Riverview Healthcare: Pressure Ulcer Harm - SD
Inspectors cited Riverview Healthcare Center on East 2nd Avenue for failures that ran across nearly every step of wound care. When residents developed skin injuries after admission, staff were not consistently completing required wound evaluations, not measuring wounds weekly, not notifying physicians when wounds failed to improve after two weeks of treatment, and not alerting the director of nursing when injuries reached the severity that demands immediate attention.
The facility's own policy required nurses to document wound size, color, odor, drainage, and pain at each evaluation. It required them to notify the medical provider, update the treatment record, and loop in the resident or their representative. When a wound worsened or failed to improve, the policy called for notifying the dietitian about nutritional needs and reassessing the entire care plan, including pressure relief, blood sugar levels, and lab values. Inspectors found those steps were not being followed.
The citation was tagged at the level of actual harm, meaning inspectors determined real injury resulted, not merely the risk of it. A few residents were affected.
Wound deterioration in nursing home residents can move quickly. Pressure injuries that go unmeasured and unreported can advance from surface-level skin damage to deep tissue destruction within days. Without physician notification, treatment orders don't change. Without care plan updates, the conditions that caused the wound in the first place, pressure, poor nutrition, inadequate repositioning, continue unchallenged.
The inspection was triggered by a complaint. Riverview Healthcare Center is a skilled nursing facility serving Flandreau, a city of roughly 2,400 people in Moody County. For residents there, it is often the only local option.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverview Healthcare Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
RIVERVIEW HEALTHCARE CENTER in FLANDREAU, SD was cited for violations during a health inspection on November 18, 2025.
Inspectors cited Riverview Healthcare Center on East 2nd Avenue for failures that ran across nearly every step of wound care.
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.