Riverview Healthcare Center

F 0600

*Former assistant director of nursing (ADON) DD and the former DON CC were notified of the incident directly after it had occurred.

Level of Harm - Actual harm -They were not interviewed as they no longer work at the facility.

Residents Affected - Few

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.”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident 2 had been found outside in front of the building; she was unsure how he had gotten there. DON B explained that it had been determined that resident 2's WanderGuard needed to be on his left ankle when worn on his lower legs to activate the alarm.*They expected that the staff members would have signed residents out in the binder at the nurses' station and entered the door code to allow residents to access the patio, and that residents would be signed back in, in that same binder, to track who was out on the patio.-Most residents did not require a staff member to remain on the patio with them unless it had been determined that they were unsafe to be on the patio unsupervised, and they had a WanderGuard. A staff member would supervise a resident with a WanderGuard when they were out on the patio.*They expected that residents assessed to be safe to leave the facility independently would sign out in the sign-out book and be allowed to exit the facility through the main entrance doors. All other residents would be signed out and then supervised by a family member or staff member when leaving the facility through the main entrance doors. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

but easily awaken. Asked her about her chronic lower abd [abdominal] pain stated she wants more pain med [medication]. Pain rated 10/10. Administer 5 mg [milligrams] oxycodone per tubing. Asked resident if

she wants to be seen @ [at] clinic now since rounds visit today was cancelled. Stated she will wait until [NAME]. [tomorrow] a.m [morning]. if [a] Physician will be here.*A progress note entered on 9/24/25 at 5:43 p.m. by RN Q stated, [Resident 7's] Daughter is here. Spoke to her, resident concern. Lower abdomen is getting bigger having a lot of pain rated 10/10. Administer PRN oxycodone 5 mg. Offered resident to go to ER [emergency room] to be seen there. Agreed. Refuses to go with ambulance. Her daughter transported her to the [[NAME] Flandreau Hospital] hosp. [hospital] ER.*A progress note entered on 9/24/25 at 11:50 p.m. by RN Q stated, Resident was sent to SF [another town] per [[NAME] Flandreau Hospital] ER (emergency room).*A progress note entered on 9/25/25 at 8:18 a.m. by director of nursing (DON) B stated, Spoke with RN on Oncology unit, stated that resident [resident 7] has been admitted [to the facility]. 3.

Interview and record review on 9/24/25 at 4:30 p.m with social services designee E revealed:*A progress note dated 9/23/25 at 11:22 p.m. had no writing in it.*Social service designee E reported that she had not finished the note, but it was because resident 7 had notified her of increased pain. 4. Interview on 9/24/25 at 4:35 p.m. with registered nurse (RN) Q regarding resident 7's pain revealed:*She was concerned about resident 7's pain because the resident frequently reported a pain level of six on a zero-to-ten scale and rated her pain that day at ten.*She stated Today is the first day she [resident 7] has been like this. 5.

Interview on 7/25/25 at 9:52 a.m. with RN G regarding resident 7's pain revealed:*She felt resident 7 was tough to read, was anxious and always rated her pain at six on a zero-to-ten scale.*After resident 7 got Tylenol (medication for mild pain) or Oxycodone (a prescription for moderate to severe pain), she would say that her pain was better. 6. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0760 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to the type of medication and the outcome of resident 2's seizure episodes, followed by the resident's transfer to the ED. 11. 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.

Event ID:

Facility ID:

If continuation sheet