Riverview Healthcare Center

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure two of two registered nurses (RNs) (D and J) had access to the emergency medication kit (e-kit) for one of one sampled resident (1) who subsequently did not receive his antipsychotic medication (a drug that alters specific brain activities to reduce symptoms of mental health conditions) and hallucinated and started a fire in his bedroom. Certified nursing assistant (CNA) K and RN J extinguished the fire, and no residents were injured as a result of the fire.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, record review, and policy review, the provider failed to ensure residents were protected from risk of injury or harm by certified nursing assistants (CNAs) who failed to safely use total body lift devices (a mechanical lift and sling used to lift a person's full body) for two of two sampled residents (1 and 3), who needed the assistance of two staff members to transfer between surfaces. Contracted travel CNAs I and H failed to safely transfer resident 1 from her wheelchair to her bed using the total body lift. CNAs K and L failed to use a compatible sling type to transfer resident 3 using the total body lift. That failure put all residents, who needed staff assistance with the use of a lift for safe transfers, at risk for falling, injury and/or serious harm. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and observation, the provider failed to protect a resident's right to be free from potential neglect by one of one certified medication aide (CMA) (N) who left one of one sampled resident (2) unattended on the toilet for about two hours. Resident 2 was identified at risk for falling and developing pressure ulcers (skin and/or underlying tissue injury from prolonged pressure), and needed staff assistance with the use of a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) to transfer on and off the toilet. That failure resulted in the resident having reddened skin on his buttocks with risk for that area developing into a pressure ulcer.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), SD DOH complaint records, interview, and policy review, the provider failed to report a FRI and results of their final investigation to the SD DOH within the required time frame regarding nine of nine residents (1, 6, 7, 8, 9, 10, 11, and 12) who had a reportable incident.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure care services were provided for:*One of one resident (4) who had pain with urination, a temperature, and physician's orders to collect a urine sample on 1/12/26, which was not collected by the provider, and may have delayed treatment.*One of one resident (5) who had black stools, strong-smelling urine, and physician's orders to collect lab work on 1/9/26, which was not collected until 1/14/26, and may have delayed treatment.

Inspectors wroteBased on review of the provider's South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure one of one resident (1) who reported an abuse allegation towards a certified nursing assistant (CNA) K, was reported within the required time frame. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to implement wound treatment orders for one of one sampled resident (1) with blisters on her buttocks and identified at risk for developing pressure ulcers, which resulted in the blisters going untreated for several days and the development of a stage 2 pressure ulcer (skin wound caused by prolonged pressure where the first two layers of skin are damaged, and the area appears as a shallow, open wound or an intact or ruptured blister) on her sacrum (lower back).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, and record review, the provider failed to ensure that a certified nursing assistant (CNA) (D) used the whirlpool bath chair safety belt while bathing one of one sampled resident (1) who fell out of the bath chair and was sent to the local emergency room for evaluation. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on review of South Dakota Department of Health Facility Reported Incident (SD DOH FRI), interview, record review, and policy review, the provider failed to protect the resident's right to be free of abuse by:*One of one certified nursing assistant (CNA) T who slapped a resident's door and told that resident that she would get her pain medication when her name came up on the nurse's list, when one of one resident (7) requested pain medication. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to provide effective pain management to one of one resident (7) who transferred to the emergency department with complaints of increased pain.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incidents (FRIs), interview, record review, and policy review, the provider failed to ensure medications were available and administered to:*One of one sampled resident (2) who did not receive physician-ordered anti-seizure medication for five doses and who had increased seizure episodes that resulted in the resident's transfer to the emergency department.*One of one sampled resident (4) who did not receive his physician-ordered blood clot preventing medication for 7 daysFindings include: 1. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to implement interventions to ensure the safety of two of two sampled residents (1 and 2) who eloped (left the facility without staff knowledge). Failure of the staff to ensure adequate supervision and interventions put those residents at risk for physical injury or serious harm.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure quality of care was provided related to one of one sampled resident's (20) wound care improperly delegated by registered nurse (RN) R to certified nurse assistant (CNA) J, hospice coordination of care for two of two sampled residents (12 and 49), and pain management for one of one sampled resident (49).

Inspectors wroteBased 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).

Inspectors wroteBased on observation, interview record review and policy review provider failed to recognize and adequately manage pain for one of two hospice sampled resident (49).

Inspectors wroteBased 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). [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to maintain a homelike environment that was free from major damages to the walls, floors, ceilings, and door frames.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure infection control and 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.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to revise and update a care plan to reflect the current needs for one of one (10) sampled resident with pressure ulcers to his heels and an abrasion to his coccyx.

Inspectors wroteBased on interviews, and quality assurance and performance improvement (QAPI) plan policy review, the 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.

Inspectors wroteBased on observation and interview, the provider failed to maintain the walk-in cooler and freezer in a functioning manner that met industry standards.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to protect two of seven sampled residents' (7 and 9) right to be free from physical, mental, and verbal abuse by certified nursing assistant (CNA) J.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to notify the required entities of allegations of physical, mental, and verbal abuse by certified nursing assistant (CNA) J towards two of seven sampled residents (7 and 9).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to thoroughly investigate allegations of physical, mental, and verbal abuse by certified nursing assistant (CNA) J towards two of seven sampled residents (7 and 9).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to ensure the facility was operated and administered by executive director (ED) A and director of nursing (DON) B in a manner that ensured the safety and overall well-being of all 62 residents in the facility. Those areas included: *Maintaining an effective abuse and neglect prohibition program that included following policies and procedures related to mandatory reporting and investigations of all allegations of abuse, relating to allegations of physical, verbal, and mental abuse by certified nursing assistant (CNA) J toward 2 of 7 sampled residents (7 and 9). *Maintaining 3 of 62 residents' (1, 3, and 6) right to personal privacy due to anonymous staff member M using their cellphone to secretly record private resident conversations.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to uphold a resident's right to personal privacy for at least 3 of 62 residents (1, 3, and 6) due to anonymous staff member M using their cellphone to secretly record private resident conversations.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake report, SD DOH facility reported incident (FRI) report, record review, interview, job description and policy review, the provider failed to ensure a thorough investigation was completed for one of one sampled resident (1) identified at risk for elopement who eloped (left the facility without staff knowledge), was found and returned to the facility by staff.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure food safety guidelines were followed by properly storing and labeling food items, not allowing a dog into the food production area, and maintenance of the following equipment in a clean and sanitary manner: *One of three kitchen windows. *One of one food mixer. *Two of two sets of stainless-steel shelves in front of the stove and oven. *One of one ventilation hood. *One of one refrigerator door. *Mop boards throughout the kitchen. *The back of the convection oven, the stove and oven, and the warming oven. *The interior of one of one microwave oven. *The floor of the walk-in freezer.

Inspectors wroteBased on observation, interview, employee competency review, and policy review, the provider failed to ensure appropriate infection control practices were followed during two of three observed wound dressing changes.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to report an incident for one of one sampled resident (1) who had a fall with a head injury according to South Dakota Department of Health (SD DOH) guidelines.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (1) had the care plan revised and updated to reflect the following: *Her [DATE] witnessed fall. *How to care for her broken left arm which required the use of a sling for immobilization. *Her daughter's request to have been contacted regarding her mother whenever there had been any change in her condition or care.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure professional standards of practice were followed for one of one sampled resident (1) for failure to: *Provide staff supervision of one of one sampled resident (1) by two of two registered nurses (RN) (E and K) to have prevented her fall on [DATE]. *Notify her physician and family member of the change in condition on [DATE] and obtain new physician orders for continuation of care. *Document the absence of vital signs for her death record.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two of four sampled residents (12 and 30) who were at risk of skin breakdown had: *Preventative measures implemented to prevent pressure ulcers from developing. *Care plans updated to reflect the current interventions to prevent skin breakdown.

Inspectors wroteBased on observation, and interview, the provider failed to ensure a clean and sanitary environment had been maintained for one of one main kitchen and two of two kitchenettes that provided food service to all 49 residents in the facility.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a thorough and accurately documented investigation had been conducted for one of one sampled resident (16) after a fall from her wheelchair and sustained a right femur fracture.

Inspectors wrote3. Observation and interview on 2/14/23 at 4:30 p.m. with resident 30 revealed he: *Was sitting in a recliner in his room with his feet elevated. *Had a Prevalon boot placed on his left foot. Review of resident 30's medical record revealed: *He had been admitted on [DATE]. *His 12/20/22 brief interview for mental status (BIMS) score was 15, indicating his cognition was intact. *His diagnosis included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, heart failure, atrial fibrillation, chronic pain syndrome, type II diabetes, and disorder of the skin and subcutaneous tissue. *He had an unstageable pressure ulcer to his left heel from 3/9/22 through 3/30/22. *On 12/17/23 he was found to have developed an unstageable pressure ulcer to his left heel again. -The pressure ulcer was healed on 1/9/23. [...]