Safety Report: Riverview Healthcare Center

Flandreau, South Dakota · Based on official CMS inspection records as of October 1, 2026.

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How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★
Health inspections★★★★★
Staffing★★★★★
Quality measures★★★★★
Long-stay quality★★★★★
Short-stay quality★★★★★

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

4Immediate jeopardy citations (severity J–L)
11Actual harm citations (severity G–I)
12Requirements cited on more than one inspection
G
Government finding: Provide enough food/fluids to maintain a resident's health.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of August 28, 2026. Facility reported correction by September 21, 2026.
Quality of Life and Care Deficiencies · Tag F692
G
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of August 28, 2026. Facility reported correction by September 21, 2026.
Quality of Life and Care Deficiencies · Tag F686
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of March 25, 2026, during a complaint investigation. Facility reported correction by March 26, 2026.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of March 25, 2026, during a complaint investigation. Facility reported correction by April 15, 2026.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
G
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of November 18, 2025, during a complaint investigation. Facility reported correction by November 25, 2025.
Quality of Life and Care Deficiencies · Tag F686
G
Government finding: Ensure that residents are free from significant medication errors.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of September 25, 2025, during a complaint investigation. Facility reported correction by September 30, 2025.
Pharmacy Service Deficiencies · Tag F760
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of September 25, 2025, during a complaint investigation. Facility reported correction by September 30, 2025.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of September 25, 2025, during a complaint investigation. Facility reported correction by September 30, 2025.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
G
Government finding: Provide safe, appropriate pain management for a resident who requires such services.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of February 27, 2025. Facility reported correction by March 27, 2025.
Quality of Life and Care Deficiencies · Tag F697
G
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of February 27, 2025. Facility reported correction by March 27, 2025.
Quality of Life and Care Deficiencies · Tag F686
G
Government finding: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of February 27, 2025. Facility reported correction by March 27, 2025.
Quality of Life and Care Deficiencies · Tag F684
J
Government finding: Respond appropriately to all alleged violations.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of January 8, 2025, during a complaint investigation. Facility reported correction by January 25, 2025.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F610
J
Government finding: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of January 8, 2025, during a complaint investigation. Facility reported correction by January 25, 2025.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F609
J
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of January 8, 2025, during a complaint investigation. Facility reported correction by January 25, 2025.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
G
Government finding: Respond appropriately to all alleged violations.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of October 31, 2024, during a complaint investigation. Facility reported correction by November 26, 2024.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F610

Citations by topic

9Abuse, neglect & exploitation
3Infection control
6Medications & pharmacy
3Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

More citations in the most recent cycle (23) than in the cycle before (19).

Two cycles ago
none serious
Prior cycle
10 serious
Most recent cycle
5 serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

RequirementTimes citedInspection dates
Respond appropriately to all alleged violations. (F610)4August 28, 2026; January 28, 2026; January 8, 2025; October 31, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686)3August 28, 2026; November 18, 2025; February 27, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684)3August 28, 2026; January 28, 2026; February 27, 2025
Provide and implement an infection prevention and control program. (F880)3August 28, 2026; February 27, 2025; February 15, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689)3March 25, 2026; November 18, 2025; September 25, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600)3March 25, 2026; September 25, 2025; January 8, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755)2August 28, 2026; June 2, 2026
Ensure that residents are free from significant medication errors. (F760)2August 28, 2026; September 25, 2025
Keep residents' personal and medical records private and confidential. (F583)2August 28, 2026; January 8, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609)2January 28, 2026; January 8, 2025
Provide safe, appropriate pain management for a resident who requires such services. (F697)2September 25, 2025; February 27, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812)2February 27, 2025; February 15, 2024

Fines and enforcement

DateTypeAmount / length
March 25, 2026Fine$20,476
November 18, 2025Fine$15,807
September 25, 2025Fine$36,414
February 27, 2025Fine$65,520
January 8, 2025Fine$15,330
October 31, 2024Fine$12,529

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

44 citations across 10 inspection dates.

August 28, 2026 — 15 citations (includes serious)
G
Provide enough food/fluids to maintain a resident's health.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F692 · corrected September 21, 2026
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F686 · corrected September 21, 2026
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · complaint · corrected September 21, 2026
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · complaint · corrected September 21, 2026
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected September 21, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected September 21, 2026
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected September 21, 2026
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected September 21, 2026
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected September 21, 2026
D
Post nurse staffing information every day.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F732 · corrected September 21, 2026
D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F726 · complaint · corrected September 21, 2026
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · complaint · corrected September 21, 2026
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected September 21, 2026
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected September 21, 2026
D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F561 · complaint · corrected September 21, 2026
June 2, 2026 — 1 citation · complaint investigation
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · complaint · corrected June 18, 2026
March 25, 2026 — 2 citations (includes serious) · complaint investigation
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 26, 2026
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected April 15, 2026
January 28, 2026 — 3 citations · complaint investigation
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected February 14, 2026
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected February 14, 2026
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected February 14, 2026
November 18, 2025 — 2 citations (includes serious) · complaint investigation
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected November 25, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected October 9, 2025
September 25, 2025 — 4 citations (includes serious) · complaint investigation
G
Ensure that residents are free from significant medication errors.
Actual harm to a resident (not immediate jeopardy) · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected September 30, 2025
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · complaint · corrected September 30, 2025
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected September 30, 2025
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · complaint · corrected September 30, 2025
February 27, 2025 — 9 citations (includes serious)
G
Provide safe, appropriate pain management for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F697 · corrected March 27, 2025
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F686 · corrected March 27, 2025
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F684 · corrected March 27, 2025
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected April 14, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected April 14, 2025
E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected March 27, 2025
D
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F908 · corrected March 27, 2025
D
Have a plan that describes the process for conducting QAPI and QAA activities.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F865 · corrected March 27, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected March 27, 2025
January 8, 2025 — 5 citations (includes serious) · complaint investigation
J
Respond appropriately to all alleged violations.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected January 25, 2025
J
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected January 25, 2025
J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Immediate jeopardy to resident health or safety · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected January 25, 2025
E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F835 · complaint · corrected January 25, 2025
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · complaint · corrected January 25, 2025
October 31, 2024 — 1 citation (includes serious) · complaint investigation
G
Respond appropriately to all alleged violations.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected November 26, 2024
February 15, 2024 — 2 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected March 15, 2024
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected March 15, 2024

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare

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