Federal inspectors documented multiple infection control failures at Riverside Postacute Care during a March 21 survey that revealed systematic breakdowns in basic safety practices designed to protect the facility's 153 residents.
The most alarming incident occurred during lunch on March 17. Resident 36 sat at a dining table with an IV access on her left hand, the tubing dangling freely and making contact with her food. Inspectors noted the tubing lacked an end cap and was not properly secured.
Registered Nurse 1, who had taped the IV to Resident 36's hand, acknowledged the serious risk. "If the IV tubing was exposed like that and was touching the food, there was a high risk for infection to occur," she told inspectors. The nurse said the tubing should have been taped securely to prevent contamination.
The facility's Infection Preventionist agreed the IV tubing should have been properly secured, possibly with netting, to prevent it from touching food. The facility's own policy states that any time dressing is not intact or end caps are missing, catheters have potential for contamination.
In the laundry room, staff demonstrated they didn't understand basic temperature requirements for killing infectious microorganisms. Laundry Staff 1 told inspectors she didn't conduct temperature checks on washers and dryers, explaining that "we might burn ourselves" if they checked water temperatures. She knew wash settings but couldn't state the required temperatures for laundering linens and clothes.
The staff member explained dryer heat settings but was unable to state actual temperatures for each setting or minimum requirements. Low setting was used for pillows, medium for linens, and hot for blankets, she said, but couldn't provide the specific temperatures.
The Housekeeping and Laundry Supervisor was equally uninformed. She couldn't state minimum temperature requirements for washers and dryers and didn't conduct temperature checks because "I do not have the thermometer to check it."
The Maintenance Director revealed he checked equipment temperatures with an infrared gun but kept no log to track whether required temperature standards were met. Equipment manuals showed hot water specifications of 185 degrees Fahrenheit and dryer settings ranging from 120 to 190 degrees. Federal guidelines recommend laundry processing in hot water at 160 degrees for 25 minutes.
The Infection Preventionist said laundry staff should have known required temperatures to prevent spreading infectious microorganisms throughout the facility.
Cross-contamination occurred when the Housekeeping and Laundry Supervisor was observed restocking linen closets from an uncovered cart. A resident in a wheelchair approached the cart and picked up a clean bed liner, saying he needed it. Instead of discarding the contaminated linen, the supervisor removed it from the resident's hands and returned it to the cart with other clean linens.
She then continued restocking linen closets from the same contaminated cart.
In the laundry room, the supervisor folded clean blankets and placed them in a large gray bin designated for clean laundry. She covered the bin with a brown linen cover that had been partially on the floor.
When questioned, the supervisor admitted she shouldn't have returned the resident-touched linen to the clean cart or used the floor-contaminated cover on clean linens.
The Infection Preventionist said she expected the contaminated linen to be placed in the dirty linen bin and a clean cover used on the linen bin. "Whatever was on the floor could transfer to the residents if the contaminated linens were distributed," she explained.
Kitchen equipment failures compounded infection risks. Inspectors found condensation ice buildup on two fans in a reach-in freezer, with ice pooled on a box of cut corn on the second shelf.
The Food and Nutrition Services Director acknowledged the freezer wasn't working properly. Cook 1 said the ice buildup had been happening randomly for two weeks.
The Engineering Plant Director explained that the freezer's defrost timing had been disrupted by daylight saving time changes. He said temperature fluctuations lead to condensation and ice formation that could affect food quality, but he had received no work orders from dietary staff about the malfunction.
Pest control failures created additional contamination risks in food preparation areas. Inspectors found four brown bugs with wings and one spider on the ceiling of the dry storage room inside the kitchen. The Food and Nutrition Services Director said the kitchen should not have any pests as they could cause cross-contamination and lead to foodborne illnesses.
A house fly was observed landing on a window in front of the steam table inside the kitchen.
The facility's Registered Dietician confirmed kitchens should be pest-free to prevent cross-contamination and infection control issues.
Facility policies addressed each violation area but weren't being followed. The pest control policy stated the facility should maintain an ongoing program to ensure premises remain free of insects, rodents, and other pests that could compromise resident health and safety.
The linen distribution policy required loading clean linen onto covered carts and transporting covered carts to storage areas.
The Administrator acknowledged during interviews that the facility lacked an effective Quality Assurance and Performance Improvement program to identify and correct issues related to staffing, dietary services, and laundry services.
Despite having written policies dating back to 2011 for IV catheter infection prevention and 2017 for clean linen distribution, basic infection control practices were not being implemented to protect residents from preventable contamination risks.
The facility's own policy on fly and vermin control noted that "flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food & Nutrition Services Department."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Postacute Care from 2025-03-21 including all violations, facility responses, and corrective action plans.