The February inspection at Riverview Healthcare Center revealed systematic breakdowns in food safety and infection control that put residents at risk. Federal inspectors documented expired food throughout the facility, contaminated wound care practices, and equipment failures that created conditions for mold growth.
During the lunch observation, inspectors watched the unidentified staff person push a cart of drinks, grab coffee mugs and plastic cups, retrieve items from the refrigerator, and scoop blueberry dessert into cups by the rim. With those same gloves, he opened cupboards, unwrapped single-serve ice cream, and placed plastic wrap on meal trays.
Dietary manager L removed his gloves after preparing a resident's plate but served the food without washing his hands. In another instance, he put on one glove, served food to a resident, then removed the glove without hand hygiene.
The facility's emergency food supply sat covered in dust, dirt, and cobwebs. Most items had been delivered months earlier and were past their expiration dates. Temperature monitoring sheets for refrigerators showed multiple unrecorded readings across several days.
In the activity room kitchenette, inspectors found containers of what appeared to be chocolate pudding scooped into serving cups with no labels or dates. Cases of sugar-free pudding were expired. The hot-holding steam table contained rust, food crumbs, and dead flies in its basins. A damp rag with a foul odor sat balled up in the sink with no detergent or sanitizer buckets available.
Cook Q told inspectors that cleaning checklists existed for each position and shift but weren't used often. She didn't know where completed checklists were supposed to be turned in.
The walk-in cooler revealed more serious problems. A box of ground beef and four gallons of milk sat directly on the floor. Sheet pans of breadsticks had no covering, labels, or dates. When inspectors shut the cooler door, light from the hallway remained clearly visible above the top, indicating the door didn't seal properly. The gap was large enough to poke several fingers through.
Black and white fuzzy growth that appeared to be mold covered the walls, door frame, floor, and shelving units throughout the walk-in cooler. In the freezer, ice buildup on the ceiling and floor indicated improper temperature control. A side panel of the condenser unit hung loose and unsecured, blowing hot air that melted the ice buildup.
Dietary manager L acknowledged awareness of the cooler and freezer problems during the inspection but was unavailable for follow-up interviews.
Expired items appeared throughout the facility. Chocolate pudding cups from months earlier sat in an unnamed refrigerator alongside decaffeinated coffee concentrate and mustard bottles past their expiration dates. A jar of peanut butter above the steam table had expired, and a dust-covered fan sat in the cupboard above the serving line.
Food thickener containers lacked proper labeling and usage directions. Scoops sat directly in the thickener powder, violating the facility's own policy requiring scoops not be stored in direct contact with food. The space beneath the steam table was rusted with food crumbs and scrambled eggs scattered throughout.
Infection control violations extended beyond the kitchen. Registered nurse B provided wound care to multiple residents while repeatedly failing to follow basic hygiene protocols.
During resident 109's treatment, she changed gloves three times without washing her hands between changes. She applied new dressings without cleaning the wounds first. The resident had no signage indicating enhanced barrier precautions were needed, despite having multiple wounds.
With resident 42, nurse B placed wound care supplies directly on bed sheets without barriers. She changed gloves four times without hand hygiene, contaminating sterile supplies by setting them on unclean surfaces. She was unaware that areas underneath the resident's scrotum had opened wounds.
Resident 28 was on enhanced barrier precautions requiring staff to wear gloves, gown, and mask. Nurse B forgot to put on her mask initially and had to leave the room to retrieve one without removing her contaminated gloves. She opened doors and handled the mask with the same gloves she later used for wound care.
During resident 24's treatment, nurse B laid multiple wound care supplies on bed covers without barriers. She changed gloves three times without hand hygiene and placed unused gauze pieces back into the bulk package with clean supplies after the procedure.
Nurse B told inspectors she had no wound care training and couldn't recall completing wound care competencies. She initially didn't consider her practices wrong but later agreed they could create infection risks and interfere with wound healing.
Certified nursing assistants U and V violated infection protocols while caring for resident 12, who required enhanced barrier precautions. CNA U contaminated clean towels by placing them on handrails, opened the resident's closet with contaminated gloves, and used the same towels to clean multiple body areas including the catheter tubing.
Equipment throughout the facility showed signs of neglect. In the whirlpool tub room, rubber bumpers were corroded and crumbling. Buildup of unidentified brown and yellow substances appeared where the door sealed with the tub. A drawer contained soiled hair picks, nail clippers, and fingernail brushes mixed together.
The therapy gym had dust, dirt, and white flakes in exercise machine footwells. Resistance bands tied to equipment were of unknown cleanliness. Some dumbbells showed rust, creating uncleanable surfaces.
Director of nursing A, who served as the infection preventionist, confirmed she hadn't completed competencies on wound care, perineal care, or catheter care. She hadn't observed nurses performing wound care to assess their practices. Her last staff education on enhanced barrier precautions occurred in September 2024.
The facility's quality assurance program identified ongoing issues with infection control, wound care, and enhanced barrier precautions that needed improvement. Medical director H felt the facility's quality improvement efforts had only recently become a priority.
Executive director I, new to his position the previous week, was unaware of the dietary department concerns but agreed the issues needed addressing.
The inspection revealed a facility where basic infection control and food safety protocols had broken down across multiple departments, creating risks for residents who depend on staff to maintain safe conditions for their care and recovery.
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.