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: 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: August 4, 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.