MARQUETTE, KS - State inspectors found significant compliance failures at Riverview Estates nursing facility during a March 2025 inspection, including improper background check procedures for staff, inadequate catheter care resulting in resident injuries, and infection control breaches that put vulnerable residents at risk.
Background Check Failures Put Residents at Risk
Inspectors discovered that Riverview Estates allowed four employees to work directly with residents before completing required criminal background checks, potentially exposing all 23 residents to individuals with unknown criminal histories. The violations affected staff across multiple departments, including certified nursing aides, housekeeping, and maintenance personnel.
Two certified nursing aides began working in January and July 2022 respectively, but their background checks weren't verified until February 2024 - delays of up to 19 months. A housekeeping staff member worked for over three years before verification, starting in November 2021 with the background check not confirmed until December 2024. Most concerning was a maintenance worker who began duties on February 20, 2024, with verification occurring just two days later on February 22, 2024.
During the inspection, Administrative Staff A confirmed that the facility had not received background check results for the four staff members prior to allowing them to work with residents. This practice directly violates federal regulations designed to protect nursing home residents from potential abuse, neglect, or exploitation.
Background checks serve as a critical safeguard in nursing homes, where residents are often vulnerable due to cognitive impairments, physical disabilities, or medical conditions that limit their ability to report abuse or protect themselves. The screening process is designed to identify individuals who may have been convicted of crimes that would make them unsuitable for working with elderly or disabled populations.
The facility's own policy, dated September 6, 2021, specifically stated that human resource personnel should routinely check state websites for background check results and track the dates of checks, results, and when results were recorded. The systematic failure to follow this protocol across multiple hires suggests inadequate oversight of hiring procedures.
Medical Device Care Results in Resident Injury
A particularly concerning violation involved the improper care of a resident requiring a urinary catheter, which resulted in the development of two open sores on the resident's penis. The case demonstrates how seemingly minor lapses in medical device management can lead to significant resident harm.
Resident 11, who had intact cognitive abilities according to assessments, required a urinary catheter due to his medical condition. The facility's care plan specifically directed staff to "use a catheter strap as needed and ensure enough slack was left in the catheter tubing between the meatus and the strap" to prevent complications. Additionally, the facility's urinary catheter care policy required staff to secure catheters with securement devices to reduce friction and movement.
However, during the inspection, nursing staff discovered that the catheter tubing had been rubbing against the resident's skin, causing two sores approximately 0.5 centimeters in diameter. Progress notes from March 12, 2025, documented that during a routine catheter change, staff found the sores where "the catheter rubbed against the sores." The facility immediately notified both the physician and the resident's family about the issue.
When inspectors observed the resident's care on March 19, they found that Licensed Nurse H was providing wound care to treat the catheter-related injuries, but the resident still had no catheter securing device in place. The nurse explained that the resident didn't keep the device on due to adhesive issues and believed he had signed a risk agreement to forgo the securing device. However, Administrative Nurse D confirmed that no such risk agreement existed and that a secure device should have been in place.
Proper catheter management is essential for preventing complications including urinary tract infections, tissue damage, and discomfort. Catheter securement devices are standard medical equipment designed to prevent the tubing from pulling or moving excessively, which can cause trauma to delicate tissues. The absence of this basic safety measure directly contributed to the resident's injuries and required additional medical treatment that could have been prevented.
Infection Control Breaches During Influenza Outbreak
The facility failed to properly implement infection control protocols for a resident with Influenza A, potentially exposing other residents and staff to the highly contagious virus. This violation highlights the critical importance of proper personal protective equipment use in preventing disease transmission in nursing homes.
Resident 13 was placed on enhanced barrier precautions due to an Influenza A diagnosis, with clear signage posted on the room door instructing all staff and visitors to wear appropriate personal protective equipment. However, inspectors observed a licensed nurse entering the resident's room wearing only gloves, despite the posted requirements for gowns, gloves, and masks.
The nurse spent approximately eight minutes in close contact with the infected resident before another staff member reminded her of the proper precautions. Only then did the nurse don a gown before continuing her interaction with the resident. This extended period of improper protection created unnecessary risk for virus transmission.
Influenza A is highly contagious and can cause severe complications in elderly nursing home residents, including pneumonia, hospitalization, and death. The virus spreads through respiratory droplets when infected individuals cough, sneeze, or talk. In nursing home settings, where residents often have compromised immune systems and underlying health conditions, proper infection control measures are essential for preventing outbreaks that can affect entire facilities.
The facility's own enhanced barrier precautions policy clearly outlined when to use protective equipment, including gloves, gowns, and masks during high-contact resident care activities. The policy specifically addressed situations involving residents with infectious diseases and the importance of changing personal protective equipment between residents to prevent cross-contamination.
Coordination Failures in End-of-Life Care
Inspectors found that the facility failed to properly coordinate hospice services for a resident receiving end-of-life care, potentially compromising the quality of palliative care during a critical time. Resident 13, who had severe cognitive impairment due to dementia and required extensive assistance with daily activities, was enrolled in hospice care on March 4, 2025.
While the facility had a hospice care plan in the resident's electronic health record, the facility's own care plan lacked essential coordination information. The plan failed to specify which services hospice provided, the frequency of support visits, what supplies and equipment hospice covered, medications included in hospice care, or hospice contact information for facility staff.
Administrative Nurse D confirmed that the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. This coordination gap creates risks for duplicated services, conflicting treatments, or gaps in care when responsibilities between the facility and hospice provider are unclear.
Effective hospice care requires seamless coordination between the nursing facility and hospice team to ensure residents receive appropriate pain management, emotional support, and dignity during their final days. The facility's own policy emphasized the importance of coordinated care plans that reflect residents' goals and wishes, including palliative objectives and interventions.
Food Safety and Vaccination Program Deficiencies
Additional Issues Identified
Beyond the major violations, inspectors documented several other compliance failures that affected resident safety and care quality:
Food Storage Violations: Kitchen staff failed to properly label opened food items in freezers with dates and expiration information. Seven opened bags of frozen vegetables and an opened box of hamburger patties were found without proper dating, creating risks for foodborne illness. Dietary staff acknowledged that the markers used for frozen foods were inappropriate as the ink rubbed off, making dates unreadable.
Vaccination Program Gaps: The facility lacked a systematic approach for offering pneumococcal PCV20 vaccines to residents according to current CDC guidelines. Seven residents had no documentation showing they were offered the vaccine or had declined it. Administrative nursing staff confirmed the facility had no definitive system to determine which residents were eligible for specific pneumococcal vaccinations.
These violations collectively demonstrate systemic weaknesses in Riverview Estates' compliance with federal nursing home regulations. The facility's 23 residents were placed at various levels of risk due to inadequate background screening, medical device management failures, infection control breaches, care coordination gaps, and food safety issues. Following the inspection, the facility was required to implement immediate corrective actions to address the most serious violations and prevent further resident harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverview Estates from 2025-03-20 including all violations, facility responses, and corrective action plans.
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