Riverview Healthcare Center
Inspection Findings
F-Tag F686
F-F686, findings 14 through 27 regarding resident 12.
3. Observations and interviews throughout the survey revealed that resident 49 was experiencing consistent pain with repositioning. There were several instances where he was heard moaning and shouting out in pain.
He was seen grimacing in pain.
Record review revealed that he had orders for as needed pain management, but that had not been administered due to pain assessment documentation showing as a 0 out of 10 on three separate occasions
on 2/25/25.
Interviews with hospice staff revealed that they had concerns about previous residents and their pain, which was to be managed by the provider. By not recognizing that the resident was experiencing increased pain and not administering the prescribed pain medication, resident 49 experienced pain with personal cares and repositioning.
Refer to
F-Tag F697
F-F697.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50916
Residents Affected - Few Based on observation, interview, record review, policy review, and job description review, the provider failed to develop and implement pressure relieving measures to ensure facility acquired pressure ulcers had not developed for three of five sampled residents (10, 12, and 49) who were identified at high risk for skin breakdown and dependent upon the staff assistance with their activities of daily living (ADL).
Findings include:
1. Observation on 2/25/25 at 10:08 a.m. of resident 10 revealed:
*He was in his room and lying on the bed with a nursing home gown on.
*He was laying mostly on his back with a pillow placed underneath of his right arm.
-His body was positioned and was facing towards the wall with the upper portion of his body towards the left of the bed.
-From his waist down his body was laying on the right side of the bed.
-His buttocks and thighs laid directly on the mattress.
*There was a heel lift device underneath the lower part of his legs to help decrease pressure from the mattress on his heels.
-He had been positioned low in the bed and his left foot was flat up against the footboard.
*His left ankle was laying directly on the edge of the mattress and his right heel was laying directly on the mattress.
-There was no pressure relief for his left ankle from the edge of the mattress or his foot from the footboard.
*He had been awake and watching television.
2. Random observations on 2/25/25 from 11:10 a.m. through 2:20 p.m. and interview with resident 10 revealed:
*He had been lying in the same position as observed above.
*He was either sleeping or watching television during those observations.
*He had a towel placed underneath his chin that had a brown stain on it from some type of liquid.
*He was not observed getting out of bed for breakfast or lunch.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 *When asked if he was getting out of bed today, he asked what day it was and then stated, Yes.
Level of Harm - Actual harm 3. Interview on 2/26/25 at 7:27 a.m. with registered nurse (RN) B revealed:
Residents Affected - Few *Resident 10 had a stage two pressure ulcer (wound with partial thickness skin tissue loss from prolonged pressure) on each heel.
*She had already completed his pressure ulcer wound care that day.
4. Observation on 2/26/25 at 8:00 a.m. of resident 10 revealed:
*He had been lying in bed with his body propped onto his left side by a pillow.
*His feet, ankles, and heels were in the same position as observed the day before (2/25/25).
5. Interview on 2/26/25 at 8:05 a.m. with certified nursing assistants (CNAs) V and W regarding resident 10 revealed:
*He did not like to get out of bed and often refused.
*He could reposition himself but they would have to verbally cue him to turn over.
*The surveyor had requested to watch them provide personal cares for him.
*CNA V stated: Not sure when today but will at some point.
6. Random observations on 2/26/25 from 8:45 a.m. through 12:10 p.m. of resident 10 revealed he had been
in the same position as observed above for the entire morning. At 12:10 p.m. CNA W came and got the surveyor to observe them providing his personal care.
7. Observation on 2/26/25 at 2:49 p.m. of resident 10 revealed he was in his wheelchair at bingo.
8. Observation and interview on 2/27/25 at 7:18 a.m. with RN B while she provided wound care treatment to resident 10 revealed:
*He had given the surveyor permission to observe his wound care.
*He had a stage two pressure ulcer on his right and left heels.
*He had an abrasion on his coccyx (tail bone).
*RN B stated the wounds were facility acquired.
*Staff were to complete wound assessments once a week.
*Skin assessments were to be completed weekly on the residents' bath days, and they label a yes or no if there was a new skin condition or not.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 *If there was a new skin condition, then staff would complete a weekly skin evaluation form.
Level of Harm - Actual harm 9. Interview on 2/27/25 at 12:27 p.m. with director of nursing (DON) A revealed:
Residents Affected - Few *She thought all facility acquired pressure ulcers were preventable including resident 10's.
*She did not think the staff were providing the residents' pressure ulcer prevention measures or completing skin assessments on residents who had risks of acquiring pressure ulcers.
*She wanted to start plan of care (POC) charting task that would include including repositioning residents every two hours and toileting.
*She planned to start staff competencies including what to look for during skin assessments and how to document them.
10. Review of resident 10's electronic medical record (EMR) revealed:
*An admitted [DATE REDACTED].
*He had a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated he was cognitively intact.
*His diagnoses included venous insufficiency, hypertension, chronic kidney disease, and diabetes.
*He was dependent on staff for bathing, bed mobility of moving right and left, transferring out of bed, toileting, and implementing any preventative interventions to ensure skin breakdown would not have occurred.
*A stage two pressure ulcer was acquired on his right heel on 8/26/2024.
*A stage two pressure ulcer was acquired on his left heel on 1/3/2025.
*A superficial abrasion to his coccyx was acquired on 2/25/25.
11. Review of resident 10's care plan last updated on 5/30/2024 related to his skin integrity included:
*Focus: I have the potential for pressure ulcer development r/t [related to] Hx [history] of ulcers, immobility.
*Goal: I will have intact skin, free of redness, blisters or discoloration by/through review date.
*Interventions:
-Elevate/float heels when in bed to offload pressure as I allow.
-Follow facility policies/protocols for the prevention/treatment of skin breakdown.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 -Frequent repositioning while resting.
Level of Harm - Actual harm -Inspect skin while providing cares, notify nurse of any new skin conditions.
Residents Affected - Few -Instruct/assist/encourage me to shift weight in W/C [wheelchair] routinely.
-Pressure reducing air mattress to bed.
-Pressure reducing cushion to wheelchair.
*There was no indication on his care plan that he had any pressure ulcers or abrasions on his skin.
12. Review of resident 10's Braden Scale for Predicting Pressure Sore Risk assessments revealed:
*On 2/23/24 and 5/17/24 his score was a fourteen which indicated he had moderate risk for the development of a pressure ulcer.
*On 8/13/24 and 9/16/24 his score was a fifteen which indicated he had mild risk for the development of a pressure ulcer.
*On 12/13/24 his score was a sixteen which indicated he had a mild risk for the development of a pressure ulcer.
13. Review of a 2/24/25 weekly skin evaluation for resident 10 signed by RN B revealed:
*The left heel had a stage two pressure ulcer acquired on 1/3/25. It:
-Had minimal drainage and measured 1 centimeter (cm) in length, 1 cm in width, and 0 cm in depth.
-Required pressure-reducing interventions including a mattress and boots.
-Had a dressing order to cleanse, pat dry, apply silicone cream, cover with Optifoam (a type of wound dressing), and change daily.
*The right heel had a stage two pressure ulcer acquired on 8/26/24. It:
-Had no drainage and measured 1 cm in length, 2 cm in width, and 0 cm in depth.
-Worsened from a stage one on 2/17/25 to a stage two on 2/24/25.
-Had the same dressing order as the left heel.
46453
14. Random observations on 2/25/25 from 9:45 a.m. through 2:20 p.m. of resident 12 revealed:
*She had been in her room sitting in a recliner.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 *Her feet were elevated by the footrest, and she appeared to have been sleeping.
Level of Harm - Actual harm *Staff were not observed assisting her to offload or reposition/transfer to another location such as her bed.
Residents Affected - Few 15. Observation on 2/25/25 at 3:18 p.m. of resident 12 in her room revealed:
*She had been moved to her wheelchair.
*She was sitting on an inflatable cushion.
16. Random observations on 2/26/25 from 7:45 a.m. through 11:20 a.m. of resident 12 revealed:
*There was a heel lift device (a device that helped decrease the pressure from the mattress on a person's heels) that was not in use. It was sitting on the other bed in her room.
*She had been lying in her bed sleeping.
*She had an air mattress overlay on her bed to help with relieving pressure to any areas that would have been at risk for skin breakdown.
*She had been laying on her back, both of her heels were positioned directly on the air mattress, and the bottoms of her feet were positioned against the footboard of the bed.
*She remained in that position for over three hours.
*At 8:00 a.m. the surveyor asked CNA D to observe them assisting the resident. He stated that he would come and get that surveyor when that happened.
17. Review of resident 12's EMR revealed:
*A nursing progress note from 2/23/25 at 11:30 a.m. that read, Called [hospice provider] to update on Res [resident] refusing pain medication and new skin issues. Hospice nurse will come to assess resident today.
*A scanned Coordination Notes Report hospice note that was signed as noted by DON A on 2/25/25.
-It included six pages of notes and assessment details. DON A signed the first page.
-On 2/23/25, RN E called the hospice triage phone number to discuss concerns with resident 12 refusing pills and [RN E] states that she believes [resident 12] may be developing a Kennedy ulcer [an ulcer that can develop rapidly as a person is in the dying process] on her coccyx, as she has discoloration that is purple in color and described as a stage 1.
-[Resident 12] also has an injury to the back of her left thigh caused by catheter tubing pressing against her skin.
-No current wound care orders for either area are present at [the] facility at this time.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 -[RN E] does not think skin issues have been assessed by hospice yet.
Level of Harm - Actual harm -Later in the day on 2/23/25, a hospice RN was present at the facility and noted that RN E was present to assist with assessments. Residents Affected - Few -Wound measures 2.5cm [centimeters] [by] 7.5cm dark purple area with a 1.5cm [by] 1.5cm open area in the center. Wound picture taken and care plan updated. Orders placed along with calendar updated.
*A weekly skin audit had been completed on 2/20/25 after her bath with no new skin impairment identified.
*There were no physician's orders or wound assessments found regarding the skin impairments on her coccyx and thigh.
18. On 2/26/25, a list of all residents with current skin and wound concerns was requested and interview on 2/26/25 at 8:27 a.m. with DON A regarding that list revealed:
*Resident 12 was not on that list.
*She was not aware that resident 12 had any skin issues relating to her coccyx or thigh.
*She was aware that the hospice provider wanted to look at her skin, but she was not aware of any current skin issues.
*Additional documentation relating to wound assessments and treatment orders was requested relating to resident 12's wounds.
Continued interview on 2/26/25 at 8:35 a.m. and 9:27 a.m. with DON A revealed:
*She could not find any orders from hospice regarding wound care.
-She had to call the hospice provider to obtain their wound assessments and treatment orders.
*She did not know if resident 12's primary care physician was notified of the wounds.
*She confirmed she missed the wound assessment note from hospice on 2/23/25.
*She confirmed she had signed her initials on that hospice note on 2/25/25.
*They had recently changed their process on how they were to complete residents' weekly skin assessments.
-Previously, the nurse would complete a weekly skin audit evaluation on each resident.
-Now, they have a yes or no question that was triggered weekly. The nurse would check yes if there was a skin issue and that would trigger a full skin assessment. If no was checked, that meant no new skin impairments.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 *They implemented the following measures to prevent pressure ulcers for resident 12:
Level of Harm - Actual harm -An air mattress.
Residents Affected - Few -The cushion for her wheelchair.
-[NAME] brand skin barrier cream.
19. Observation and interview on 2/26/25 at 10:20 a.m. with RN X regarding resident 12 revealed:
*She was massaging resident 12's hands and washing her face.
*She was the hospice care case manager and had come in that day to see the resident.
*She was not there to complete personal care for the resident but to offer comfort and support in other measures.
*She would have expected the residents on hospice care to have been repositioned at a minimum of every two hours.
*The resident had recently acquired a Kennedy ulcer to her coccyx area.
-That ulcer had the potential to worsen when proper repositioning had not occurred.
*They would have completed a wound assessment for their own purposes and records.
-That skin assessment would not have been provided for the facility's records.
-The facility was responsible for completing their own skin assessments.
-The residents were still the primary responsibility of the facility.
-She explained that hospice services were an additional support for the resident.
20. On 2/26/25 at 11:20 a.m., CNA U came and got the surveyor to observe them assisting the resident. That had been the first time in the morning that the staff had assisted her with repositioning and personal care.
21. Interview on 2/26/25 at 12:58 p.m. with RN E about resident 12's wound revealed:
*She noticed the bruise on resident 12's coccyx on Sunday 2/23/25. The area was purple.
*She did not assess it at that time because I didn't want to be pressing on it. I didn't know if it was a deep tissue injury.
*She called the hospice provider because Hospice takes care of the wound care orders and the assessments.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 -The hospice provider indicated that they would send someone that day to assess the wound.
Level of Harm - Actual harm *She did not notify the resident's primary care physician, saying, I didn't even think to do that.
Residents Affected - Few -She also did not notify the DON because she did not want to disturb her on a Sunday.
*She passed the information along to RN R who was the oncoming nurse for the next shift.
*For pressure ulcer preventative measures, she expected staff to reposition resident 12 on a regular basis, such as moving from the bed to a chair, shifting to different positions in the chair, and moving her to the wheelchair.
*Resident 12 had an air mattress on her bed and a cushion in her chair for pressure redistribution.
22. Observation on 2/26/25 at 1:08 p.m. of resident 12 revealed that she was dressed for the day and had been moved to her recliner.
23. Observation on 2/26/25 at 4:07 p.m. of resident 12 revealed that she was still sitting in her recliner. The recliner was in a slight reclined position.
24. Interview on 2/26/25 at 4:53 p.m. with RN R revealed:
*She confirmed she was present at the facility on 2/23/25 when the hospice nurse came to assess resident 12's wounds.
*She did not perform a wound assessment because hospice did the assessment.
-The hospice nurse measured the wound.
-She asked me to apply Optifoam and that's it.
-At the time of the assessment, resident 12's coccyx was red and there was a little bit of scraping and bleeding.
*She did not notify the resident's primary care physician because they have their own hospice physician and hospice staff notify the physician.
*She did not notify the DON.
*She indicated that if the hospice nurse had a new order, she would have entered it into the EMR system, and the DON would have been notified that way.
-There were no new orders that she entered from hospice regarding that wound.
*Wound treatments were usually completed during the day shift.
25. Interview on 2/27/25 at 8:05 a.m. with DON A revealed:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 *She expected staff to complete assessments on wounds when they were noticed right away, complete the skin evaluation, and notify the family and physician. Level of Harm - Actual harm *They used telehealth services to obtain treatment orders. Residents Affected - Few *That process should not change due to a resident receiving hospice services.
*She explained that hospice was an additional service, and staff should not be passing along the responsibility of caring or a resident onto the hospice service.
26. Review of resident 12's current care plan revealed:
*She was completely dependent on staff and required substantial to maximum assistance for ambulation, transferring, and repositioning.
*One intervention read, Skin at risk: Barrier cream, Lotion to dry skin, Pressure reducing mattress, Specialty mattress: Air Mattress, Turn/reposition routinely, Wheelchair cushion. Initiated on 10/4/23. Revised on 1/31/24.
*There were several interventions that mentioned she experienced frequent loose stools and was incontinent of her bowels. Her care plan indicated for Staff to cleanse and keep skin dry. Apply barrier cream BID [twice per day] and with each incontinent episode.
*She preferred to lay on her back and would only reposition to her side for short periods of time.
*Pressure-reducing measures included the specialty air mattress and a pressure reducing cushion in her wheelchair.
*She had a history of a venous ulcer to the bottom of her right foot.
*Another intervention that read, Utilize pillows/foam wedges for placement between bony prominences. Initiated on 3/16/25. Revised on 2/13/24.
27. Review of resident 12's EMR revealed:
*Her diagnoses included endometrial cancer, multiple sclerosis, type 2 diabetes, peripheral vascular disease, and congestive heart failure, among others.
*A significant change Minimum Data Set assessment was completed on 1/6/25 that included:
-Her BIMS assessment score was 10, which indicated she was moderately cognitively impaired.
-She was dependent on staff to transfer from surface to surface.
-She required substantial to maximum assistance for repositioning.
-She had a catheter due to a neurogenic bladder, and she was always incontinent of bowel.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 -She was at risk for developing pressure ulcers.
Level of Harm - Actual harm -She did not have any pressure ulcers at the time of the assessment.
Residents Affected - Few 50915
28. Observations on 2/25/25 from 9:45 a.m. through 3:00 p.m. of resident 49 revealed:
*At 9:45 a.m., the resident was laying on his back with a pillow under his back on the right side, but mostly flat.
*At 1:10 p.m., the resident was laying in the same position, mostly flat, with a pillow under his back on his left side.
*At 2:15 p.m., the hospice nurse was at his bedside, the pillow was moved to right side, and the resident laying mostly flat.
*At 3:00 p.m., his position was unchanged.
29. Interview on 2/26/25 at 7:50 a.m. with RN E revealed resident 49 was to be repositioned every two hours to help prevent pressure ulcers.
30. Observation and interview on 2/26/25 at 8:10 a.m. with certified medication aide (CMA) D revealed:
*He was repositioning resident 49 every two hours.
*He reported the resident's condition had significantly declined over the past few days.
*During observation of repositioning, resident 49 was unable to follow commands and moaned in pain when moved.
31. Observations on 2/26/25 of resident 49 revealed:
*At 9:00 a.m. he had been in bed and was laying on his back.
-The extra pillow had been placed above his head.
-Both of his feet and heels had been laying directly on the mattress with no pressure relieving device in place.
-He had been positioned down low on the mattress to where his feet rested directly up against the footboard.
32. Interview on 2/26/25 at 12:30 p.m. with CNA U revealed:
*Residents should have been repositioned every two hours.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 *He agreed:
Level of Harm - Actual harm -Residents 12 and 49 were dependent upon the staff to reposition them.
Residents Affected - Few -Those residents were vulnerable and were at risk for skin breakdown and should have been repositioned every two hours.
*His partner had left early that day, and he was left by himself to reposition them.
-He confirmed those residents had gone longer than two hours without being repositioned.
*He agreed:
-Repositioning residents with their feet directly against the footboard created the potential for skin breakdown to have occurred.
-The residents' heels should not have been left directly on the mattress. A heal lift should have been used to relieve the pressure.
33. Observation on 2/26/25 at 4:30 p.m. of CNA K revealed:
*She was changing resident 49's brief because he had been incontinent.
*There was a bandage on resident's buttock.
*CNA was not sure what the bandage was covering but would let the charge nurse know it was starting to peel away from his skin.
34. Interview on 2/26/25 at 5:20 p.m. with hospice nurse RN G revealed:
*She reported doing resident 49's skin assessments.
*She reported there was some redness to the resident's coccyx, but did not believe there were any pressure ulcers.
35. Observation and interview on 2/27/25 at 10:47 a.m. with RN B revealed:
*She was performing skin cares on resident 49's coccyx and buttocks.
*After removing cream from resident's coccyx, two open area were revealed, each measuring approximately one centimeter (cm) around.
*She reported these to be stage two pressure ulcers.
*She reported this was the first time she had seen these ulcers.
*She reported when performing resident cares on 2/24/25, the ulcers were not present.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 *She did not feel the ulcers could have been prevented because resident was repositioned appropriately.
Level of Harm - Actual harm 36. Interview on 2/27/25 at 12:33 p.m. with DON A revealed:
Residents Affected - Few *She found out about resident 49's pressure ulcers earlier in the morning.
*Regarding resident 49's pressure ulcers, she felt they were absolutely preventable.
*Regarding facility acquired pressure ulcers, she felt they are all preventable.
*She did not think CNAs received appropriate training.
*She felt sometimes staff did not listen to her guidance in regard to the education she provided them.
*She wanted to implement POC [point of care] documenting. (The care is documented at the time it occurs, not when it is scheduled). This would increase accountability of completing resident tasks.
*It was her expectation for staff to follow her instructions.
*She planned to implement a competencies program with a skills checklist.
-She was hopeful with the hiring of a new assistant DON education of staff and competencies could soon become a priority.
37. Review of resident 49's EMR revealed:
*He was admitted to hospice care on 2/18/25.
*His BIMS assessment score was three, which indicated he was severely cognitively impaired.
*He had medical diagnoses including Alzheimer's/dementia with behaviors, fall with major injury, right humerus fracture, congestive heart failure, and depression.
*He was dependent upon the staff to:
-Assist him with all of his mobility needs (repositioning in bed) and ADL.
-Implement any preventative interventions to ensure skin breakdown would not have occurred.
-Anticipate his needs as he was unable to make them known.
*His Braden Scale score on 2/20/25 was sixteen.
-That score had indicated he was at mild risk for skin breakdown.
*On 2/27/25 his Braden Scale score was reassessed and was an eight.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 -Within seven days his skin breakdown risk had increased to a very high risk.
Level of Harm - Actual harm *The first documentation of his pressure ulcers was in nursing progress note on 2/26/25 at 11:59 p.m. by RN R, after his skin bandage was witnessed earlier in the day. Residents Affected - Few -Resident in bed PM cares. Reposition to sides. No intake. Took his comfort meds. Hospice nurse here after supper. Both writer & hospice nurse [name], we did measure open sores. Coccyx one cm [centimeter] x 3/4 cm. Right cheek [buttock] 1 cm x 3/4 cm.
38. Review of resident 49's care plan revealed:
*A focus of I have the potential for impairment to skin integrity r/t [related to] edema, fragile skin.
*Goals of The resident will maintain or develop clean and intact skin by the review date. The resident will be free from injury through the review date.
*Interventions/tasks of Avoid scratching and keep hands, and body parts from excessive moisture. Follow facility protocols for treatment of injury. Keep skin clean and dry. Use lotion on dry skin. The resident needs pressure reducing cushion to protect the skin while up in chair. The resident needs pressure reducing mattress to protect the skin while IN BED. Use draw sheet or lifting device to move resident.
39. Review of the provider's January 2025 Skin Integrity policy revealed:
*In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds.
*1. The nurse completes the Braden Scale/Skin Integrity Evaluation at admission, weekly for three weeks, and then annually. The Braden Scale is s guide to determine risk stratification for skin impairment.
-a. Residents are at a level of risk per the Braden scale and the completion merely guides the practitioner to determine if future intervention is required.
-2. The nurse establishes a plan of care based on risk factors in an effort to limit their potential effects.
-3. The resident's skin is inspected daily with completion of ADL's [activities of daily living] (unless resident is independent in ADL completion). Changes in the resident's skin are reported to the Licensed Nurse (LN).
-Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the Treatment Administration Record (TAR) with their initials, and either a 'No' or 'Yes.'
*If skin impairment is noted after admission, the LN:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0686 -a. Initiates alert charting.
Level of Harm - Actual harm -b. Completes (and documents) notifications to the physician and Resident or Resident Representative.
Residents Affected - Few -c. Implements new interventions as needed. Documents on the resident's care plan and ISP.
-d. Notifies Food and Nutrition Services Manager (FANS) and/or Registered Dietician of new pressure injury or worsening wound condition for nutritional needs evaluation.
-e. Notifies Director of Nursing Services (DNS) of skin Impairments that indicate a potential significant change in condition (State II or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on
an area of the body not usually vulnerable to trauma (e.g. head, breasts, inner thighs, groin).
-f. The DNS and/or designee complete a comprehensive review of the resident's medical record to evaluate if the pressure injury was avoidable or unavoidable. This evaluation is documented in the Nurse's Notes.
*If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates,
the Physician and Resident's Representative are notified.
40. Review of the provider's March 2012 CNA job description revealed:
*Essential Functions: .5. Turns and repositions bedfast residents, alone or with assistance, and utilizing proper body mechanics, to prevent pressure ulcers.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0697 Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm 50915
Residents Affected - Few Based on observation, interview record review and policy review provider failed to recognize and adequately manage pain for one of two hospice sampled resident (49). Findings include:
1. Observation on 2/25/25 at 2:11 p.m. revealed:
*Resident 49 was being repositioned by certified nursing assistant (CNA) F and hospice registered nurse (RN) G.
*Resident 49 could be heard in the hall moaning.
*Resident grimaced and moaned in pain with any repositioning.
2. Observation and interview on 2/26/25 at 8:31 a.m. with CNA D revealed:
*CNA was repositioning and checking resident 49 for incontinence every two hours.
*Resident 49 grimaced and moaned in pain with even small movement.
*Resident 49 would shout help, help with repositioning.
*CNA made effort to be very gentle with the resident, but the resident was still in pain.
*He reported resident 49 has had increased pain with repositioning for the past several days.
*CNA reported his increased pain to RN E.
3. Interview on 2/26/25 at 8:40 a.m. with RN E revealed:
*She tried to assess resident 49's pain as often as possible.
*She also relied on the CNAs to let her know if he was having increased pain.
*She was aware he was having increased pain with repositioning.
*She did not feel his pain was adequately controlled with pills; she would prefer liquid morphine for pain control for a hospice resident.
4. Interview on 2/26/25 at 1:30 p.m. with director of nursing (DON) A and RN C revealed:
*It was DON A's expectation resident 49 would be repositioned every two hours.
*RNC C stated pain should be assessed every shift.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0697 *There were changes to resident 49's medication that day and DON A would like to see if the new medication was effective in relieving the resident's pain. Level of Harm - Actual harm 5. Phone interview on 2/26/25 at 2:15 p.m. with hospice RN G revealed: Residents Affected - Few *She had no concerns with the quality of care resident 49 was receiving from the provider's staff.
*She recognized the resident's increased pain during her previous visit and requested a change of pain medication to scheduled morphine.
*She reported observing past hospice residents not having their pain controlled. She reported she thought resident pain was perceived as behavior issues.
6. Observation and interview on 2/26/25 at 4:30 p.m. with CNA K revealed:
*CNA K was repositioning and checking the resident's brief for incontinence.
*She reported the resident appeared to be more comfortable than usual.
*She reported the resident seemed to have a lot of pain with movement and repositioning.
7. Review of resident 49's electronic medical record (EMR) revealed:
*He was admitted to hospice care on 2/18/25.
*His brief interview for mental status (BIMS) score was was 3, which indicated he was severely cognitively impaired.
*He had medical diagnoses including right humerus fracture, congestive heart failure, and depression.
*Nursing progress note on 2/25/25 at 1:11 a.m. documented by licensed practical nurse (LPN) S noted Repositioned q [every] 2 hrs [hours]. He is lethargic, but yells every time he is touched. Refuses to eat, drink, and take medication.
8. Review of resident 49's 12/30/24 care plan revealed:
-A Focus of I am on pain medication therapy r/t [related to] injury to R [right] Humerus fx [fracture].
-Goals of The resident will be free of any discomfort or adverse side effects from pain medication through the
review date.
-Interventions/tasks of Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift].
-A Focus of I have an alteration in musculoskeletal status r/t fracture of the R Humerus.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0697 -Goals of The resident will remain free from pain or at a level of discomfort acceptable to the resident through
the review date. Level of Harm - Actual harm -Interventions/tasks of Anticipate and meet needs. Be sure call light is within reach and respond promptly to Residents Affected - Few all requests for assistance. Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness.
-A Focus of I have identified PAIN that interferes with sleep, rehabilitation activities, day to day activities Depression, Fracture of R Humerus.
-Goals of The resident will not have an interruption in normal day to day activities due to pain through the
review date. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The resident will display a decrease in behaviors of inadequate pain control such as irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying through
the review date.
-Interventions/tasks of Administer analgesia as per orders. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.
9. Review of resident 49's treatment administration record (TAR) revealed:
*His pain was to be monitored each shift, at 7:00 a.m, 3:00 p.m., and 11:00 p.m.
*On 2/25/25 at 7 a.m., RN CC documented the resident's pain was 0 out of 10 during repositioning, indicating the resident had no pain.
*On 2/25/25 at 3 p.m., RN R documented resident's pain 0 out of 10.
*On 2/25/25 at 11 p.m., LPN DD documented resident's pain 0 out 10
*Resident 49 had a physician's order to receive 2.5 milligrams (mg) of Oxycodone (narcotic pain medication) every hour as needed for pain.
*On 2/25/25, resident 49 did not receive Oxycodone for pain.
10. Review of the provider's 1/2025 pain management policy revealed:
*Policy Statement: It is the policy of the center that residents receive care to attain and maintain the highest quality of care and life.
*Residents are evaluated for pain upon admission, routinely, and prn [as needed] with the RAI [resident assessment instrument] process.
*Procedure: 2. The resident is evaluated every shift for signs and symptoms of pain, receiving pain management according to the Preliminary Plan of Care and/or physician order. This data is collected on the medication administration record (MAR), in the interdisciplinary progress notes and through the Daily Clinical meeting process.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0697 *An appropriate pain scale is selected for use based upon resident ability and needs. Examples may include but are not limited to: Numeric 1-10, Verbal Descriptor Scale, Wong-Baker Faces, and the Pain AD (Pain Level of Harm - Actual harm Assessment in Advanced Dementia).
Residents Affected - Few *11. If the resident is a hospice client or receiving palliative/comfort care the nurse and the hospice manager collaborate to develop and evaluate the pain management plan of care.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food
in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46453
Residents Affected - Many Based on observation, interview, record review, and policy review, the provider failed to maintain standard food safety practices including:
*Unsanitary kitchen equipment and food storage and preparation areas including the dishwasher, the stovetop range, the convection oven, the walk-in cooler and freezer, the emergency food supply area, and
the kitchenettes.
*Improper food storage throughout the facility including storing foods past its quality date, storing foods that were visibly rotting, unsealed foods open to air in the cooler, storing raw meats above milk cartons, storing foods on the floor in the cooler, storing measuring scoops inside food thickener, and not labeling or dating bulk food ingredient items.
*Improper hand hygiene and glove use during one of one meal service observations by two of two staff members (dietary manager L and an unidentified staff person).
*Incomplete temperature monitoring for two of at least three communal resident food and beverage refrigerators.
Findings include:
1. Observation during the initial kitchen tour on [DATE REDACTED] from 8:28 a.m. through 9:09 a.m. of the dish room revealed:
*There was a fan blowing into the dish room. The back of the fan was covered with a thick layer of dust.
*A large section of the tile flooring, about three feet by nine feet, was missing, and the subfloor beneath it was exposed.
*There was a large puddle of water under the dishwasher.
*The metal paneling under the dishwasher was coming loose from the floor. Water splashed out from underneath the metal paneling when it was stepped on.
*There was a limescale buildup throughout the dishwasher:
-On both the top and bottom wash arms.
-On top of the dishwasher.
-Along the edges of the dishwasher doors.
*There was a thick layer of food scum buildup along the top inside edge of the dishwasher.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0812 *The ventilation hood above the dishwasher had a buildup of rust and wet dust, suggesting poor ventilation from that hood. Level of Harm - Minimal harm or potential for actual harm *The paint on the ceiling was peeling off.
Residents Affected - Many *Interview at that time with dietary manager L revealed:
-One of the cooks was responsible for deliming the dishwasher every Wednesday. There was no documentation to show when that was last completed.
-He was aware that the ventilation hood might not have been functioning properly.
2. Observation during the initial kitchen tour on [DATE REDACTED] from 8:28 a.m. through 9:09 a.m. of the main kitchen area revealed:
*The drip tray under the stovetop range was filled with food crumbs, burnt-on stains, and burned rotini noodles.
*The backsplash of the stovetop range and flattop grill was stained black with burnt-on grease stains.
*The tunnel that went from the flattop grill to the grease trap drawer was caked with black grease.
*The trash can to the left of the stovetop was uncovered. There was a cover available and hanging off the trash can.
*There were two ovens stacked on top of each other. The inside of the bottom oven was covered in burnt-on food and grease.
*There were three bins of bulk food ingredients. One bin contained rice, another bin contained what looked like sugar, and the third bin contained what looked like flour. None of the bins were labeled or dated when
they had been filled.
*There was another uncovered trash can to the left of those bulk food ingredient bins. The cover was lying on
the floor under the trash can.
*There were several large containers of dried spices. Some of the containers had been there for several years, including a bottle of dried oregano with a delivery date of [DATE REDACTED].
3. Observation during the initial kitchen tour on [DATE REDACTED] from 8:28 a.m. through 9:09 a.m. in the walk-in cooler and freezer revealed:
*There was an abundance of an unidentified black and white fuzzy growth on the walls, door frame, floor, and shelving units that appeared to have been mold.
*The floor in the cooler was vinyl flooring that was damaged and curling up.
*There was a buildup of dirt, food scraps, and packaging on the floor.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0812 *There was a crate of four gallons of milk sitting directly on the floor.
Level of Harm - Minimal harm or *A box of raw bacon was stored directly above several gallons of chocolate milk. potential for actual harm *Several food items were past the manufacturer's best by date: Residents Affected - Many -Three jars of Grey Poupon mustard, one opened, with the best by date of [DATE REDACTED].
-One case of at least 10 jars of parmesan cheese with a best if used by date of [DATE REDACTED]. That case was delivered on [DATE REDACTED].
*Several food items had started to rot:
-Two bags of celery were visibly turning brown and mushy.
-One bag of lettuce was starting to [NAME] and turn brown. There was brown liquid in the bag.
*The wooden floor inside of the freezer had turned black. There was an abundance of dirt, food, dust, and food wrappers.
*Refer to
F-Tag F908
F-F908, finding 1, for details on how the cooler and freezer were malfunctioning.
4. Observation during the initial kitchen tour on [DATE REDACTED] from 8:28 a.m. through 9:09 a.m. revealed in the storage room where the emergency food supply was stored:
*There was a layer of dust, dirt, and cobwebs on the emergency food supply.
*Most of the food in the emergency supply was delivered on [DATE REDACTED] and was past the manufacturer's best by date.
5. Observation on [DATE REDACTED] from 12:54 p.m. to 1:38 p.m. during the lunchtime meal service revealed:
*An unidentified staff person wore the same pair of gloves throughout the meal service and did not wash his hands. With those gloved hands he:
-Pushed a cart of drinks and served them to residents.
-Pushed a resident in their wheelchair to her designated table.
-Grabbed coffee mugs and plastic cups, poured drinks into them, and served them to residents.
-Grabbed a tray of drinks from the fridge.
-Grabbed a stack of plastic cups and poured multiple juices and set them on the tray of drinks.
-Put the tray of drinks back in the fridge and covered them with another tray.
-Grabbed dessert cups by the rim and scooped a blueberry dessert into them.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0812 -Grabbed an individual butter condiment from a container full of butter condiments and placed it on a plate of mashed potatoes and roast beef and served that plated food to a resident. Level of Harm - Minimal harm or potential for actual harm -Grabbed a package of crackers from a container full of packaged crackers and placed it on a plate along with a soup spoon he retrieved from a container of soup spoons and served those items to a resident. Residents Affected - Many -Opened a cupboard in the kitchenette and pulled out a cup and lid.
-Opened a single-serve ice cream for a resident.
-Placed plastic wrap on top of juices and desserts for resident room meal trays.
*Dietary manager L prepared a resident's plate while wearing gloves, removed the gloves, and served the plate of food to the resident without washing his hands.
*Dietary manager L put on one glove, served a plate of food to a resident, removed the glove and did not wash his hands.
6. Observation on [DATE REDACTED] at 12:57 p.m. of the refrigerator labeled Drink Fridge in the main dining room revealed:
*The temperature monitoring sheet had several slots with no temperatures recorded.
*Those unrecorded temperatures included the AM and PM slot on [DATE REDACTED] and the PM slot from [DATE REDACTED] through [DATE REDACTED].
7. Observation on [DATE REDACTED] at 1:25 p.m. in the activity room kitchenette revealed:
*The temperature monitoring sheet on the refrigerator labeled Snack Fridge had several unrecorded temperatures including:
-The PM slot from [DATE REDACTED] through [DATE REDACTED].
-The AM slot on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED].
*In the snack fridge, there were several containers of what looked like chocolate pudding that had been scooped into individual plastic serving cups.
-There was no label that identified what it was.
-There was no date that indicated when it was dished.
*In the closet, there were at least three cases of sugar-free chocolate and vanilla pudding with a best if used by date of [DATE REDACTED].
*The hot-holding steam table a buildup of rust, food crumbs, and dead flies in the basins. It was not used
during the survey.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0812 *There was a damp rag balled up in the sink that had a foul odor coming from it. There were no detergent or sanitizer buckets to store the rag in. Level of Harm - Minimal harm or potential for actual harm 8. Interview on [DATE REDACTED] at 9:23 a.m. with FANS cook Q revealed:
Residents Affected - Many *There were cleaning checklists designated for each position and shift.
-She indicated that the checklists were not used that often.
-She did not know where the completed checklists were supposed to have been turned in.
*She thought that one of the other cooks delimed the dishwasher every Saturday.
*The person who put the groceries away was supposed to go through the cooler and freezer and discard the old and expired foods.
9. Continued observations on [DATE REDACTED] at 9:38 a.m. in the walk-in cooler revealed:
*A box of ground beef and a crate of four gallons of milk sitting directly on the floor.
*A sheet pan of breadsticks that were not covered, labeled, or dated.
10. Interview on [DATE REDACTED] at 9:56 a.m. with executive director I revealed:
*He was new to his position as of the previous week.
*He was not aware of the above observed dietary department concerns.
*He agreed that the issues needed to be addressed.
11. Observation on [DATE REDACTED] at 1:51 in the main dining room kitchenette revealed:
*The missing temperatures from the drink fridge temperature monitoring sheet were now all filled out.
*A jar of peanut butter on the shelves above the steam table had a manufacturer's best by date of [DATE REDACTED].
*An unnamed refrigerator contained the following expired foods:
-Eight chocolate pudding cups with best by dates of [DATE REDACTED].
-Two cartons of decaffeinated coffee concentrate for the coffee dispenser with a manufacturer's code of Consume Before [DATE REDACTED].
*There were two bottles of unopened mustard in the cupboards with a best by date of [DATE REDACTED].
*There was a small fan in the cupboard above the serving line that was covered in dust.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0812 *There was a container of Prairie Farms Sour Cream on the counter that had Thickener ,d+[DATE REDACTED] written on it. Level of Harm - Minimal harm or potential for actual harm -There was white powder on the inside which appeared to be powdered food thickener.
Residents Affected - Many -The scoop was sitting in the thickener.
-There were no directions included with the packaging of how to use the food thickener, or how many scoops were required for the different thickness levels.
*There was another clear plastic container that was labeled ,d+[DATE REDACTED] Thickener.
-The scoop was sitting in the thickener.
-There were no directions on that container.
*The space beneath the steam table was very rusty and had food crumbs and scrambled eggs scattered throughout. An electric flattop griddle and a perforated steam pan were stored in that space.
*The particle board under the sink had completely disintegrated, leaving behind a mound of black, damp, musty-smelling powdered wood and exposed sub-floor.
12. Follow-up interviews with dietary manager L were attempted on [DATE REDACTED], but he was not available.
13. Review of the provider's [DATE REDACTED] Food Storage policy revealed:
*Policy Statement: Food storage areas are maintained in a clean, safe, and sanitary environment.
*Procedure:
-1. Food storage areas are kept clean at all times.
-2.Packaged food, canned foods, or food items stored are kept clean and dry.
-3. Dry, bulk foods, (flour, sugar, dry beans, food thickener, spices, etc.) are stored in seamless metal or plastic containers with tight fitting covers or in bins that are easily sanitized. It is recommended that foods in bins (e.g. flour or sugar) be removed from original packaging. Scoops are not stored in direct contact with food. Do not add more product to a bin container until it is empty and sanitized.
-4.Empty food cans are not reused.
-5. Foods are dated with month and year of delivery to the Center .
-6. Food products are used within one year unless the manufacturer's expiration date is different.
- .9. Foods stored in walk-in refrigerators and freezers are stored above the floor on shelves, racks, dollies, or other surfaces to facilitate thorough cleaning .
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0812 -10. Opened items have 'use by' dates indicated on them. This 'use by' date may be circled to differentiate it from date received or date opened. May indicate date opened or date prepared if required by your survey Level of Harm - Minimal harm or agency. potential for actual harm -11. The manufacturer's expiration date, when available, is the use by date for unopened items. Residents Affected - Many -12.thawing meats are stored in the refrigerator, preferably on the bottom shelf. Do not store them over ready to eat foods.
14. Review of the provider's [DATE REDACTED] Glove Use policy revealed:
*Policy Statement: Gloves are worn to maintain safe and sanitary food preparation and service.
*Procedure:
-1. Proper utensils are used for food handling.
-2. Bare hand food contact is prohibited.
-3. Proper use of gloves:
--a. Wash hands thoroughly before and after wearing or changing gloves. Bacteria build up under gloves and are washed away after wearing gloves.
--b. Use gloves that fit properly and that are designed for the task being performed.
--c. Change gloves periodically to minimize the buildup of perspiration and bacteria.
--d. Gloves are single use and thrown away after each task. Change gloves whenever leaving the workstation or changing the type of food being prepared.
--e. Change gloves and wash hands after sneezing, coughing, or touching your hair or face with gloved hands.
--f. Avoid wearing gloves whenever their use presents a potential safety hazard (near hot equipment where melting may occur, etc.).
--g. All foods on tray line are served out with utensils, no bare hand contact.
15. Review of the provider's [DATE REDACTED] Refrigerator and Freezer Temperatures policy revealed:
*Procedure:
- .2. Refrigerator/Freezer temperatures are recorded twice a day, once in the morning and once in the evening.
50916
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.
Level of Harm - Minimal harm or 50015 potential for actual harm Based on interviews, and quality assurance and performance improvement (QAPI) plan policy review, the Residents Affected - Few provider failed to ensure they identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, monitored, and regarding pressure ulcer prevention and treatment, infection control including enhanced barrier precautions, and pain management. Findings include:
1. Review of the provider's current QAPI PIPs included:
-Maintenance projects.
-Dietary cleaning, labeling, and dating.
-QAPI.
2. Interview on 2/27/25 at 12:58 p.m. with medical director (MD) H revealed:
*He was aware some residents had pressure ulcers.
*He completed rounds once a month.
-He was updated on pressure ulcers during rounds.
*His Nurse practitioner would complete rounds opposite of his rounds schedule.
-She received information via fax regarding resident skin issues.
*He did not know all the details about the facility and their processes.
*He attended the facility's QAPI meetings.
-He did not create a QAPI plans.
-He provided his insight to the facility QAPI team.
*He felt the facility's QAPI had improved within the last month and that it was not a priority before.
*He observed wounds when he saw the residents.
*He was not aware the facility did not have a repositioning policy.
*He wanted the residents to have high-quality care.
3. Interview on 2/27/25 at 1:43 p.m. with the director of nursing (DON) A revealed:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0865 *She was the QAPI advisor.
Level of Harm - Minimal harm or *Areas considered for quality improvement opportunities per the QAPI plan included: potential for actual harm -Areas needing systemic changes. Residents Affected - Few -Cross-departmental issues.
-Evidence-based practices.
-Issues that require environmental changes.
-Issues affecting staff satisfaction and safety.
*Adverse events were monitored by the QAPI team having identified patterns regarding falls and staff who had worked when those events occurred.
-They had started a PIP and completed audits to monitor those events.
*QAPI was updated in January 2025.
*QAPI training had been assigned to staff.
-QAPI training was completed by 56 out of 59 of those staff who were assigned that training.
*Regarding so few staff attending Interdisciplinary team (IDT) meetings for resident care updates:
*Departments should attend to give input into resident care improvement these include:
-Nursing department.
-Activities department.
-Social service department.
-Dietary department.
-Therapy department.
-MDS Coordinator.
*IDT meetings were scheduled by social service, quarterly, annually and with significant change in resident condition.
-Invites were sent to all department heads.
-Things would come up and they would not attend.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0865 -There had been discussion about more people needing to be in attendance.
Level of Harm - Minimal harm or *She was aware infection control, wound care, and enhanced barrier precautions (EBP) all needed potential for actual harm improvement.
Residents Affected - Few *Feeding assistance was discussed with her, and she agreed improvement was needed.
*Building Environment regarding maintenance PIP still needs much improvement:
-Missing ceiling tiles in resident bathroom.
-Uncleanable surfaces on shower chairs.
-Missing flooring in the therapy rooms.
-Equipment in therapy being dirty and unclean.
Review of the provider's March 2024 QAPI plan policy revealed:
*QAPI is a dynamic process used to facilitate identification of areas for improvement
and to drive quality of care and services. The Quality Assurance (QAA) Committee
oversees the Center QAPI program. They are tasked with identifying areas requiring
performance improvement, collecting data, developing and implementing corrective
action, and creating monitors to determine and validate changes are effective and
sustained.
*QAA Committee is responsible for collecting and reviewing data from various sources.
These include but are not limited to; the Center Assessment, data derived from Center
quality management program (Abaqis) activities, input and suggestions from staff,
residents and other internal and external stakeholders. When performance indicators
deviate from expected or benchmarked performance the QAA Committee will
prioritize opportunities for improvement and determine the appropriate response
including specialized workgroups.
*Workgroups are initiated to focus on high-risk, high-volume, or problem-prone areas.
Consideration is given to the incidence, prevalence, and the severity of the problem;
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0865 affect to health outcomes, resident safety, resident autonomy, resident choice, and
Level of Harm - Minimal harm or quality of care. Workgroups address process improvement through corrective action potential for actual harm plans and Plan, Do, Study, Act (PDSA) rapid improvement cycle model. Residents Affected - Few *The QAA committee may determine that some concerns are limited in scope and may
be effectively corrected through simple process adjustments. These are quick fix
items that do not warrant Workgroup or subcommittee development.
*The QAPI Plan and revisions are communicated to the governing body, staff, residents
and family members with appropriate communication tools. Examples may include a
designated QAPI bulletin board for staff, residents and family members, discussion of
QAPI activities during all staff meetings and the provision of routine reports to our
governing body.
*QAA Committee identifies opportunities for improvement:
-QAA Committee evaluates ongoing effectiveness of Performance Improvement Plan (PIP).
-QAA Committee sets timetable for follow-up review, if necessary.
-QAA Committee determines duration of continued monitoring for sustained improvement.
-QAA repeats/returns to PDSA if sustained improvement is not achieved.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or 50916 potential for actual harm Based on observation, interview, and policy review, the provider failed to ensure infection control and Residents Affected - Some prevention practices were followed relating to:
*One of one registered nurse (RN) (B) who provided wound care treatments for five of seven sampled residents (109, 42, 28, 24, and 10) with ordered wound care treatments.
*Two of three certified nursing assistants (CNA) (T, U, and V) who provided direct patient care and catheter care for two of two sampled residents (12 and 109).
*Resident care equipment cleanliness in the therapy gym and the whirlpool tub located on the first floor.
Findings include:
1. Observation and interview on 2/26/25 at 7:39 a.m. with RN B during resident 109's wound care treatment revealed:
*There was no sign that indicated staff needed to use enhanced barrier precautions (EBP) or personal protective equipment (PPE) while providing his care posted outside or inside his room.
*She had two adhesive dressings and a hydrocolloid patch (wound healing product) with the date labeled on them laying on a treatment cart.
*She performed hand hygiene (HH) with hand sanitizer, applied gloves, picked up the dressings and entered
the resident's room.
*Resident 109 gave his permission to be observed.
*Resident 109 was completely uncovered sitting on a bath chair while CNA T attached a full body mechanical lift (a mechanical lift and sling used to lift a person's full body) and transferred him to the bed.
*CNA T was wearing gloves and no other PPE.
*While resident 109 was lying in bed, RN B:
-Removed the soiled dressing from resident 109's right ankle and discarded it in the garbage can.
-Removed her gloves, discarded them into the garbage can, and applied new gloves without performing HH.
-Without cleaning the wound, she applied a new adhesive dressing to his right ankle wound.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 -Removed her gloves, discarded them into the garbage can, and applied new gloves without performing HH.
Level of Harm - Minimal harm or -Removed the soiled hydrocolloid patch from his second toe on his right foot. potential for actual harm -Without cleaning the wound, she applied a new hydrocolloid patch to his stage two pressure ulcer (wound Residents Affected - Some with partial thickness skin tissue loss from prolonged pressure).
-Removed her gloves, discarded them into the garbage can, and applied new gloves without performing HH.
-Assisted CNA T in rolling resident onto his side, removed the soiled adhesive dressing from his upper middle back, and without cleaning the wound applied a new adhesive dressing to the abrasion.
-Discarded the soiled dressing in the garbage can, removed and discarded her gloves, and performed hand hygiene.
*She stated the hydrocolloid patch was a big patch that she had cut into tiny pieces to fit onto his toe. She kept the unused patch pieces in the opened patch package in the treatment cart.
2. Observation and interview on 2/26/25 at 7:55 a.m. with RN B while providing resident 42's wound care treatment revealed:
*She performed HH, retrieved her wound care and suprapubic catheter (a flexible tubing surgically placed through the abdomen to drain urine from the bladder) care supplies (dressings) from the treatment cart, entered the resident's room, and placed the dressing packages on the bed sheet without a barrier under them next to the resident.
*Resident 42 gave his permission to be observed.
*RN B put on a gown, mask, and gloves.
*She wet a washcloth in the bathroom and placed it on the bed sheet next to the resident along with wet wipes and a skin barrier cream.
*After she removed the resident's undergarments, she:
-Removed the suprapubic catheter dressing and wiped around the tubing with a wet washcloth.
-Removed and discarded her gloves into a garbage can and put on new gloves without performing HH.
-Opened the suprapubic catheter dressing, set it on the bed sheet, applied the barrier cream on the resident's skin, and applied the dressing.
-Removed and discarded her gloves into garbage can and put on new gloves without performing HH.
-Opened the adhesive dressing (to be placed on resident's coccyx (tailbone)), pulled it out of the package and set it on the bed sheet.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 -Labeled the adhesive dressing and put on new gloves without performing HH.
Level of Harm - Minimal harm or -Helped roll the resident onto his side. potential for actual harm -Removed the soiled dressing from the resident's coccyx. Residents Affected - Some -Wiped the area with the wet wipes lying on the bed.
-Removed and discarded her gloves into the garbage can and put on new gloves without performing HH.
-Applied the barrier cream and new patch to his coccyx.
*RN B was not aware of the areas underneath his scrotum (skin pouch under the penis) had opened and stated they had been putting a barrier cream on it.
*RN B then applied a barrier cream to those open areas.
*While performing wound care for his colostomy bag she:
-Laid paper towels down onto the resident's lap and placed a black plastic bag on top of them.
-Set scissors, wet wipes, a colostomy bag, skin paste, powder, and colostomy adhesive wafer onto the bed sheet without having placed a barrier under those supplies.
-Removed the used colostomy bag and cleaned the opening with wet wipes.
-Removed and discarded her gloves into the garbage can and put on new gloves without performing HH.
-Opened a skin prep wipe and wiped the skin around the colostomy opening.
-Applied the powder to the skin, set the powder in the black plastic bag. Resident 42 asked her if it was empty, to which she said, No and removed it from the bag and set it back on the bed sheet.
-Measured the colostomy opening, cut the new colostomy adhesive wafer, set it back on the bed, applied the skin paste, applied the wafer to the skin, and attached the new colostomy bag to the wafer.
-Discarded the used supplies, set the powder and skin paste on the resident's tray table, removed her PPE, grabbed the powder and skin paste, and exited the room without performing HH.
3. Observation on 2/26/25 at 8:30 a.m. of RN B during resident 28's wound care treatment revealed:
*There was signage on his door that he was on EBP and the staff should have worn gloves, gown, and a mask.
*She had a medication cup containing a small amount of white cream and a pair of gloves that had been lying on the treatment cart.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 *She took those supplies to resident 28's room.
Level of Harm - Minimal harm or *The resident was on EBP, and that required her to put on PPE prior to entering his room. potential for actual harm *She placed the medication cup and gloves on the siderail located outside of the resident's room while she Residents Affected - Some put on the PPE.
*She put on those gloves and was not observed to have sanitized her hands before she put them on.
*With those gloved hands she:
-Opened the resident's door and placed the medication cup on the resident's bedside dresser without a barrier under the medication cup.
*She had forgotten to put on a mask and had to leave the room to get one.
*Without removing her gloves, she opened the door, got a mask, and put it on her face.
*She entered the resident's room, and with those same gloved hands she:
-Grabbed a package of wet wipes from the resident's roommate's bedside table.
-Removed the bed covers off the resident and assisted him with rolling over to his right side.
-Exposed and cleansed his bottom area with a wet wipe.
-Removed the cream from the medication cup and applied to his bottom and coccyx area.
*She removed her gloves and then washed her hands.
4. Observation on 2/26/25 at 11:30 a.m. of RN B during resident 24's wound care treatment revealed:
*She removed several supplies from the treatment cart and placed them on top of the treatment cart without
a barrier under them including:
-Several gauze dressings she had been taken out of a bulk package.
-A bottle of wound cleanser and several gloves.
-A pair of scissors and a protective dressing.
*She gathered those supplies. took them to the resident's room, and laid them on his bed covers without a barrier under them.
*The resident was seated in his wheelchair.
*She placed a disposable pad underneath his right foot.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 *On his door he had signage that he was on EBP and required the staff to use PPE when caring for him.
Level of Harm - Minimal harm or *She sanitized her hands prior to putting on gloves, gown, and a mask. potential for actual harm -She put on a pair of gloves that had been lying on resident 24's bedcovers. Residents Affected - Some *She:
-Removed his sock and ace bandage from his right foot/leg.
-Removed a protective dressing from his right ankle. The dressing had a moderate amount of serous sanguineous drainage on it.
*The resident had an open wound and a scabbed wound in that area.
*She:
-Removed her gloves, sanitized her hands, and put on another pair of gloves that had been lying on the resident's bedcovers.
-Took the bottle of wound cleanser and moistened the opened gauze that had been lying on top of a dressing package.
-Cleansed his wounds with that same gauze.
-Took off the gloves and without sanitizing her hands, put on another pair of gloves that had been laying on his bedcovers.
-Opened a package that contained a medicated dressing, cut it with the scissors laying on the resident's bedcovers, moistened it with a syringe of saline that was lying on the resident's bedcovers.
-Placed that dressing on a foam bordered dressing, and applied it to the wounds on the his ankle.
-Removed her gloves, washed her hands, removed her gown and mask, gathered up the rest of the supplies, and placed them on the treatment cart.
-Opened the cart and placed the unused pieces of gauze back into the bulk package that contained clean gauze.
5. Interview on 2/26/25 at 11:25 a.m. with RN B regarding the observations above revealed:
*There was no designated wound care nurse.
*Whomever was assigned on the schedule for that day was responsible for providing the resident's wound care.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 *She had not had any training on wound care and could not recall having wound care competencies completed. Level of Harm - Minimal harm or potential for actual harm *She:
Residents Affected - Some -Confirmed the steps observed above was her usual process for completing the resident's sound care.
-Had not considered that process to be wrong or that it could have created the potential for the residents to acquire an infection.
*She then agreed her wound care process did not follow appropriate infection control practices and could have created the potential for infection and may have interfered with the wound's healing process.
6. Observation on 2/27/25 at 7:18 a.m. with RN B during resident 10's wound care treatment revealed:
*She applied a gown, mask, and gloves.
*There was a barrier placed on the resident's tray table with a bottle of hand sanitizer, two unpacked and dated adhesive dressings, a bottle of skin cleanser, Vaseline in a plastic cup, and unpacked gauze.
*She removed a box of gloves from the wall organizer and placed it onto the barrier with the wound care supplies.
*Resident 10 gave his permission to be observed.
*After performing HH she:
-Applied gloves, placed a barrier under both of his feet, removed the resident's left sock and soiled dressing.
-Discarded her gloves in the garbage can, performed HH, and put on new gloves.
-Sprayed the skin cleanser on a piece of gauze, lifted the resident's left heel, dabbed it with the gauze, and set the left heel on his other foot.
-Discarded her gloves in the garbage can, performed HH, and put on new gloves.
-Lifted the resident's left heel, applied Vaseline, a new dressing, and placed his sock back on.
-Discarded her gloves in the garbage can, performed HH, and put on new gloves.
-Removed the resident's right sock and soiled dressing.
-Discarded her gloves in the garbage can, performed HH, and put on new gloves.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 -Sprayed the skin cleanser on a piece of gauze, lifted the resident's right heel, dabbed it with the gauze, and set the right heel down on the barrier. Level of Harm - Minimal harm or potential for actual harm -Discarded her gloves in the garbage can, performed HH, and put on new gloves.
Residents Affected - Some -Lifted the right heel, applied the Vaseline and a new dressing, and his sock. She then removed the barrier from under the resident's feet.
-Discarded the extra gauze, removed her PPE, performed HH, gathered the hand sanitizer, wound cleanser, and box of gloves off of the barrier they were on and set them on the treatment cart.
*RN B stated she forgot about his abrasion on his coccyx so she would treat that next.
*She set a barrier on the tray table, then set the skin cleanser, bottle of hand sanitizer, gauze, and a folded-up barrier on the barrier.
*She removed a barrier cream from the treatment cart and placed some of it into a plastic cup, set it on the barrier.
*She removed an unopened adhesive dressing from the treatment cart and set it on the barrier.
*She removed the adhesive dressing from the package and labeled it with a marker.
*After she performed HH, she:
-Applied a gown, mask, and gloves, and set the box of gloves from the treatment cart on the barrier.
-Lowered the head of the resident's bed, assisted him to roll onto his side, discarded her gloves into the garbage can, performed HH, and put on new gloves.
-Removed the resident's incontinence brief and soiled bandage.
-Discarded her gloves into the garbage can, set the barrier on the bed and the bottle of skin cleanser and gauze on top of it.
-Performed HH and put on new gloves.
-Sprayed the skin cleanser on a piece of gauze, dabbed the resident's wound, then removed and discarded her gloves.
-Grabbed the new adhesive dressing and barrier cream and set them on the barrier on the bed.
-Performed HH and put on new gloves.
-Applied the barrier cream, wiped off excess cream from her gloved hands onto the resident's incontinence brief and applied the new dressing to his coccyx.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 -With those same gloves, she grabbed the skin cleanser bottle, set it on the barrier on the tray table, re-applied the resident's incontinence brief, and assisted the resident onto his back. Level of Harm - Minimal harm or potential for actual harm -Discarded her gloves in the garbage, performed HH, and put on new gloves, helped the resident reposition and lifted the head of the bed back up. Residents Affected - Some -Removed her PPE, performed HH, grabbed the skin cleanser and box of gloves and set them on the treatment cart.
7. Interview on 2/27/25 immediately following that wound care treatment with RN B revealed:
*She would use EBP with residents who had wounds and catheters.
*She agreed she should have been using EBP with resident 109 during his wound care treatment.
*She agreed she did not perform appropriate HH or infection control practices during her wound care treatments that she provided to residents 109, 42, and 10.
8. Observation on 2/26/25 at 11:20 a.m. with CNAs U and V with resident 12 revealed:
*They had prepared to assist resident 12 with her personal cares and to transfer her out of bed.
*On her door there had been signage that she was on EBP and the staff had been required to wear gloves, gown, and a mask when assisting her with personal care.
*Without sanitizing his hands, CNA U opened the cover of the linen cart and took out several towels.
-He placed those clean towels on the handrail outside of the resident's room.
*Without sanitizing their hands, they put on gloves, gown, and a mask and entered resident 12's room.
*Resident 12 had been awake and lying on her bed.
*CNA U placed the towels inside of the resident's sink, turned the water faucet on to moisten the towels and applied cleansing body soap on them.
*With those same gloved hands CNA U:
-Opened the resident's clothes closet, took out two hanging clothes items, and showed them to the resident for approval.
*They had moved the resident's bed, her bedside table, and the mechanical lift.
*With those same gloved hands CNA U:
-Turned off the water faucet and took the wet towels out of the sink.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 -Placed them on the bedside table and assisted CNA V with removing the resident's incontinent brief and repositioning her. Level of Harm - Minimal harm or potential for actual harm -Took the towels from the bedside table and washed underneath of the resident's abdominal folds.
Residents Affected - Some -Used those same towels to cleanse her perineal area and catheter tubing.
-He assisted CNA V in moving the resident to her left side and used those same towels to cleanse her bottom. He then cleaned the catheter tubing again with those same towels.
-Assisted CNA V with putting on a clean incontinent brief on resident 12 and rolling her to her back.
*The Hoyer (mechanical lift and sling used to move a person's full body) lift. sling was too small and he stated he had to leave the room to get a different one.
*He then removed the PPE and left the room without sanitizing his hands.
9. Interview on 2/26/25 at 12:30 p.m. with CNA U regarding the observation above with resident 12 revealed:
*That had been his usual process for gathering supplies, putting on PPE, and assisting her with her personal hygiene and catheter care.
*He then agreed those practices created the potential for the resident to acquire a urinary tract infection.
*He could not recall having had any education or competencies completed for performing appropriate residents' personal hygiene needs.
10. Observations throughout the building on 2/26/25 from 9:04 a.m. to 9:25 a.m. revealed:
*In the whirlpool tub room on the first floor:
-The rubber bumpers on the whirlpool tub chair were corroded and crumbling apart. It was not a cleanable surface.
-There was a buildup of an unidentified brown and yellow substance in the whirlpool tub where the door sealed with the tub.
-In one of the drawers in the tub room, there was a scattered variety of soiled hair picks, a gait belt, nail clippers, and fingernail brushes.
*In the therapy gym:
-There was a buildup of dust, dirt, and unidentified white flakes in the footwells of the NuStep exercise machine.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 -Resistance bands were tied to the foot pedals on the NuStep exercise machine.
Level of Harm - Minimal harm or -Interview at that time with physical therapist assistant (PTA) Y revealed the physical therapist would potential for actual harm sometimes use the resistance bands to strap the resident's feet in place on the NuStep exercise machine.
She was unsure how often the resistance bands were cleaned. Residents Affected - Some -Some of the dumbbells were rusted, which were uncleanable surfaces.
-PTA Y indicated that they clean the therapy equipment in between each resident use with sanitizing wipes, and the housekeeping staff were responsible for deep cleaning the therapy equipment daily.
11. Interview on 2/27/25 at 9:25 a.m. and 12:27 p.m. with director of nursing (DON) A revealed:
*She confirmed she was the infection preventionist.
*She had not completed competencies on wound care, perineal care, and catheter care.
-That had been one of her future goals.
*She would have expected:
-The staff to sanitize with each glove change and between tasks.
-A barrier to have been used underneath all wound supplies taken into the residents' rooms.
-Staff to wear PPE during all direct care activities with residents who were on EBP which included bathing, using mechanical body lifts, and wound care.
*She confirmed objects such as handrails, bedcovers, the inside of sinks, bedside tables and dressers were all unclean surfaces.
*She was not aware the staff had been placing unused gauze from dressing changes back in the bulk package with clean ones.
-The expectation was that they were to have been thrown away.
*She had last provided staff education on EBP on 9/25/24.
*She confirmed resident 109 had not been on EBP, but he should have been.
*She felt all staff could use more education on infection prevention.
*She has not observed her nurses performing wound care to view their wound care processes and infection control practices.
46453
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 12. Interview on 2/27/25 at 1:55 p.m. with district housekeeping manager BB revealed that the housekeeping staff were responsible for sweeping and mopping the therapy room daily, but the housekeeping staff did not Level of Harm - Minimal harm or deep clean the therapy gym equipment. potential for actual harm 13. Review of the provider's revised 4/26/24 Enhanced Barrier Precautions policy revealed: Residents Affected - Some *1) Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.
*2) EBP are indicated for residents with any of the following:
-b) Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
-d) Chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.
-e) Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.
*6) Enhanced Barrier Precautions requires use of gown and gloves during high contact resident care activities that have been demonstrated to result in transfer of MDROs to hand and clothing of healthcare personnel.
*7) Enhanced Barrier Precautions is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities, including transfers, are bundled together with other high contact activity, such as part of morning or evening care.
*12) for residents for whom EBP are indicated, EMP is employed when performing the following high-contact resident care activities:
-a) Dressing
-b) Bathing/showering
-c) Transferring
-d) Providing hygiene
-e) Changing linens
-f) Changing briefs or assisting with toileting
-g) Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
-h) Wound care: any skin opening requiring a dressing
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 -i) Therapy activities
Level of Harm - Minimal harm or *14) When Enhanced Barrier Precautions are implemented, the Infection Preventionist or designee: potential for actual harm -a) Validates protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room Residents Affected - Some so that everyone entering the room can access what they need.
-b) Posts the appropriate notice on the room entrance door and in the front of the residents' chart so that all personnel will be aware of precautions or be aware that they must first see a nurse to obtain additional information about the situation before entering the room.
14. Review of the provider's updated 4/2018 Handwashing/Hand Hygiene policy revealed:
*7. Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:
-b. Before and after direct contact with residents;
-c. Before preparing or handling medications;
-d. Before performing any non-surgical invasive procedures;
-e. Before and after handling an invasive device (e.g. urinary catheters, IV access sites);
-g. Before handling clean or soiled dressings, gauze pads, etc.;
-h. Before moving from a contaminated body site to a clean body site during resident care/
-i. After contact with a resident's intact skin;
-k. After handling used dressings, contaminated equipment, etc.;
-l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident;
-m. After removing gloves;
-n. Before and after entering isolation precaution settings;
*8. Hand hygiene is the final step after removing and disposing of personal protective equipment.
*9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
15. Review of the provider's updated 4/2012 Charge Nurse Job Description revealed:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0880 *h. Assesses and reports changes in resident's condition, including development of pressure ulcers, to physician, the DNS and responsible party, and takes recommendations for nursing action to be implemented. Level of Harm - Minimal harm or potential for actual harm *4. Assesses on a weekly basis via resident rounds the condition of existing pressure ulcer by stage, size (measurements), sites depth, color, drainage, and odor. Reports problems to the DNS; takes necessary Residents Affected - Some follow up action.
*9. Observes infection control procedures performed by staff to validate compliance.
16. Review of the provider's updated 4/2012 Director of Nursing Services Job Description revealed:
*3. Establishes systems for care planning, including assessments, plan of treatment, objectives and goals, evaluations, and discharge planning. Maintains accurate and timely documentation reflecting same. Coordinates care needs with other departments.
*5. Responsible for recruiting, interviewing, hiring, disciplining, coaching, and conducting performance appraisals on assigned units, or delegating to the appropriate individuals. Confers with ED prior to termination of subordinate staff.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 52 435086 Department of Health & Human Services Printed: 09/07/2025 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 02/27/2025
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 0908 Keep all essential equipment working safely.
Level of Harm - Minimal harm or 46453 potential for actual harm Based on observation and interview, the provider failed to maintain the walk-in cooler and freezer in a Residents Affected - Few functioning manner that met industry standards. Findings include:
1. Observation and interview on 2/25/25 from 8:28 a.m. to 9:09 a.m. in the kitchen with dietary manager L revealed:
*Upon walking into the walk-in cooler and shutting the door, the light from the hallway was clearly visible above the top of the door, indicating the door did not seal properly.
-The gap was large enough to poke several fingers through.
-There was an abundance of an unidentified black and white fuzzy growth on the walls, door frame, floor, and shelving units that appeared to have been mold. Mold growth in a walk-in cooler could potentially be due to improper temperature control.
*There was ice buildup on the ceiling and floor of the walk-in freezer, which indicated improper temperature control.
-At the time of the observation, a side panel of the condenser was hanging and not secured to the condenser unit. The condenser was blowing hot air, which was melting the ice buildup on the ceiling and floor.
*Interview at that time with dietary manager L revealed that he was aware of the issues in the walk-in cooler and freezer.
2. Follow-up interviews with dietary manager L were attempted on 2/27/25, but he was not available.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 52 435086