Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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'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 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 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.
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 634 citations issued within 25 miles in the last 12 months — including the 3 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 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 | — | 1 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Rivers Health & Rehabilitation Center Of Gross.
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 August 2026) and official state health department websites.