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 Health & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and intact cognition was found with facial bruising and a posterior nasal fracture of unknown origin. Although the facility's policy required immediate reporting of such injuries to the State Agency, the incident was not reported as required, despite an internal investigation being initiated.
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness risks. Issues included improper sanitization, non-operational hand washing sink, faulty refrigeration equipment, and expired milk cartons. These deficiencies potentially affected 138 residents receiving meal services.
The facility failed to maintain an effective pest control program, resulting in the presence of live flies in various areas, including the basement hallway, kitchen's dishwashing area, and near the kitchen's walk-in cooler. The Certified Dietary Manager acknowledged the issue, and a review of the pest control service record revealed ongoing treatment for gnats and cockroaches, with a recommendation to remove trash with food waste nightly.
The facility failed to provide a safe, functional, and sanitary environment for its 138 residents and staff. Observations included debris in laundry dryers, an unlocked clean linen supply room, a soiled hopper in a utility room, lack of PPE in soiled utility rooms, and improper storage of lift batteries and charging stations. These issues were acknowledged by the Environmental Services Manager, Staff C.
The facility failed to document a resident's advance medical directives (AMD) in their EHR. Despite the resident's Legal Guardian providing the necessary paperwork, including a completed AMD form indicating the resident was a 'full code', the documents were not scanned into the EHR. This lapse was discovered during a review with the Director of Nursing.
The facility failed to ensure the PAS/ARR form for Mental Illness/Intellectual Disability was accurate, complete, and sent for a Level II evaluation for a resident. The resident, who was receiving treatment for mental illness, had an outdated form, and both the Social Worker and Director of Nursing confirmed the deficiency.
A facility failed to implement a low-air-loss (LAL) mattress for a resident with a stage 4 pressure ulcer, as recommended in their care plan. The resident was observed on a regular mattress, and staff confirmed the oversight, attributing it to a possible mix-up during a hospital transfer. The facility's policy requires appropriate treatment to promote healing and prevent new ulcers.
A resident was found with debris-filled and odorous feet due to inadequate ADL care. Despite requiring total assistance and having a care plan that included regular showers and daily care, the resident's feet were neglected, leading to an accumulation of debris and odor. The DON acknowledged the issue, confirming that the resident's feet should not have been in such a condition.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident involving a resident who was found with facial bruising and a posterior nasal fracture of unknown origin. The resident, who had intact cognition and was able to communicate, was admitted with multiple medical conditions including acute respiratory failure, tracheostomy, and morbid obesity, and required mechanical ventilation. On the evening of the incident, the resident was observed with facial swelling and green discharge from the right eye, prompting a transfer to the hospital for further evaluation. The hospital later diagnosed the resident with a minimally displaced left posterior sinus wall fracture, but there was no documented trauma or incident preceding the injury, and the resident did not report any event that could have caused it. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the State Agency, the incident was not reported as required. The Director of Nursing confirmed that while an internal investigation was initiated by the Nursing Home Administrator, there was no evidence that the incident was reported to the State Agency. The facility's abuse policy specifically mandates reporting all injuries of unknown source that are suspicious in nature within 24 hours, but this protocol was not followed in this case.
Plan Of Correction
This plan of correction is submitted to meet state and federal requirements. Except with respect to statements finally determined to be indisputable, submission of this plan of correction is not an admission that the deficiency exists or that it is cited accurately. ELEMENT # 1 The resident identified (R702) has returned from the hospital and is receiving services per her plan of care. ELEMENT # 2 The Director of Nursing (DON) and/or their appropriate designee will assess each resident to ensure any unusual findings have been addressed and reported if necessary. ELEMENT # 3 The citation states: “the facility failed to report facial bruising and posterior nasal fracture of unknown origin for one (R702)...” The facility will ensure the following action: 1) The facility policy titled “Abuse and Neglect Prohibition Policy” will be reviewed and updated to ensure clarity; 2) Facility staff will receive re-education on the facility’s updated policy with an emphasis on identifying and timely reporting any injuries of unknown origin to the Administrator; 3) Any discovery of an injury of unknown origin will also be reported to the nurse on staff at the time of discovery who will then be responsible for informing the incoming nurse of the following shift to ensure proper attention is provided related to reporting and follow-up investigation and/or care if necessary; 4) Any injury of unknown origin will be reported to the Administrator and relayed to the DON upon knowledge; 5) The Administrator or the DON as their designated representative will timely report to any other required parties the discovery of the injury of unknown origin and the result of the investigation; and 6) In cases of verified violations of this facility policy, the Administrator will ensure timely and appropriate corrective action is taken. ELEMENT # 4 The DON and/or their appropriate designee(s) will randomly assess 25% of the residents for a period of three consecutive months to ensure any injuries of unknown origin have been identified, addressed, and reported appropriately. Random assessments for 25% of the residents will occur three times per week for the first month, twice per week for the second month, and once a week for the third month. Any instances of non-compliance with the facility policy will be reported to the Administrator, DON, and abuse coordinator for appropriate follow-up. The Administrator will report any outcome or concern related to the cited deficiency to QA for three months. The Administrator is responsible for sustained compliance.
Sanitary Conditions and Equipment Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During an observation, a cook was seen using a cloth towel as a sanitizer, which was later found to have a concentration of zero when tested. The Certified Dietary Manager confirmed the issue and attempted to rectify it by switching to bleach. Additionally, the dish room's designated hand washing sink was found to be non-operational for years, and the walk-in cooler's refrigeration equipment was observed dripping onto the floor. The walk-in freezer's refrigeration equipment was partially iced over, and its entry door was unable to latch shut consistently. Expired milk cartons were also found in a milk bin, which the Certified Dietary Manager could not explain. These deficiencies indicate a lack of adherence to the 2017 U.S. Public Health Service Food Code. The facility's equipment was not maintained in a state of good repair, and proper sanitization procedures were not followed. The issues with the refrigeration equipment and the presence of expired milk further highlight the facility's failure to ensure food safety and proper storage conditions. These findings potentially affected the facility's total census of 138 residents who receive meal services.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live flies in various areas, including the basement hallway, kitchen's dishwashing area, and near the kitchen's walk-in cooler. Observations were made by the surveyor on multiple occasions, and the Certified Dietary Manager acknowledged the issue, stating it had improved but was still present. A review of the facility's pest control service record revealed ongoing treatment for gnats and cockroaches, with a recommendation to remove trash with food waste nightly to reduce gnat problems. The facility's pest control policy was not readily accessible, as indicated by the staff's response to the surveyor's request for the policy documentation.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for its 138 residents and staff. During an environmental tour, both dryers in the laundry room were found with melted and baked-on debris inside the drums. The Environmental Services Manager, Staff C, acknowledged that clothes should be checked for items in pockets before washing to prevent such issues. Additionally, the clean linen supply room in the six south memory care wing was observed to be unlocked, and Staff C admitted that the room should have restricted access to prevent unauthorized use, especially given the resident population in the area. The fifth south soiled utility room's hopper was also found soiled, and PPE was not available in the soiled utility rooms on the fifth south and three south floors. Staff C was unsure who was responsible for replenishing the PPE, suggesting it might be the nursing staff's duty. Furthermore, lift batteries and charging stations were being stored in all the soiled utility rooms, which Staff C confirmed had always been the practice but agreed to move them to a cleaner area. These observations indicate a lack of proper maintenance and oversight in ensuring a safe and sanitary environment, increasing the potential for harm to residents and staff.
Failure to Document Advance Medical Directives in EHR
Penalty
Summary
The facility failed to ensure that a resident's advance medical directives (AMD) were properly documented in their Electronic Health Record (EHR). The resident, who was admitted with multiple diagnoses including traumatic brain injury and respiratory failure with dependency on mechanical ventilation, had no AMD form in their EHR to indicate their code status or treatment preferences. Although the resident's face sheet indicated they were a 'full code', there was no follow-up documentation from the Social Worker (SW) after an AMD form was sent to the resident's Legal Guardian (LG). The LG reported that they had provided the necessary paperwork, including a completed AMD form, but this was not reflected in the EHR. The SW also failed to follow up with the LG regarding the AMD form, leading to a lack of proper documentation in the resident's medical record. Further review with the Director of Nursing (DON) revealed that the LG had indeed sent a signed AMD form and valid LG paperwork, indicating the resident was a 'full code'. However, these documents were not scanned into the resident's EHR as required by the facility's Advance Directive Policy and Procedure. The DON could not explain why the documents were missing from the EHR, highlighting a lapse in the facility's process for handling and documenting advance directives.
Failure to Ensure Accurate and Timely PASARR Screening
Penalty
Summary
The facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) was accurate, complete, and sent to the local state agency for an evaluation for a Level II determination for one resident. The resident had a diagnosis of mental illness and was receiving treatment that included antipsychotic and antidepressant medications. A review of the resident's Electronic Health Record (EHR) revealed that the DCH-3877 form was outdated and indicated it was a 'Hospital Exempt Discharge' form, valid for only 30 days. The Social Worker confirmed that the form was past due and that the resident needed a Level II evaluation. The Director of Nursing also acknowledged the deficiency, confirming that the resident should have had a current DCH-3877 form and a Level II evaluation.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to consistently implement interventions for a resident with a stage 4 pressure ulcer. The resident, who had a tracheostomy connected to a ventilator and was unable to be interviewed due to impaired cognition, was observed lying on a regular mattress instead of the recommended low-air-loss (LAL) specialty mattress. The resident's Electronic Health Record (EHR) indicated that the resident was readmitted to the facility with a stage 4 pressure ulcer on the sacral area, and the Minimum Data Set (MDS) confirmed the need for a pressure-relieving device for the bed. A wound care note recommended the continuation of a LAL mattress, but this intervention was not in place during the observation. Licensed Practical Nurse (LPN) confirmed that the resident should have been on a LAL mattress and could not explain why it was not in place. The Director of Nursing (DON) acknowledged the issue, suggesting that the mattress might have been swapped out when the resident was hospitalized and not replaced upon return. The facility's Pressure Ulcer and Skin Care Management policy mandates that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent new ulcers, which was not adhered to in this case.
Inadequate ADL Care Results in Resident's Poor Foot Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a resident, resulting in the resident having debris-filled and odorous feet. On May 14, 2024, the resident was observed lying in bed with yellowish thick dry debris between all toes and an unpleasant odor. The Unit Manager/Licensed Practical Nurse confirmed the condition of the resident's feet and acknowledged that there should not have been such an accumulation of debris if routine showers were completed. The resident's medical record indicated that they were unable to make their needs known and required total assistance with ADLs due to cognitive and physical impairments. The resident's care plan, dated March 4, 2021, specified the need for total one-to-two person assistance with ADLs and mobility, with staff required to anticipate the resident's needs. The facility's ADL Care policy stated that residents should receive ADL care per their personalized care plan, including at least two showers per week and AM and HS care on non-shower days. Despite these guidelines, the Director of Nursing was informed of the resident's condition on May 17, 2024, and acknowledged that the resident's feet should not have had an odor or dry skin between the toes.
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 1,120 citations issued within 25 miles in the last 12 months — including the 5 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 Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ambassador, A Villa Center | 0.1 mi | ★★★★★ | 8 | 0 |
| Hamilton Nursing Home | 0.9 mi | ★★★★★ | 10 | 0 |
| Qualicare Nursing Home | 1.1 mi | ★★★★★ | 8 | 0 |
| Regency At Chene | 1.8 mi | ★★★★★ | 1 | 0 |
| Mission Point Nursing & Physical Rehab Center Of D | 2 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverview Health & Rehab Center.
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.