Riverview Healthcare Center

F-F600 finding 20, 21, 22, and 23 for the provider's policies on Abuse prohibition and investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 435086 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435086 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Healthcare Center 611 East 2nd Ave Flandreau, SD 57028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or 46453 potential for actual harm Based on South Dakota Department of Health (SD DOH) complaint intake review, interview, document Residents Affected - Some review, and policy review, the provider failed to ensure the facility was operated and administered by executive director (ED) A and director of nursing (DON) B in a manner that ensured the safety and overall well-being of all 62 residents in the facility. Those areas included:

*Maintaining an effective abuse and neglect prohibition program that included following policies and procedures related to mandatory reporting and investigations of all allegations of abuse, relating to allegations of physical, verbal, and mental abuse by certified nursing assistant (CNA) J toward 2 of 7 sampled residents (7 and 9).

*Maintaining 3 of 62 residents' (1, 3, and 6) right to personal privacy due to anonymous staff member M using their cellphone to secretly record private resident conversations.

Findings include:

1. Record reviews, interviews, and policy reviews throughout the course of the survey, conducted from 1/6/25 through 1/8/25, revealed that ED A and DON B had not ensured the safe management and overall well-being of residents who lived in the facility. This was evidenced by a system breakdown to ensure they had implemented:

*An effective abuse prohibition program that included monitoring, reporting, investigating, and preventing alleged staff-to-resident abuse.

*An effective system to uphold resident rights, including the right to privacy.

Interview on 1/6/25 at 5:28 p.m. with DON B revealed that she initially denied any knowledge of recent allegations of staff-to-resident abuse.

Interview on 1/6/25 with anonymous staff member M revealed that they had secretly recorded resident conversations to have proof and show management that the residents had concerns regarding their care. Anonymous staff member M confirmed that they shared a recording with ED A.

Interview on 1/6/25 at 6:30 p.m. with ED A revealed that he initially denied any knowledge of recent allegations of staff-to-resident abuse.

Continued interview on 1/6/25 at 6:35 p.m. with ED A and DON B revealed they confirmed they had been aware of the allegations of staff-to-resident abuse by CNA J towards residents 7 and 9. Neither ED A nor DON B reported the allegations of abuse to the required entities. Their investigation was not thorough in that other staff were not initially interviewed to understand the whole story, the residents affected were allegedly assessed for physical injury but there was no documentation to support this, and 3 of 62 total residents were interviewed about any concerns for abuse. Nothing about the investigation was documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 435086 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435086 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Healthcare Center 611 East 2nd Ave Flandreau, SD 57028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Interview on 1/6/25 at 7:04 p.m. with DON B revealed that registered nurse (RN) F reported concerns about CNA J being rough with residents on 1/1/25 at around 1:30 p.m. DON B did not investigate the allegations Level of Harm - Minimal harm or further until the next day, and allowed CNA J to work an overnight shift from 1/1/25 to the morning of 1/2/25, potential for actual harm which potentially put all residents at risk for further abuse by CNA J. She was not aware of the provider's abuse and neglect policy on suspending staff pending investigation. Residents Affected - Some

Interview on 1/7/25 at 2:21 p.m. with divisional director of clinical operations (DDCO) C revealed that ED A was placed on suspension related to his failure to follow the provider's policy regarding abuse and neglect prevention, prohibition, reporting, and investigating. She confirmed that ED A was supposed to have been acting as the abuse coordinator. She confirmed that all allegations of abuse should have been taken seriously, reported to the required entities within the required timeframe, and investigated thoroughly. It was also discovered that ED A was aware of the secret recordings referenced above, as anonymous staff member M had emailed one of the recordings to ED A.

Interview on 1/8/25 with anonymous staff member N revealed that they reported their concerns for CNA J's abusive behaviors toward residents 7 and 9 to ED A on 12/30/24. ED A did not report or investigate those allegations.

Review of the provider's March 2012 Director of Nursing Services (DNS) job description revealed:

*Job summary: Is directly accountable to the Executive Director (ED) for the day-to-day operations, activities, and success of the resident care staff, as governed by the Center policies, and state and federal regulations. Validates that the nursing department continues to develop and maintain high standards of excellence by being knowledgeable of industry changes and trends, and by implementing up-to-date nursing practices.

*Essential Functions

-1. Develops and maintains a nursing service philosophy, objectives, standards of practice, policy and process manuals.

- .6. Demonstrates an understanding and knowledge of certification laws and requirements, survey requirements, and Medicare program.

- .8. Validates that reporting departments consistently meet state and federal requirements for long-term care facilities for licensure.

- .10. Maintains open communication with ED regarding resident care activities, personnel or staffing problems, and other related topics.

Review of the provider's November 2019 Executive Director job description revealed:

*Job summary: The Executive Director (ED) is directly accountable .to provide strong overall leadership and management of a long-term care center. Manages delivery of the highest level of health services and quality of care that is responsive to customers' needs.

*Essential Functions

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 435086 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435086 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Healthcare Center 611 East 2nd Ave Flandreau, SD 57028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 - .2. Quality Management

Level of Harm - Minimal harm or --a. Lead the process to develop and implement programs to maintain quality of care to meet established potential for actual harm goals.

Residents Affected - Some --b. Responsible to maintain a safe, healthy, clean, and well-organized building that reflects a high standard of care and service.

-- .d. Verify the Center meets state and federal requirements for long-term care Centers for licensure.

-3. Human Resource Management

-- .e. Ultimately accountable for the adequate staffing of the Center.

--f. Hire and manage within Federal and State laws, and Center policies and processes.

--g. Facilitate communications from administrative level to staff and vice versa to promote optimum performance and understanding of goals.

-- .j. Implement a management style that embodies the company's core mission, values, and culture, and holds department managers to the same standards.

-4. Compliance Management

-- .b. Grievance Official: Responsible for overseeing the grievance process. Responsibilities include: receiving and tracking grievances through to their conclusion, leading any necessary investigations, and complying with federal and state regulations and company policies as they apply to the grievance process.

-c. Abuse Coordinator: Oversee the implementation of policies and procedures necessary to prohibit and prevent abuse and neglect, including but not limited to: screening, training, prevention, identification, protection, and reporting/response. Coordinate abuse and neglect investigations.

--d. Compliance Liaison: Oversee the facility Compliance and Ethics Program. Coordinate employee, contractor, and volunteer compliance training to include the Code of Conduct, HIPAA [Health Insurance Portability and Accountability Act] policy, and other mandatory compliance policies.

*Knowledge, Skills, and Abilities

-1. Familiarity with State Nursing Center rules and regulations, and applicable Federal and State laws.

Refer to

F-F609 was determined to have been removed on 1/7/25 at 4:30 p.m. after onsite review.

After removal of the immediacy, the severity and scope was a level G.

The census was 62.

2. Review of the SD DOH complaint intake form dated 12/31/24 revealed:

*The SD DOH received an email on 12/27/24 detailing allegations of abuse by CNA J. They wanted to remain anonymous.

*The complainant claimed to have reported their concerns to management previously. They did not include any dates about when the concerns were reported.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 34 435086 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435086 B. Wing 01/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Healthcare Center 611 East 2nd Ave Flandreau, SD 57028

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 -I reported [CNA J's] rudeness and 'roughness' prior, she would get talked [to] and [had her work] hours cut but within a week [she's] back to being rude and rough with the residents. Level of Harm - Immediate jeopardy to resident health or *See

F-F610.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 435086