FLANDREAU, SD - Federal inspectors documented significant failures in pressure ulcer prevention, pain management, and food safety practices at Riverview Healthcare Center during a February 27, 2025 inspection that resulted in multiple citations for violations affecting resident health and safety.
Multiple Residents Develop Preventable Pressure Ulcers
The inspection revealed that three residents developed facility-acquired pressure ulcers due to inadequate positioning and pressure relief measures. Inspectors observed residents lying in the same positions for hours without proper repositioning, despite being completely dependent on staff for movement and care.
One resident was observed lying in the same position from 10:08 a.m. through 2:20 p.m. with his left ankle pressing against the edge of the mattress and his foot flat against the footboard. Despite having heel lift devices available, they were not properly positioned to relieve pressure. This resident had already developed stage two pressure ulcers on both heels and an abrasion on his tailbone.
Medical Significance: Pressure ulcers develop when sustained pressure restricts blood flow to tissue, causing cell death and skin breakdown. Stage two ulcers involve partial thickness skin loss and can progress to deeper, more serious wounds without proper intervention. The standard of care requires repositioning immobile residents at least every two hours to redistribute pressure and maintain tissue viability.
Another resident, who was receiving hospice care, developed multiple pressure ulcers on her coccyx and buttocks. Staff failed to provide adequate repositioning despite her complete dependence on assistance. A certified nursing assistant acknowledged that residents had gone longer than two hours without repositioning, stating his partner had left early, leaving him alone to care for multiple dependent residents.
The facility's Director of Nursing acknowledged that "all facility acquired pressure ulcers were preventable" and expressed concerns that staff were not implementing proper pressure ulcer prevention measures or completing required skin assessments.
Inadequate Pain Management for Dying Resident
A hospice resident experiencing severe pain during routine care received inadequate pain relief despite having available medication orders. Inspectors observed the resident grimacing and moaning in pain during repositioning, with staff reporting he would "shout help, help" when moved.
Despite having a physician's order for oxycodone every hour as needed for pain, nursing staff documented the resident's pain as "0 out of 10" on multiple occasions, indicating no pain, and administered no pain medication on the day of observation. This contradicted direct observations of the resident's obvious distress during movement.
Clinical Context: Proper pain assessment is fundamental to quality care, particularly for hospice residents who may be unable to verbally communicate their discomfort due to cognitive impairment. Pain scales must accurately reflect observed behaviors, not assumptions. Untreated pain can worsen the dying process and prevent comfort care goals from being achieved.
The facility's pain management policy required evaluation every shift for signs and symptoms of pain, yet documentation consistently showed zero pain scores despite visible evidence of distress. A hospice nurse later requested medication changes to provide better pain control, recognizing the inadequacy of current management.
Widespread Food Safety Violations Throughout Facility
Inspectors documented extensive food safety hazards across multiple areas of the facility's food service operations. The kitchen's dishwasher showed significant sanitation problems, including thick limescale buildup, food scum accumulation, and standing water pooling underneath the equipment.
The walk-in cooler contained what appeared to be black and white fuzzy mold growth on walls, door frames, floors, and shelving units. Food storage violations included expired items, rotting vegetables, and improper placement of raw meat above dairy products - a cross-contamination risk that could cause foodborne illness.
Public Health Implications: Mold contamination in food storage areas poses serious health risks, particularly for elderly residents with compromised immune systems. Cross-contamination between raw meat and ready-to-eat foods can transmit dangerous pathogens like Salmonella and E. coli. Proper food safety protocols are essential in congregate care settings where residents may be more vulnerable to foodborne infections.
During meal service observation, dietary staff failed to follow basic hygiene practices, not using gloves or proper handwashing techniques when handling resident food. This directly violates food safety standards designed to prevent disease transmission.
Systemic Failures in Care Standards
The violations indicate broader systemic issues with staff training, supervision, and adherence to established care protocols. The Director of Nursing acknowledged that staff were not receiving appropriate training and sometimes did not follow provided guidance regarding resident care.
Care plans for affected residents included specific interventions such as frequent repositioning, pressure-reducing equipment, and regular skin assessments, yet inspectors observed these measures were not being implemented consistently. This suggests a gap between documented care requirements and actual practice.
Industry Standards: Federal regulations require nursing homes to provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This includes preventing avoidable decline and ensuring residents receive appropriate treatment and care.
The facility's skin integrity policy outlined proper procedures for wound prevention and assessment, including weekly skin evaluations and immediate notification protocols when problems arise. However, staff failed to follow these established procedures, resulting in preventable harm to vulnerable residents.
Additional Issues Identified
Beyond the major violations, inspectors noted several other concerning practices:
- Inadequate temperature monitoring of resident food refrigerators - Unsealed food containers open to contamination in storage areas - Measuring scoops stored directly in food thickener products - Expired food items including mustard and parmesan cheese past safety dates - Unlabeled bulk food ingredients without preparation dates - Missing flooring in dish room exposing subfloor - Peeling paint and poor ventilation in food preparation areas
The comprehensive nature of these findings suggests the need for significant operational improvements across multiple departments to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverview Healthcare Center from 2025-02-27 including all violations, facility responses, and corrective action plans.
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