Riverview Healthcare Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

35.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 61 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 33 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 63 beds and averages 54.2 residents a day — about 86% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 3.79 on weekdays — 16% thinner on weekends. RN hours go from 0.70 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

36 citations, most serious first. The 24 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-03-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Immediate Jeopardy (IJ) at F689, scope and severity J, began on [DATE] at 5:40 p.m. when resident 3 was lowered to the floor during a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-01-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing via email on 1/6/25 at 8:32 p.m. to executive director (ED) A, director of nursing (DON) B, and over the phone to division director of clinical operations (DDCO) C for F600 related to allegations of physical, mental, and verbal abuse that several staff had reported with no actions taken to protect the residents from further potential abuse. A plan for removal of the immediacy was requested. On 1/7/25 at 10:20 a.m., DDCO C provided a written plan for removal of the immediate jeopardy via email. The removal plan, after agreed-upon revisions, with guidance from the long-term care advisor for the SD DOH, was approved on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-01-08 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy at F609 was given verbally and in writing via email on 1/8/25 at 3:57 p.m. to director of nursing (DON) B and division director of clinical operations (DDCO) C relating to failure to report allegations of abuse. A plan for removal of the immediacy was requested. On 1/8/25 at 4:30 p.m., DDCO C emailed a written plan for the removal of the immediate jeopardy. The removal plan was approved soon after 4:30 p.m. on 1/8/25. It was determined that the removal plan for F600 sent on 1/7/25 at 12:56 p.m. included action items to report the allegations of abuse to the required entities. F609. The provider learned about concerns regarding the care and services a CNA was providing to residents on 1/1/25 at…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-01-08 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy at F610 was given verbally and in writing via email on 1/8/25 at 3:57 p.m. to director of nursing (DON) B and division director of clinical operations (DDCO) C relating to failure to report allegations of abuse. A plan for removal of the immediacy was requested. On 1/8/25 at 4:30 p.m., DDCO C emailed a written plan for the removal of the immediate jeopardy. The removal plan was approved soon after 4:30 p.m. on 1/8/25. It was determined that the removal plan for F600 sent on 1/7/25 at 12:56 p.m. included action items to report the allegations of abuse to the required entities. F610. The provider learned about concerns regarding the care and services a CNA was providing to residents on 1/1/25 at around 1:30…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include:1. Review of the provider's 2/9/26 final SD DOH FRI revealed that resident 2 was found sitting on the toilet in the beauty shop bathroom at around 4:20 p.m. on 2/7/26. He required the use of the sit-to-stand lift for transfers, and that lift was left attached to the resident. The door…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-11-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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).Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed that she was admitted on [DATE] with diagnoses of sepsis (a life-threatening condition caused by the body's extreme response to an infection), pneumonia (a lung infection), epilepsy (a neurological condition causing seizures), neuromuscular dysfunction of bladder (bladder control problems caused by nerve or muscle signal issues), restlessness and agitation, dysphagia (difficulty swallowing), major…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-09-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. The resident reported that interaction caused her increased anxiety.*One of one certified medication aide (CMA) U who refused refused to assist a resident with taking medication for one of one sampled resident (6) who cried and expressed feelings of emotional distress.*One of one CNA V who told a resident he would fight him, grabbed the resident's arm, and took a breakfast bar from one of one sampled resident (5) with diet restrictions who took a breakfast bar from a snack cart.Findings include: 1. Review of the provider's 8/19/25 SD DOH FRI revealed: *On 9/19/25, resident 7 reported to social services designee (SSD) E that she used her…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-09-25 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: 1. Observation and interview on 9/24/25 at 8:50 a.m. with resident 7 revealed:* She had resided at the facility for about a month.*She had increased pain over the past several days.*She reported that her pain was not being adequately controlled and was getting worse.*Her left lower abdomen was visibly swollen.*She reported she was not able to turn to her side anymore due to the discomfort.*She stated, the nurses have looked at it, but she did not feel anything was being done.*She stated, I'd like to see my specialist. 2. Review of resident 7's electronic medical record (EMR) revealed:*She had medical diagnoses that included secondary malignant neoplasm (cancer) of other digestive organs, acute kidney failure (kidney's inability to filter blood properly), and anxiety…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-09-25 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Review of the provider's SD DOH FRI received on 9/3/25 revealed:*Resident 2 did not receive five doses of his physician-ordered scheduled anti-seizure medication.*On 9/2/25, resident 2 had seizures that lasted longer than five minutes.*He was sent to the emergency department (ED) for evaluation due to his increased seizure activity. 2. Review of resident 2's electronic medical record (EMR) revealed.*He had orders to receive Zonisamide (a medication to treat seizures) 100 milligrams (mg)/5 milliliters (ml) scheduled twice daily…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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). Findings include: 1. Interview on 2/25/25 at 10:11 a.m. with resident 20 and his wife in their room revealed: *He had a sore on his bottom. *He was supposed to have his wound dressing changed every other day in the evenings. *Both resident 20 and his wife indicated that CNA J had performed the wound dressing change that previous evening. *They indicated that RN R was supposed to have completed the wound dressing change, not CNA J. *They described a specific type of ointment that was placed on the wound. They mentioned the word collagen. Review of resident 20's electronic medical record (EMR) revealed: *His 1/7/25 annual Minimum Data Set assessment indicated a Brief Interview for Mental…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: 1. Observation on 2/25/25 at 10:08 a.m. of resident 10 revealed: *He was in his room and lying on the bed with a nursing home gown on. *He was laying mostly on his back with a pillow placed underneath of his right arm. -His body was positioned and was facing towards the wall with the upper portion of his body towards the left of the bed. -From his waist down his body was laying on the right side of the bed. -His buttocks and thighs laid directly on the mattress. *There was a heel lift device underneath the lower part of his legs to help decrease pressure from the mattress on his heels.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-27 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview record review and policy review provider failed to recognize and adequately manage pain for one of two hospice sampled resident (49). Findings include: 1. Observation on 2/25/25 at 2:11 p.m. revealed: *Resident 49 was being repositioned by certified nursing assistant (CNA) F and hospice registered nurse (RN) G. *Resident 49 could be heard in the hall moaning. *Resident grimaced and moaned in pain with any repositioning. 2. Observation and interview on 2/26/25 at 8:31 a.m. with CNA D revealed: *CNA was repositioning and checking resident 49 for incontinence every two hours. *Resident 49 grimaced and moaned in pain with even small movement. *Resident 49 would shout help, help with repositioning. *CNA made effort to be very gentle with the resident, but the resident was still in pain. *He reported resident 49 has had increased pain with repositioning for the past several days. *CNA reported his increased pain to RN E. 3. Interview on 2/26/25 at 8:40 a.m. with RN E revealed: *She tried to assess resident 49's pain as often as possible. *She also relied on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-31 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: 1. Review of the 10/11/24 SD DOH complaint intake report revealed: *Resident 1 had eloped. Staff found him approximately a half mile away and returned him to the facility. *Resident 1 has since moved to another facility. *The provider had completed a SD DOH FRI report. 2. Review of the provider's 7/17/24 SD DOH FRI report revealed: *Resident 1 was found in a wheelchair by staff at 12:10 p.m. on 7/17/24 on sidewalk outside facility. *Charge nurse was notified of elopement. *His vital signs were taken and were within normal limits. *Resident 1 stated he wanted to go home. *His Brief Interview for Mental Status (BIMS)assessment score was 10, which…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-02-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Observation on 2/14/23 at 10:58 a.m. of resident 30 revealed he: *Was sleeping in a recliner in his room with his feet elevated. *Had a Prevalon boot (cushioned boot that floats the heel to reduce pressure) under his left ankle propping his heel off the footrest of the chair. 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…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-02 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:1. Review of the provider's 5/27/26 SD DOH FRI revealed that at approximately 5:00 a.m. on 5/27/26, staff found resident 1 in his room with a lighter after a small fire ignited and damaged a plastic water mug, part of his mattress, and his bed linens. Resident 2, resident 1's roommate, had alerted the staff, who quickly extinguished the fire with water and evacuated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2026-01-28 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include:1. Interview and review of the SD DOH FRI (a required reporting of unexpected or adverse events) reports and 1/22/26 SD DOH complaints records with administrator A and director of nursing (DON) B on 1/28/26 at 6:51 p.m. revealed: *Resident 1 reported an allegation of abuse on 1/3/26 at 6:00 p.m. -The initial report was submitted on 1/14/26 at 9:45 a.m. -The final investigation report was submitted on 1/16/25. -The complaints record stated, The facility failed to ensure timely reporting for Resident [1]. Review of reporting records showed the initial report was not submitted until 1/14/26, approximately 11 days after the event occurred. Additionally, while a final report was submitted on 1/16/26, the initial…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-28 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:1. Interview on 1/28/26 at 2:20 p.m. with resident 4 in his room revealed:*He had his urine tested in Sioux Falls, he was unsure when, but it had been negative, but he continued to have burning with urination. 2. Review resident 4's paper and electronic medical record (EMR) revealed:*He was admitted to the facility on [DATE].*He had diagnoses of alcoholic cirrhosis of the liver with ascites (extensive scarring and fluid buildup caused by long-term alcohol use) and acute kidney failure (sudden…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include:1. Review of the initial 1/14/26 SD DOH FRI dated revealed:*Resident 1 had an abuse allegation involving CNA K on 1/3/26 at 6:00 p.m. *Resident 1 alleged that during the provision of care, CNA K verbally assaulted him, slapped him, and pushed him into his bed.*Upon the allegation being reported to the CNA J on 1/6/26.*Interviews were conducted with resident 1 and the staff members involved in the incident.*Resident 1 was assessed with no signs or symptoms of injury. *Resident 1's family, physician, and local police department.*A full investigation was in process, and a final…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: 1. Review of the provider's final FRI received by the SD DOH on 10/20/25 revealed that on 10/9/25, resident 1 was scheduled for a bath and was assisted to the whirlpool tub chair using the full-body mechanical lift. CNA D and another CNA assisted resident 1 into the bath chair. CNA D brought resident 1 in the bath chair to the whirlpool bathtub and gave the resident a bath. After the bath and while still sitting in the bath chair, CNA D wheeled resident 1 out and away…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2025-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:1. Review of the provider's 7/3/25 SD DOH FRI revealed:*On 7/3/25, registered nurse (RN) Q noticed resident 1 was missing at 8:15 p.m., and instructed facility staff members to search all rooms and the perimeter of the facility.*The sheriff was notified, and the search was extended into the community.*Resident 1 exited the doors leading to the patio area. The door is not alarmed but is wanderguard [WanderGuard door alarming system] protected.*Resident 1 had not signed out at the nurses' station or let staff know he was leaving.*Resident 1 stated he…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-02-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). *Incomplete temperature monitoring for two of at least three communal resident food and beverage refrigerators. Findings include: 1.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-27 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: 1. Observation on 2/25/25 at 9:48 a.m. of the bathroom shared by residents 6, 9, and 34 revealed: *The ceiling consisted of bare chicken-wire-type metal sheeting. *There was plaster stuck to parts of the chicken wire. *A portion of the chicken wire had been partially cut out from the rest. It was hanging down and was attached by five pieces of wire twisted around it. The pieces of wire looked like bread bag twist ties. *The piece of chicken wire that was hanging down was directly above the toilet. -If a person were sitting on the toilet and the piece of chicken wire fell, it would have landed on top of that person. *Interview at that time with resident 9 revealed that ceiling had been like that for quite some time, but she could not remember exactly how long. 2. Observations throughout the building on 2/26/25 from 9:04 a.m. to 9:25 a.m. revealed: *The door frame of an emergency…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-27 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: 1. Observation and interview on 2/26/25 at 7:39 a.m. with RN B during resident 109's wound care treatment revealed: *There was no sign that indicated staff needed to use enhanced barrier precautions (EBP) or personal protective equipment (PPE) while providing his care posted outside or inside his room. *She had two adhesive dressings and a hydrocolloid patch (wound healing product) with the date labeled on them laying on a treatment cart. *She performed hand hygiene (HH) with hand…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-27 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings include: 1. Observation and interview on 2/25/25 at 10:50 a.m. with resident 10 in his room revealed: *He was lying in bed and had a breakfast tray on his side table. *He stated he had wanted to stay in bed for breakfast. *He had a catheter and a feet elevation cushion (to keep heels off the bed) which was not positioned correctly, and his heels were touching the bed. Interview on 2/26/25 at 7:27 a.m. with registered nurse (RN) B revealed: *Resident 10 had a stage II pressure ulcer (wound with partial thickness skin tissue loss from prolonged pressure) on each heel. *She had already done the pressure ulcer wound care. Review of resident 10's electronic medical record (EMR) revealed he had: *A stage II pressure ulcer was found on his right heel on 8/26/2024. *A stage II pressure ulcer was found on his left heel on 1/3/2025. *A…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$176,867 in federal fines across 6 penalties.

• $31,500 — penalty dated 2026-03-25
• $15,574 — penalty dated 2025-11-18
• $36,414 — penalty dated 2025-09-25
• $65,520 — penalty dated 2025-02-27
• $15,330 — penalty dated 2025-01-08
• $12,529 — penalty dated 2024-10-31

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 40 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $114K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD