.
Failure to Notify Physician and Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician or family when staff observed an abnormal bulge in the resident's right abdomen. The bulge, measuring 10 centimeters in diameter, was noted during care, but no further assessment or follow-up was documented. The resident denied pain, and there was no evidence that the physician or family was informed of this new finding, as required by the care plan and facility policy. Subsequent documentation showed the resident experienced changes in condition, including lethargy, low blood pressure, and decreased oral intake. Although the physician was notified at one point and provided instructions for monitoring and possible transfer to the emergency room if the condition worsened, there were additional episodes of deterioration. The resident later developed shallow, labored respirations, pale and moist skin, and unresponsiveness to verbal stimuli. Despite these significant changes, there was no documentation that the physician was contacted or that emergency services were called at that time. Administrative staff confirmed that they were unaware of the initial abdominal bulge and that there was no follow-up assessment. They also verified that staff should have contacted the physician or emergency services when the resident's condition worsened, as per the physician's prior order. The facility's policies required prompt notification of changes in condition, but these were not followed, resulting in a failure to provide timely medical intervention.
Failure to Secure Urinary Catheter Tubing Resulting in Skin Breakdown
Penalty
Summary
A resident with a urinary catheter was not provided with a securement device to prevent the catheter tubing from pulling and causing discomfort, as required by the facility's policy and the resident's care plan. The resident's medical record documented diagnoses including an open wound of the penis, pain, and a urinary tract infection. The care plan directed staff to use a catheter strap as needed and ensure slack in the tubing, but observations showed that no securement device was in place. Staff interviews revealed that the resident did not have a risk agreement to refuse the device, and administrative staff confirmed that a securement device should have been used. The deficiency was identified when, during a catheter change, two open sores were found on the resident's penis, which were attributed to the catheter tubing rubbing against the skin. Documentation indicated that the catheter had been rubbing against the area, and the facility's policy required the use of a securement device to reduce friction and movement at the insertion site. The lack of a securement device led to the development of the sores, as directly observed and recorded in the resident's medical record.
Failure to Coordinate Facility and Hospice Care Plans
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and the hospice provider for a resident with severe cognitive impairment, dementia with behavioral disturbance, arteriosclerotic heart disease, and anxiety. The resident required extensive staff assistance with activities of daily living and was receiving hospice services. The facility's care plan documented the need for comfort measures and support but did not include specific instructions regarding the hospice services, such as the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, or hospice contact information. Although the resident's electronic health record included the hospice plan of care, the facility's care plan lacked integration and coordination with the hospice provider's plan. This was confirmed by administrative staff, who acknowledged the absence of specific information on the facility care plan that coordinated with the hospice care plan. The facility's policy required coordinated care plans reflecting both facility and hospice services, but this was not implemented for the resident in question.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 69 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marquette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Home Association | 8.4 mi | ★★★★★ | 2 | 0 |
| Mcpherson Operator, Llc | 14.3 mi | ★★★★★ | 0 | 0 |
| Sandstone Heights | 14.5 mi | ★★★★★ | 0 | 0 |
| The Cedars | 15.5 mi | ★★★★★ | 9 | 0 |
| Pinnacle Park Nursing & Rehab Center | 19.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverview Estates.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.