Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 The Rivers Health & Rehabilitation Center Of Gross during CMS and state inspections, most recent first.
Failure to supervise a cognitively impaired resident with a documented high elopement risk led to an elopement from the facility. The resident had schizophrenia, dementia, severe cognitive impairment, and a history of wandering toward the elevator and lobby area. Staff interviews showed the resident was known to be exit-seeking, but security had stepped away from the desk and the front door was not alarmed when the resident pushed it open and left the building.
A resident with dementia, bilateral above-knee amputation, and other chronic conditions, who required two-person assistance for bed mobility, was being cared for by only one CNA. During care, the resident became agitated and fell, sustaining an injury that required hospital evaluation. The care plan and facility guidelines specified the need for two-person assistance, but this was not followed.
A resident with DM2 and cardiac history had a pink foam dressing with dried blood on the arm that was not dated, remained unchanged across observations, and had no nursing or medical documentation despite a shower sheet noting a skin change at the same site. Another resident with dementia, COPD, and severely impaired cognition was repeatedly found slid down in bed and near the bed edge, including while eating with the tray table in front; the CNA and unit nurse manager noted the resident needed repositioning and regular checks for proper bed positioning.
A resident with a recent MI, AFib, and type 2 DM wore a WCD vest, but 3 of 3 direct care nursing staff lacked basic knowledge of the device's purpose and function. One LPN thought it only alerted for low HR, another did not know what it was, and a third knew how to check battery status but did not know it could deliver a shock. The DON said the device company gave an in-service, but there was no sign-in sheet to show which staff were educated.
A medication pass observation found an LPN mishandling non-crushable meds for a resident with severe cognitive impairment and multiple diagnoses, including stroke, seizures, AFib, and schizoaffective disorder. The resident was receiving Depakote and Keppra, both ordered not to be crushed, yet the LPN initially indicated they might be opened or crushed, removed them with an ungloved hand, left them unattended on the cart, and placed them in the trash bag during the pass. The UM and DON stated extended-release meds should not be opened or crushed, and the EMR contained do-not-crush instructions for both meds.
Improperly Labeled Medications in Medication Cart: An LPN was observed administering meds from a medication cart that included a Lispro insulin pen, Tobramycin eye drops, and Enulose without open dates, plus a vial of Novolog without a resident label or open date. A bottle of Latanoprost eye drops was also found with an expired date, and interviews with the LPN, UM, and DON confirmed that multi-use prescription meds should have a resident identifier and open date.
Call Light Not Within Reach for Dependent Resident: A dependent resident with dementia and COPD was repeatedly observed in bed without the call light within reach, and the resident was unaware of its location. The call light was seen on the floor away from the bed, while the UNM/LPN and DON stated that the call light should be accessible, clipped to the resident, and within reach. The facility policy stated that the resident should have the call system within reach and be able to use it if desired.
A resident's new knee fracture was not communicated to their family or physician in a timely manner, despite documented pain and swelling. The x-ray report was not acted upon, leading to a delayed hospital transfer and surgery. The facility's notification policy was not followed, contributing to the deficiency.
The facility's dish machine failed to sanitize dishware, with recorded temperatures of 124 and 125 degrees Fahrenheit, below the required 160 degrees. Despite awareness of the issue and a work order submitted, dietary staff continued using the machine, potentially affecting all residents consuming food from the kitchen.
A resident experienced a fall during care, resulting in abrasions and a delayed diagnosis of a clavicle fracture. The facility failed to notify the responsible party and obtain x-ray results promptly. The x-ray, ordered stat, was delayed, and the results were not communicated until two days later. The facility's policies on fall management and change of condition were not followed, leading to a delay in treatment and notification.
A resident experienced impaired vision due to the facility's failure to timely facilitate the provision of eyeglasses. Despite having a prescription since July, the eyeglasses were not ordered until mid-August, as the Social Services Director forgot about the request. The facility's policy requires timely coordination of ancillary services, which was not adhered to, resulting in a deficiency.
A resident in a LTC facility, requiring two-person assistance, fell from bed due to a CNA providing care alone, resulting in a fracture and other injuries. The incident was not documented by the midnight shift, and the resident's family and DON were not immediately notified. The facility's care plan was not followed, and there was a delay in receiving the x-ray report, leading to a late hospital transfer.
A facility failed to change a PICC line dressing timely for a resident with osteomyelitis. The dressing was observed to be dated over a week old, despite protocol requiring changes every seven days and upon readmission. The LPN and Infection Control Nurse acknowledged the oversight, and the DON confirmed the protocol. The resident's physician order specified maintaining sterile technique with dressing changes.
The facility failed to label and date medications when opened, as observed in two of three medication carts. Inhalers and eyedroppers lacked identifiers and open dates, contrary to the facility's policy and professional guidelines. The DON confirmed the need for proper labeling, but the facility's policies did not address inhalers specifically.
Failure to Supervise a High-Risk Resident to Prevent Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of one cognitively impaired resident who had a documented history of wandering and attempting to leave the building. The resident had diagnoses including schizophrenia, dementia, and insomnia, and the MDS documented a BIMS score of 5/15 indicating severe cognitive impairment. The record also showed an elopement risk assessment score of 22, which was considered high risk, and care plans noted wandering halls and into other rooms, attempting to leave the facility unattended, and placement in elopement books throughout the facility and at security. On the night of the incident, the resident exited the building and was later returned to the room. Facility documentation and camera review showed the resident left the building while security staff had stepped away from the security desk and the front door was not alarmed. The DON confirmed the security desk was unattended at the time of the exit and that the resident pushed the front door open when it did not open automatically. Security staff later reported they were in the bathroom after being unable to reach staff by phone, and when they returned, a female staff member reported a resident was missing. Staff interviews showed multiple employees were aware the resident wandered toward the elevator and lobby area and had been more actively wandering in the prior weeks. CNA staff, an LPN, the unit clerk, and security staff all described the resident as frequently moving toward the elevator, going downstairs, or looking for a way out, and some noted the resident was usually redirectable once found. The facility’s elopement policy stated exit doors were to be checked each shift and that if the alarm system was not working, staff were required to check all doors hourly until it was restored; however, the front door was not alarmed at the time of the elopement.
Failure to Provide Required Two-Person Assistance Resulting in Resident Fall
Penalty
Summary
A resident with diagnoses including dementia, chronic obstructive pulmonary disease, heart failure, diabetes, and bilateral above-knee amputation was identified as cognitively impaired and required extensive assistance of two staff for bed mobility. Despite this, the resident was provided care by only one CNA, who attempted to change the resident alone. During the care, the resident became agitated and combative, let go of the grab bar, and fell to the floor. The resident sustained an injury with active bleeding above the right amputation site, necessitating transfer to the hospital for further evaluation. The resident's care plan specifically required two-person assistance for bed mobility due to impaired mobility and cognitive status. Documentation and interviews confirmed that the CNA was aware of the resident's combative behavior and the need for two-person assistance but proceeded alone. The DON acknowledged that only one CNA was present during the incident, contrary to the care plan and facility fall management guidelines, which required individualized fall prevention interventions based on assessment.
Failure to Document and Treat a Wound and to Maintain Proper Bed Positioning
Penalty
Summary
The facility failed to assess and treat a wound for one resident with a history of non-ST elevation myocardial infarction, atrial fibrillation, and type 2 diabetes. On 8/18/25, the resident was observed with a pink foam dressing between the elbow and wrist that had dried blood on the upper border and was not dated. The dressing remained unchanged on subsequent observations on 8/19/25, and the resident stated that an unknown staff member had touched a large blood blister on the arm, causing it to bleed, and had applied the dressing, which had not been changed since it was first placed. The resident’s shower sheet from 8/12/25 documented a change in skin condition on the right forearm at the same location as the dressing, but the electronic medical record contained no documentation of the wound by nursing or medical staff. The facility also failed to ensure appropriate positioning for another resident who had dementia, COPD, severely impaired cognition, and required partial to moderate assistance with bed mobility and other ADLs. The resident was repeatedly observed in bed positioned a quarter to a third of the way down from the top of the mattress and close to the side of the bed, with mats on both sides. During one observation, the resident was lying in bed with the head of the bed elevated about 30 degrees and the tray table in front while eating lunch, and the resident agreed to be repositioned. A CNA stated another aide would be needed to reposition the resident. The unit nurse manager stated the resident tended to slide down in bed and lay close to the side, had a history of falls, and should be checked regularly to ensure proper positioning. The DON confirmed that during meals the resident should be seated with the tray table directly in front and that the resident should be positioned appropriately in bed as needed.
Staff Lacked Training on Resident WCD Device
Penalty
Summary
The facility failed to provide staff with education regarding a resident's Wearable Cardioverter Defibrillator (WCD) for 3 of 3 direct care nursing staff. The resident was observed sitting in a wheelchair and stated they wore the WCD vest after recently having a heart attack. The resident reported that the device had not delivered a shock since they began wearing it, that there were two batteries with one always charging while the other was on the device, and that the vest was only removed for showers. The resident's EMR showed diagnoses of non-ST elevation myocardial infarction, atrial fibrillation, and type 2 diabetes, and the MDS indicated intact cognition. A physician order directed staff to monitor WCD function every shift, confirm both batteries were fully charged, and notify the MD with concerns. Interviews showed that the LPNs did not understand the device's purpose or function. One LPN stated the device alerted staff if the heart rate dropped too low and did not know it could deliver a shock or what risks were involved. Another LPN did not know what the device was or what it was used for. A third LPN knew how to check for a battery charge message but was unaware the device would deliver a shock if activated. The Staff Educator stated they were not invited to the in-service provided by the company supplying the device, and the DON stated the company gave about an hour of in-service but no sign-in sheet was provided, so there was no documentation of who was educated or whether those staff were caregivers for the resident.
Medication Pass Error Involving Crushing and Handling of Non-Crushable Medications
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent for one resident reviewed during medication pass. The resident had been admitted with traumatic subdural hemorrhage, diabetes, convulsions/seizures, atrial fibrillation, and schizoaffective disorder, and the MDS showed severe cognitive impairment with maximum to substantial assistance needed for activities of daily living and mobility. During observation of the medication pass, the resident was receiving Depakote and Keppra, both extended-release medications that should not be crushed. The LPN stated that if the medications were in capsule form, the capsule contents would be emptied into the medicine cup and mixed with applesauce, and after hesitation acknowledged that extended-release medications should not be crushed or opened. During the same observation, the LPN removed the Depakote and Keppra from the dispensing cup with an ungloved finger/hand, placed the tablets on the medication cart top near the opened packages, crushed the remaining medications, mixed them with applesauce, and administered them while leaving the extended-release medications unattended on the cart outside the room. The LPN then returned to the cart, gathered the packages and the two medications, and placed them in the cart trash bag, stating the medications would be removed from the trash later and placed in the drug buster container. The UM stated that extended-release medications should not be opened or crushed and that the order should indicate this, and the DON stated that nurses should know extended-release medications should not be opened or crushed and that a do-not-crush list was available. The EMR showed orders for levetiracetam and valproex with instructions that they should not be crushed.
Improperly Labeled Medications in Medication Cart
Penalty
Summary
The facility failed to properly label medications in one of two medication carts. During observation of the second floor medication cart, a Licensed Practical Nurse was seen administering medications that included a Lispro Insulin Pen, Tobramycin eye drops, and a bottle of Enulose liquid without open dates. A vial of Novolog was also observed without a resident label or open date, and a bottle of Latanoprost eye drops had an expired date of 5/31, with a sticker underneath indicating it should be discarded 42 days after opening. During interviews, the LPN stated that all multi-use prescription medications should have a resident identifier and an open date, the Unit Manager stated that medication carts are reviewed weekly for unlabeled or undated medications and that such items are discarded, and the DON stated that all medication in the carts should be dated when opened and have a resident identifier, and any prescription item without either should be discarded. A policy for Medication Storage was requested but was not received by survey exit.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure that a working call system was within reach for one dependent resident, R11, who had diagnoses including dementia and COPD and required partial to moderate assistance for all ADLs except eating. On 8/18/25, R11 was observed lying in bed with no call light anywhere in sight, and R11 was unaware of the call light location when interviewed. On 8/19/25, the call light was repeatedly observed on the floor by the side of the bed farthest from the door, and R11 again stated they were unaware of its location. During interviews on 8/20/25, the UNM/LPN and the DON both stated that when residents are in bed, the call light should be accessible, clipped to the resident, and within reach. The facility policy titled Accommodation of Needs stated that the resident should have the call system within reach and be able to use it if desired.
Failure to Notify of X-ray Findings and New Fracture
Penalty
Summary
The facility failed to notify the responsible party and physician of x-ray findings in a timely manner for a resident who was diagnosed with a new left knee fracture during their stay. The resident's family member reported concerns after learning about the fracture during an orthopedic follow-up visit, which led to an emergent hospital transfer and surgery. The family member had previously reported swelling in the resident's knee to nursing management, but no explanation was provided by the facility staff regarding the cause of the injury. The resident's medical records revealed no documentation of falls or incidents during their stay, and the x-ray report indicating a new fracture was not communicated to the nursing management or the physician. The resident had been experiencing increased pain and leg rotation, which was documented by the nursing staff, but there was no evidence of physician communication or intervention related to the fracture. The x-ray report was initialed by the nurse practitioner but was not dated, and the focus remained on a blood clot diagnosis rather than the fracture. The facility's policy on notification of changes requires immediate communication with the resident, their representative, and the physician when there is a significant change in condition or treatment. However, the lack of timely notification and intervention for the resident's new fracture, as well as the absence of documentation and communication, contributed to the deficiency identified by the surveyors.
Dish Machine Fails to Sanitize Dishware
Penalty
Summary
The facility failed to maintain its dish machine to ensure proper sanitization of dishware, which could potentially affect all residents consuming food from the kitchen. On the morning of August 20, 2024, dietary staff were observed using the dish machine to clean soiled dishware. A plate simulating dishwasher tester was used to check the sanitizing properties of the high-temperature dish machine, and the maximum temperatures recorded were 124 and 125 degrees Fahrenheit, both below the required sanitizing temperature. Despite this, dietary staff continued to use the dish machine. The Dietary Manager acknowledged awareness of the issue and mentioned that a work order had been submitted the previous week. However, no explanation was provided for the continued use of the dish machine despite its failure to sanitize properly. The Maintenance Supervisor confirmed that the issue had been reported and indicated that the dish machine was rented, requiring the company to be contacted for service. A review of the work order dated August 14, 2024, noted that the dish machine was not reaching the necessary temperature. According to the 2017 FDA Food Code, the dish machine should achieve a utensil surface temperature of 160 degrees Fahrenheit to ensure proper sanitization.
Delayed Notification and X-ray Result in Resident Fall
Penalty
Summary
The facility failed to notify the responsible party and obtain x-ray results in a timely manner for a resident who experienced a fall. The incident occurred when a Certified Nursing Assistant (CNA) had to lower the resident to the floor during peri care due to the resident reaching and grabbing onto the CNA. The fall resulted in abrasions on the resident's left shoulder and torso, and an x-ray was ordered to rule out any injury. However, the responsible party was not informed about the fall until hours later, and there was a delay in obtaining and communicating the x-ray results. The resident, who was non-verbal and required total care, was not sent to the hospital immediately after the fall. The x-ray was ordered as a stat, but there was a delay in receiving the results, which were not available until two days later. The x-ray revealed a mild displaced fracture of the mid to distal left clavicle. The facility's staff, including the Director of Nursing (DON), were not notified of the fall in a timely manner, and the x-ray company did not promptly communicate the results to the facility. The facility's policies on fall management and change of condition were not followed, as the fall was not reported to the DON or the responsible party as soon as practicable. Additionally, the x-ray company's contract did not specify time frames for stat x-rays, contributing to the delay. The lack of timely communication and follow-up on the resident's condition and x-ray results led to a delay in treatment and notification of the responsible party.
Failure to Timely Facilitate Eyeglass Provision
Penalty
Summary
The facility failed to assist a resident, R2, in obtaining eyeglasses in a timely manner, resulting in impaired vision for the resident. R2 had provided the facility with a prescription for eyeglasses over a month prior to the survey, but had not received any updates or the eyeglasses themselves. During interviews, R2 expressed uncertainty about the status of their eyeglasses and was observed not wearing any. R2's responsible party confirmed that the prescription was given to the facility following an eye appointment in July 2024, but no further communication had been received. The Social Services Director admitted to sending the prescription to the facility's eyeglass provider on August 14, 2024, but acknowledged forgetting about the request, which delayed the process. The facility's policy on ancillary services requires timely coordination and follow-up by the Interdisciplinary Team to ensure residents receive necessary services. The Administrator stated an expectation for such services to be completed within one to two weeks, which was not met in this case, leading to the deficiency.
Failure to Prevent Fall and Ensure Adequate Supervision
Penalty
Summary
The facility failed to implement necessary interventions to prevent a fall from the bed for a resident, resulting in a fracture, facial trauma, skin abrasions, and bruising. The resident, who was non-verbal, total care, and required two-person assistance for care, was reportedly turned by a CNA alone during the midnight shift, leading to the fall. The CNA had to lower the resident to the floor for safety, but the incident was not documented in the progress notes by the midnight shift staff. The resident's care plan required two-person assistance for bed mobility and transfers, but the agency CNA did not follow this plan, working alone during incontinence care. The CNA reported that no one responded when they called for help, and the assigned nurse did not assess the resident after the fall. The facility's policy required that falls be reported to the DON and the responsible party, but this was not done until later. Additionally, there was a delay in receiving the x-ray report, which confirmed a clavicle fracture, and the resident was not sent to the hospital until two days after the fall. The facility's documentation and communication were inadequate, as evidenced by the lack of immediate notification to the DON and the resident's family, and the absence of vital signs documentation during the night of the fall. The care guide for the resident was also incomplete, with no indication of the required number of persons for assistance. The facility's failure to adhere to its fall management guidelines and ensure proper supervision and assistance contributed to the resident's injuries.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to ensure timely dressing changes for a Peripherally Inserted Central Catheter (PICC) line for a resident. On observation, the PICC line dressing on the resident's left upper arm was dated 8/12/24, despite the resident being readmitted to the facility and the dressing requiring a change upon admission and every seven days thereafter. The Licensed Practical Nurse (LPN) acknowledged the need for a dressing change. The Infection Control Nurse confirmed that the dressing was not changed when the resident returned from the hospital, and the Director of Nursing (DON) stated that the dressing should have been changed every seven days according to protocol. The resident had been diagnosed with osteomyelitis of the left ankle and foot, and the physician's order specified a PICC dressing change every seven days, maintaining sterile technique.
Failure to Label and Date Medications
Penalty
Summary
The facility failed to properly label and date medications when opened, as observed in two of three medication carts reviewed. On the second-floor cart, an Incruse inhaler was found without a date opened on both the box and the inhaler itself, and it lacked an identifier. Similarly, a Breo Ellipta inhaler and a Latanoprost eye dropper were not dated when opened. On the first-floor back cart, several inhalers, including Fluticasone propionate/salmeterol and Trelegy inhalers, were found without identifiers or dates indicating when they were opened. Additionally, a Trelegy inhaler on the first-floor cart two was missing a resident identifier. The Director of Nursing confirmed that the open date should be applied to the actual container when opened and that medications should be returned to their original pharmacy box to ensure proper identification. However, the facility's medication administration policy did not specify the need to label inhalers when opened, and the medication ordering and receipt policy did not address the labeling and dating of inhalers or eyedroppers. Information from Drugs.com indicated specific storage and disposal instructions for the medications involved, highlighting the importance of proper labeling and dating to ensure compliance with these guidelines.
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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.
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Nursing homes near Grosse Pointe Woods
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Health And Rehab Center North | 1.3 mi | ★★★★★ | 1 | 0 |
| The Orchards At Harper Woods | 1.6 mi | ★★★★★ | 11 | 0 |
| Optalis Health And Rehabilitation Of Grosse Pointe | 2 mi | ★★★★★ | 1 | 0 |
| Regency At St. Clair Shores | 2.7 mi | ★★★★★ | 0 | 0 |
| Shorepointe Nursing Center | 4.3 mi | ★★★★★ | 1 | 0 |
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