Riverview Healthcare: Resident Abuse Violation - SD
The woman had been rating her chronic lower abdominal pain at six on a 10-point scale for weeks. But on September 23, something changed dramatically.
That evening, the resident told social services designee E about increased pain. The staff member started a progress note at 11:22 p.m. but never finished writing it. The note sat empty in the resident's file.
By the next afternoon, the resident's condition had deteriorated sharply. Her daughter arrived to find her mother's lower abdomen visibly swollen and the pain escalating to 10 out of 10.
Registered nurse Q documented the crisis at 5:43 p.m. on September 24: "Resident concern. Lower abdomen is getting bigger having a lot of pain rated 10/10."
The nurse offered to send the woman to the emergency room. She agreed but refused ambulance transport. Her daughter drove her to Flandreau Hospital instead.
Emergency room doctors took one look and knew the resident needed immediate specialized care. At 11:50 p.m., nurse Q noted that the hospital had transferred the woman to another facility for treatment.
The next morning, director of nursing B confirmed the resident had been admitted to an oncology unit.
Federal inspectors found that Riverview Healthcare Center had failed to properly manage the resident's pain despite having detailed policies requiring staff to monitor and respond to uncontrolled pain.
Nurse Q told inspectors she had been concerned about the resident's condition because the woman "frequently reported a pain level of six" but had jumped to rating her pain at 10. "Today is the first day she has been like this," the nurse said.
Another nurse, RN G, described the resident as "tough to read" and "anxious," always rating her pain at six. After receiving Tylenol or oxycodone, "she would say that her pain was better," the nurse said.
But the facility's own pain management policy, updated in June 2025, required staff to take specific action when residents reported uncontrolled pain. The policy stated that if pain "is not controlled to the resident satisfaction, the medical provider is consulted, and the resident remains on alert charting."
The inspection report shows no evidence that staff followed these protocols during the critical period when the resident's pain spiked from her usual six to 10 out of 10.
Instead, nurses administered 5 milligrams of oxycodone through the resident's feeding tube and asked if she wanted to visit the clinic. When she said she would wait until the next morning to see a physician, staff took no further action.
The resident spent at least 18 hours in severe pain before her daughter's arrival prompted the emergency room visit.
The facility's policy required staff to use "an appropriate pain scale based upon resident ability and needs" and ensure residents "receive care to attain and maintain the highest quality of care and life." Examples included numeric scales, verbal descriptor scales, and specialized tools for residents with dementia.
Yet when this resident's pain pattern changed dramatically, jumping from her baseline six to maximum 10, staff failed to recognize the significance or follow their own protocols for uncontrolled pain.
The empty progress note from September 23 symbolized the gap in care. Social services designee E had started to document the resident's increased pain but never completed the entry, leaving no record of when the crisis began.
By the time the resident reached the emergency room with her visibly swollen abdomen and maximum pain rating, local doctors immediately recognized she needed specialized care beyond what they could provide.
The woman ended up in an oncology unit, suggesting the delayed response may have had serious medical consequences that could have been avoided with earlier intervention.
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 abuse-related violations during a health inspection on September 25, 2025.
The woman had been rating her chronic lower abdominal pain at six on a 10-point scale for weeks.
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.