Riverview Healthcare: Accident Hazard Failures - SD
The resident, identified only as Resident 7 in inspection documents, consistently rated her lower abdominal pain at six on a ten-point scale. Staff described her as someone who "always rated her pain at six" and was "tough to read" and anxious about her condition.
Everything changed on September 24.
A progress note from 3:43 that afternoon documented the dramatic shift. The resident appeared sleepy but easily awakened when nurses checked on her. When asked about her chronic lower abdominal pain, she requested more pain medication. Her pain rating had jumped to 10 out of 10 - the maximum level on the facility's pain scale.
Staff administered 5 milligrams of oxycodone through her feeding tube. They offered to arrange a clinic visit since her scheduled physician rounds had been cancelled that day. She declined, saying she would wait until the next morning when a physician would be at the facility.
Hours later, at 5:43 p.m., registered nurse Q documented a concerning development. The resident's daughter had arrived and was speaking with staff about her mother's condition. The resident's lower abdomen was "getting bigger" and she continued reporting pain at the maximum 10/10 level.
Staff administered another dose of oxycodone. Only then did they offer emergency room evaluation.
The resident agreed to go to the emergency room but refused ambulance transport. Her daughter drove her to Flandreau Hospital's emergency department instead.
The situation proved more serious than facility staff had recognized. At 11:50 p.m., nurse Q documented that Flandreau Hospital had transferred the resident to another facility. The next morning, the director of nursing spoke with staff at an oncology unit, confirming the resident had been admitted there.
Federal inspectors interviewed multiple staff members about the facility's response to the resident's escalating pain. Registered nurse Q, who cared for the resident on September 24, told inspectors she was concerned because the resident "frequently reported a pain level of six" but had never before rated her pain at ten.
"Today is the first day she has been like this," the nurse told investigators.
Another nurse, RN G, described the resident as someone who would say her pain improved after receiving Tylenol or oxycodone. This nurse also characterized the resident as "tough to read" and noted her consistent pattern of rating pain at level six.
The inspection revealed a gap in documentation that raised additional concerns. Social services designee E had created a progress note dated September 23 at 11:22 p.m., but the note contained no written content. When investigators questioned her about the blank entry, she explained she had not finished writing the note because Resident 7 had notified her of increased pain.
Inspectors reviewed the facility's pain management policy from June 2025, which stated that residents should "receive care to attain and maintain the highest quality of care and life." The policy required staff to select appropriate pain scales based on resident ability and needs, including numeric scales from 1-10.
Most significantly, the policy mandated that "if it is determined that pain is not controlled to the resident satisfaction, the medical provider is consulted, and the resident remains on alert charting."
The inspection found the facility failed to follow this protocol. Despite the resident's pain escalating from her typical level-six reports to the maximum 10/10 rating, staff did not immediately consult medical providers or implement enhanced monitoring procedures.
The resident's transfer to an oncology unit suggests the underlying cause of her worsening abdominal pain required specialized medical intervention that the nursing home was not equipped to provide.
Federal investigators classified the violation as causing "actual harm" to the resident, finding that staff failed to properly assess and respond to her deteriorating condition before it reached a crisis point requiring emergency hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverview Healthcare Center from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
RIVERVIEW HEALTHCARE CENTER in FLANDREAU, SD was cited for violations during a health inspection on September 25, 2025.
The resident, identified only as Resident 7 in inspection documents, consistently rated her lower abdominal pain at six on a ten-point scale.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.