Rivergate Health Care Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

ago they witnessed RR grab Resident R501's arm with force and snatched Resident R501 away from the table where Resident R501 was socializing with other residents. RR then took Resident R501 to another table in the dining room. According to DA B, This made me feel uncomfortable. DA B said with her experience and training, she knows what abuse looks like. DA B said this incident was immediately reported to a group of staff persons at the nurse's desk. Interviews revealed incomplete instructions and rationale were given to staff regarding RR's visitation with Resident R501. 1. On 10/8/25 at 11:43 AM, LPN G who was currently assigned to Resident R501, was asked about supervised intervention. LPN G stated, I was not aware of supervised visitation for (Resident R501).2. On 10/8/25 at 11:50 AM, Certified Nursing Assistant (CNA) H who was currently assigned to Resident R501, was asked about supervised visitation. In response, CNA H stated, I was not aware of any incident.3. On 10/8/25 at 11:55 AM, Registered Nurse (RN) D was interviewed and stated, The (RR) was flustered with (Resident R501), so the (NHA) suggested that the (RR) meet with (Resident R501) in the dining room. RN D was unable to state the purpose of the change. 4. On 10/8/25 at 12:00 PM, CNA's M, N and O were interviewed and reported they did not witness an incident but were told that the RR and Resident R501 were to sit in the dining room during meals. CNA's M, N, and O were unable to state the purpose of the change. A record review of the electronic medical

record revealed Resident R501 was admitted to the facility on [DATE REDACTED] with a diagnosis of Atrial Fibrillation, Alzheimer's with late onset, Hypertension, Obstructive Pulmonary Disease, Anemia, Dementia and Adjustment Disorder. Further review of the clinical record revealed a Brief Interview for Mental Status (BIMS) score of 0/15 denoting a severe cognitive impairment. A review of Resident R501's care plans documented:resident plans to discharge home- dated 9/15/25-resident has impaired cognitive ability related to dementia- dated 9/15/25-resident is alert with confusion- dated 9/19/25-resident requires set-up assistance for meals- dated 9/12/25-resident has a potential for a nutritional problem - intervention included: provide verbal encouragement/assistance with meals as needed to ensure adequate intake- dated 9/25/25A review of Resident R501's care plans documented the following intervention initiated on 9/28/25- Provide meals to RR when

in the facility during mealtime so that RR can eat meals with Resident R501 in the dining room to help promote visual cuing to increase oral intake. Staff to provide assistance when indicated. However, the facility failed to provide care plan interventions for Resident R501 related to the prevention of further physical harm. On 10/8/25 at approximately 1:30 PM, the NHA was requested to provide a complete investigation regarding the alleged abuse of Resident R501. On 10/8/25 at 3:30 PM, the NHA was queried about the incident between the RR and Resident R501. The NHA reported not doing an investigation or reporting this incident due to It not being abuse. The NHA acknowledged being out of the office when they received a telephone call from staff regarding the RR grabbing Resident R501's jaw in an attempt to make Resident R501 eat. When asked, why would they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. According to the NHA, after receiving the telephone call from the nurse regarding RR grabbing the jaw of Resident R501, the NHA spoke directly to the RR by telephone and educated the RR about dementia. The NHA admitted telling LPN C, (RR) is not trying to hurt (Resident R501). Even though there was not a skin assessment completed on Resident R501, the NHA indicated that it was not abuse.A review of the document titled, Abuse-Inservice Training, dated 5/6/25, revealed the following:- The facility must develop and implement written policies and procedures that prohibit and prevent abuse. -Procedures include staff orientation and training to identify and prevent behaviors constituting abuse.No further documentation related to abuse identification was provided by the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivergate Health Care Center

14041 Pennsylvania Rd Riverview, MI 48193

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

3:30 PM, the NHA was queried about the incident between the RR and Resident R501. The NHA reported not doing

an investigation or reporting this incident due to It not being abuse! The NHA acknowledged that she was out of the office when she received a telephone call from staff regarding the RR grabbing Resident R501's jaw in an attempt to make Resident R501 eat. When asked, why would they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. The NHA admitted telling LPN C, (RR) is not trying to hurt (Resident R501).No further documentation related to abuse identification was provided by the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivergate Health Care Center

14041 Pennsylvania Rd Riverview, MI 48193

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

regarding the alleged abuse of Resident R501. On 10/8/25 at 3:30 PM, the NHA was queried about the incident between the RR and Resident R501. The NHA reported not doing an investigation or reporting this incident due to It not being abuse! The NHA acknowledged that she was out of the office when she received a telephone call from staff regarding the RR grabbing Resident R501's jaw in an attempt to make Resident R501 eat. When asked, why would

they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. The NHA admitted telling LPN C, (RR) is not trying to hurt (Resident R501). The NHA indicated that it was not abuse.A

review of Form Centers for Medicare & Medicaid Services (CMS) 20059 Abuse Critical Element Pathway dated 10/2022 revealed the following: 6) For alleged violations of abuse, did the facility:-Report the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency)?No further documentation related to abuse identification was provided by the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Rivergate Health Care Center

14041 Pennsylvania Rd Riverview, MI 48193

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R501. The NHA reported not doing an investigation or reporting this incident due to It not being abuse! The NHA acknowledged that she was out of the office when she received a telephone call from staff regarding

the RR grabbing Resident R501's jaw in an attempt to make Resident R501 eat. When asked, why would they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. The NHA admitted telling LPN C, (RR) is not trying to hurt (Resident R501).A review of Form Centers for Medicare & Medicaid Services (CMS) 20059 Abuse Critical Element Pathway dated 10/2022 revealed the following: 6) For alleged violations of abuse, did the facility:-Report the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency)?- Develop policies and procedures related to ensuring the reporting of suspected crimes, within mandated timeframes (i.e., immediately but not later than two hours if the suspected crime resulted in serious bodily injury, within 24 hours for all other cases) and notifying covered individuals annually of their reporting obligations. No further documentation related to abuse identification was provided by the facility.

Event ID:

Facility ID:

If continuation sheet