Riverview Healthcare Center
611 East 2nd Ave · Flandreau, SD · 57028 · 6059972481
63 certified beds For profit - Limited Liability company Chain: Evergreen Healthcare Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $204,860 in fines in the last 24 months.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
6 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
8 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$204,860 in federal fines in the last 24 months
6 fines — CMS fines are reserved for verified, serious non-compliance.
65% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.36 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.60 | 0.55–0.75 |
| Weekend hours / resident-day | 2.96 | ≈ weekday level |
| Nursing turnover / year | 65% | median 45% |
| Fines (3-yr window) | 6 · $204,860 |
Inspection citations (35 in the current record)
-
Immediate jeopardy · J March 25, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 26, 2026 · Quality of Life and Care
-
Actual harm · G March 25, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 15, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · E January 28, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 14, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D January 28, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected February 14, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · E January 28, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 14, 2026 · Quality of Life and Care
-
Actual harm · G November 18, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 25, 2025 · Quality of Life and Care
-
Potential for harm · D November 18, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 9, 2025 · Quality of Life and Care
-
Actual harm · G September 25, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G September 25, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected September 30, 2025 · Quality of Life and Care
-
Actual harm · G September 25, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected September 30, 2025 · Pharmacy Service
-
Potential for harm · E September 25, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 30, 2025 · Quality of Life and Care
-
Actual harm · G February 27, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 27, 2025 · Quality of Life and Care
-
Actual harm · G February 27, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 27, 2025 · Quality of Life and Care
-
Actual harm · G February 27, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected March 27, 2025 · Quality of Life and Care
-
Potential for harm · E February 27, 2025
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.
Corrected March 27, 2025 · Resident Rights
-
Potential for harm · D February 27, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 27, 2025 · Resident Assessment and Care Planning
-
Potential for harm · F February 27, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 14, 2025 · Nutrition and Dietary
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Potential for harm · D February 27, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected March 27, 2025 · Administration
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Potential for harm · E February 27, 2025
Provide and implement an infection prevention and control program.
Corrected April 14, 2025 · Infection Control
-
Potential for harm · D February 27, 2025
Keep all essential equipment working safely.
Corrected March 27, 2025 · Environmental
-
Immediate jeopardy · J January 8, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J January 8, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J January 8, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected January 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D January 8, 2025 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected January 25, 2025 · Resident Rights
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Potential for harm · E January 8, 2025 · found via complaint
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected January 25, 2025 · Administration
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 25, 2026 | Fine | $31,500 |
| November 18, 2025 | Fine | $23,960 |
| September 25, 2025 | Fine | $56,021 |
| February 27, 2025 | Fine | $65,520 |
| January 8, 2025 | Fine | $15,330 |
| October 31, 2024 | Fine | $12,529 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435086 · certified since April 1, 1995. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.