Riverview Healthcare Center
RIVERVIEW HEALTHCARE CENTER in FLANDREAU, SD — inspection on September 25, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the provider's 3/2025 CNA job description revealed: *”Reporting Relationships, 1.
Reports to the Licensed Nurse directing and overseeing resident care on assigned unit.” Review of the provider's 10/2022 Abuse Reporting and Response policy revealed: *“Policy Statement: The center immediately reports all suspected and or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and feral law.” -“Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director.” -“Reports of alleged violations by others such as staff, residents, visitors, other health care providers, or others do not need to be explicitly characterized as “abuse”, “neglect”, “mistreatment”, or “exploitation” to require reporting, investigation, and further necessary steps.” *”The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law (such as Adult Protective Services and local law enforcement) as follows:” *”c.
Serious bodily injury means an injury involves extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.” Review of the provider's 10/2022 Abuse Investigation policy revealed: *”Policy Statement: The center conducts a thorough investigation of potential, suspected and or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown origin, in accordance with state and federal regulations.” -“The center identifies and interviews, involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.” -“ The center protects the alleged victim during and after the course of the investigation.”
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Center
611 East 2nd Ave Flandreau, SD 57028
SUMMARY STATEMENT OF DEFICIENCIES
Review of the provider's updated February 2025 Elopement/Wandering policy revealed:*Elopement: The resident/patient exits the Center without staff knowledge OR the resident/patient enters an unsafe area without staff knowledge or presence.*A resident exits the front door without staff knowledge or presence.
This is elopement.*A resident with substance use disorder, leaves the premises without signing out or doesn't let staff know they are leaving.
This is an SUD [substance use disorder] elopement.*Based on the result of the Elopement/Exit seeking Evaluation, care plan interventions to manage wandering and/or exit seeking behaviors are initiated/implemented.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Center
611 East 2nd Ave Flandreau, SD 57028
SUMMARY STATEMENT OF DEFICIENCIES
Review of the provider's 6/2025 pain management policy revealed:*Policy Statement: It is the policy of this center that resident's receive care to attain and maintain the highest quality of care and life.*4) 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 PAINAD (Pain Assessment in Advanced Dementia).*6) If it is determined that pain is not controlled to the resident satisfaction, the medical provider is consulted, and the resident remains on alert charting.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Center
611 East 2nd Ave Flandreau, SD 57028
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility's medication re-order sheet from 8/31/25 revealed:*A request for a refill of resident 2's Zonisamide.-with comments that included Total Quantity Remaining-0, Unable to give this morning.
Next [dose] due [on] 8/31/25 [at] 2000 [8 p.m.].*The bottom of the medication reorder sheet included instructions to, *Please reorder medication in advance (3 day minimum) of need to assure an adequate supply is on hand.* 12.
Review of the provider's SD DOH FRI received on 8/13/25 revealed:*Resident 4 did not receive his coumadin, a blood thinning medication used to prevent blood clots from 8/7/25 through 8/12/25.*The provider reported that the resident's coumadin medication was unavailable due to an updated lab schedule. 13.
Review of resident 4's EMR revealed:*Resident 4 was to receive Coumadin every day to prevent blood clots.*There was no administration of Coumadin from 8/7/25 through 8/12/25. 13.
Interview on 9/23/25 at 4:20 p.m. with registered RN G regarding resident 4's missed doses of coumadin revealed:*She reported that resident 4 had recently had a change in his lab schedule to determine is dose of Coumadin.-The order was changed from every week to every two weeks and pharmacy must not have been notified.-The pharmacy would adjust resident 4's Coumadin dose each week based on his lab values.-Because there were no new lab values, pharmacy did not re-order the resident's Coumadin.*She stated Something definitely should have been done. -She did not say exactly what should have been done. 14.
Review of the provider's January 2022 medication ordering and receiving from pharmacy provider policy revealed:*Procedure, Section 1. C, All medications shall be reordered in advance by writing the medication and prescription number, or applying the peel-off bar coded label from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to [the] pharmacy.
Facility ID: