Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Valley Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
A resident with heart disease and severe cognitive impairment was sent to the ED three times for respiratory changes including crackles, wheezing, shortness of breath, hoarse voice, and low O2 saturation, but the facility had no documentation that the provider was notified for any of the transfers. Staff notified family and the on-call nurse/DON, and an LPN stated the facility would send residents out without calling the provider first; the DON stated a provider would not necessarily be notified when a resident’s condition changed requiring ED transfer.
Incorrect MDS Coding for Pressure Ulcer: A resident admitted with a sacral pressure ulcer and documented coccyx wound had an admission MDS that incorrectly indicated no unhealed pressure ulcers/injuries. Later MDS documentation, the care plan, and staff interviews confirmed the wound should have been coded as a pressure ulcer, and the MDS nurse acknowledged the coding error while the MDS specialist confirmed it was miscoded.
A resident with a pressure-related right foot wound did not receive the ordered wound treatment when an LPN reported the lodosorb was unavailable and applied only Aquacel and a foam dressing. The LPN did not notify the provider, wound care team, or RN manager at the time, and later acknowledged forgetting to call. The DON and wound care RN stated staff are expected to follow provider orders and notify the provider if supplies are unavailable, and the wound provider noted ongoing discrepancies between ordered and completed wound care.
A resident with CHF and anxiety did not receive a physician-ordered lorazepam for several days because the facility and pharmacy had conflicting dose orders, and the issue was not resolved over the weekend. Progress notes showed the medication was unavailable, the nurse manager later identified a 0.25 mg vs 0.5 mg discrepancy, and family members questioned why the order had not been handled sooner. The DON and administrator said they were unaware of the problem, and the pharmacy reported the original order was not a valid controlled-substance prescription because it lacked required elements.
The facility did not ensure an RN was on duty for at least eight consecutive hours on four days, as confirmed by staff schedule reviews and interviews with the scheduling coordinator, interim DON, and administrator. Staffing shortages, reliance on agency staff, and lack of a specific RN coverage policy contributed to the deficiency.
The facility did not have an RN on duty for a minimum of 8 consecutive hours per day for 5 out of 7 days reviewed, affecting all 32 residents. Staffing schedules and interviews revealed a shortage of RN coverage, with attempts by the DON and RN-B to cover shifts, but some days remained uncovered. The administrator confirmed the issue was due to staffing shortages and recruitment challenges.
The facility failed to submit accurate staffing data to CMS for a quarter, as the DON's 12-hour shift as a staff RN was not logged under the correct role, leading to an inaccurate PBJ report. The HR director was unaware of the error until the end of the quarter, despite the facility's policy to submit staffing data according to CMS guidelines.
A facility failed to timely notify a physician of new onset pressure ulcers for a resident at risk. The resident, with a history of dementia and malnutrition, developed pressure ulcers on the hips, but the physician was informed two days after discovery. The medical director was not initially notified, and the facility's policy requiring immediate notification was not followed, leading to the deficiency.
A resident with COPD and respiratory failure used a ventilator with expired sterile water for four months. The LPN was unaware of the expiration, and the facility's TAR did not include checking expiration dates. The ventilator company and administrator were not informed of the expired water, and no policy for the ventilator was provided.
A facility failed to meet the psychosocial needs of a resident grieving the death of a spouse. Despite being at risk for mood and behavior changes, the resident's care plan lacked specific monitoring for coping with the loss. The resident's participation in activities declined, and while staff checked on the resident, visits were undocumented, and no formal assessment was conducted. The facility lacked a bereavement policy, and staff were not guided on assisting the resident with grieving.
A facility failed to ensure proper PPE use during a sterile dressing change for a resident with a PICC line and hip infection. The resident's care plan required Enhanced Barrier Protections (EBP), including a mask, gown, and gloves, but RN-B did not wear a gown during the procedure. Interviews confirmed the oversight and emphasized the importance of adhering to EBP guidelines to prevent the spread of multi-drug-resistant organisms.
The facility failed to document shared clinical decision-making for additional pneumococcal vaccinations for two residents at higher risk due to existing health conditions. Despite having a process for offering vaccinations, the facility did not adhere to CDC guidelines, resulting in a deficiency.
A resident with mild cognitive impairment and severe pain was injured after falling from a mechanical lift due to the use of an incorrectly sized toileting sling. The facility failed to assess and document the appropriate sling size, leading to the use of an extra-large sling instead of a large one. The resident's history of behaviors during transfers and frequent complaints about the sling were not adequately addressed, resulting in a fall and shoulder fracture.
Failure to Notify Provider of Resident Change in Condition
Penalty
Summary
The facility failed to notify the medical provider of a change in condition for 1 resident (R33) who had heart disease and severe cognitive impairment. R33 required supervision or partial assistance for most activities of daily living. The resident’s physician orders did not include an order for transfer to the hospital, the facility’s standing orders did not provide guidance for hospital transfer, and the care plan did not include focus areas for heart disease or respiratory concerns. Progress notes showed no documentation that a provider was notified for three consecutive transfers to the local ED. On 2/22/26, R33 was sent by ambulance for bilateral lung crackles, wheezing, and shortness of breath; family member A and RN A were notified, and the hospital later reported the resident would be returning. On 2/23/26, R33 was again transported for hoarse voice, phlegm crackling in the throat, difficulty clearing the throat, diminished lung sounds, and wheezing; family member A and the on-call nurse were notified, and the resident returned that night. On 2/24/26, R33 was transported for audible crackles in the lungs and low oxygen saturation; family member A was notified, and the hospital later reported the resident would be admitted for acute respiratory failure. During interviews, the DON stated a provider would not necessarily be notified when a resident’s condition changed requiring ED transfer, while LPN A stated staff called the on-call nurse and/or DON, family member, and faxed the provider, but did not call the provider to notify them of the change in condition or ask for guidance before sending the resident to the hospital.
Incorrect MDS Coding for Pressure Ulcer
Penalty
Summary
The facility failed to accurately code the presence of a pressure ulcer on a resident’s admission MDS assessment. The resident was admitted with diagnoses including a pressure ulcer of the sacral region, and the hospital summary identified a sacral wound as the likely source of infection and pressure injury of the skin of the sacral region. The Admission/Initial Data Collection assessment documented a wound on the coccyx area measuring 4.5 cm by 1 cm, yet the admission MDS Section M-Skin Conditions indicated there were no unhealed pressure ulcers or injuries. Later assessments and interviews showed the wound should have been coded as a pressure ulcer. The resident’s Interim Payment Assessment MDS indicated one or more unhealed pressure ulcers and one stage 3 pressure ulcer, and the care plan addressed pressure injury to the buttocks with daily skin checks, weekly nurse skin inspections, and treatment to open areas per order. During interview, the resident stated she had a pressure ulcer on admission from a previous facility. The MDS nurse acknowledged the admission MDS was completed remotely and that marking no pressure ulcer was an error, and the MDS specialist confirmed the wound should have been coded as a pressure ulcer and was miscoded. The DON stated MDS assessments were expected to be accurate, and the administrator stated the facility had no specific MDS policy and relied on the RAI Manual for coding and accuracy.
Failure to Follow Ordered Wound Care and Notify Provider
Penalty
Summary
The facility failed to follow ordered wound care treatments for a resident with a right dorsum foot pressure-related wound. The resident had diagnoses including sepsis, a third-degree burn of the buttock, unhealed pressure ulcers/injuries, and a stage 3 pressure ulcer present on admission. The resident was readmitted from a short-term hospital, used a wheelchair, and required substantial to maximal assistance with personal hygiene and was dependent for transfers. The care plan identified pressure ulceration to the right buttock and right dorsum foot with treatment to open areas per order. The wound provider documented the right anterior foot ulcer as pressure-related and, after debridement, ordered lodosorb to the wound bed, Aquacel Ag hydrofiber, and a Mepilex foam dressing, with dressing changes every 3 days or sooner if saturated or soiled. The treatment administration record reflected this order, and staff documented the treatment as completed on two occasions. The resident stated staff were performing dressing changes and repositioning, and the resident reported the area was improving. On one dressing change, an LPN stated the ordered lodosorb was unavailable and she applied Aquacel and a foam dressing without the lodosorb. She stated she did not notify the provider, wound care team, or RN manager at that time and later acknowledged she had forgotten to contact the provider. The DON stated staff are expected to follow physician orders and notify the provider if supplies are unavailable. The wound care RN stated the provider would have left necessary supplies at the facility and that staff were expected to contact the pharmacy, provider, or wound clinic if lodosorb was not available. Observation later showed lodosorb was present in the resident’s room, and the wound provider stated there had been ongoing concerns and discrepancies between ordered and completed wound treatments and that staff should notify the provider if treatments cannot be completed as ordered.
Failure to Administer Ordered Lorazepam
Penalty
Summary
The facility failed to administer a physician-ordered lorazepam for one resident with congestive heart failure and generalized anxiety, resulting in a medication omission for several days. The resident’s record showed intact cognition, clear speech, and independence or partial assistance with most activities of daily living. A handwritten physician order dated 12/12/25 directed lorazepam 0.25 mg at 7:00 a.m. and 7:00 p.m., and the resident had been experiencing anxiety related to shortness of breath. Progress notes showed the order was faxed to the pharmacy on 12/12/25, but the medication was not available that evening, remained undelivered through the weekend, and was still unresolved on 12/15/25. On 12/15/25, the nurse manager documented that the facility order was for lorazepam 0.25 mg, while the pharmacy label reflected 0.5 mg. The nurse contacted the pharmacy and the clinic for clarification, but no response was received at that time. Family members questioned why the medication had not been given since the order was written and expressed concern that the issue had not been handled over the weekend. Further documentation showed the discrepancy continued into 12/16/25, when the physician’s nurse was contacted again to clarify whether the dose should be 0.25 mg or 0.5 mg. The first documented administration of lorazepam occurred on 12/16/25 at 7:00 p.m. During interviews, the nurse manager stated she first became aware of the issue on 12/15/25 and did not know whether weekend staff had contacted a provider or leadership. The DON and administrator stated they had not been aware of the discrepancy or the failure to administer the medication, and the DON said he would have expected staff to notify the provider and him. The pharmacy later stated the original order received from the facility was not a valid prescription because it lacked a provider signature, quantity, and DEA number, and that an e-prescription for lorazepam 0.5 mg was later received from the physician.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of eight consecutive hours per day for four out of thirty days reviewed. Review of nursing staff schedules revealed that there was no RN coverage for the required eight hours on four specific days. The scheduling coordinator confirmed that the facility had only two RNs in-house and had to rely on agency staff to fill gaps, but sometimes only LPNs were available. The gaps in RN coverage occurred when scheduled RNs called off and replacements could not be found. Interviews with the scheduling coordinator, interim director of nursing, and administrator confirmed the lack of RN coverage on the identified days. The interim DON stated that attempts were made to fill open RN shifts in-house and through agencies, but weekends were particularly challenging. The administrator, new to the facility, acknowledged the deficiency and was not previously informed of the coverage gaps. The facility did not have a specific policy regarding RN coverage, instead following state guidelines.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of 8 consecutive hours per day for 5 out of 7 days reviewed, potentially affecting all 32 residents. The nursing staff schedules and time punches for specific dates showed no evidence of an RN working the required hours. An interview with RN-B revealed that the facility was short on RN coverage, and attempts were made by either her or the Director of Nursing (DON) to cover shifts, but some days no replacements could be assigned. The administrator confirmed the lack of RN coverage on the specified dates due to staffing shortages and recruitment challenges. A policy addressing RN coverage or staffing was requested but not provided by the end of the survey.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate staffing data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 4, as required by CMS specifications. The deficiency was identified through a review of staffing schedules and timecard verifications, which revealed that the Director of Nursing (DON) worked a 12-hour shift as a staff RN on a specific date. However, her hours were not logged under the correct role, leading to an inaccuracy in the Payroll-Based Journal (PBJ) report submitted to CMS. This discrepancy was confirmed by the facility's administrator, who acknowledged that the PBJ report did not accurately reflect the DON's active nursing shift. The human resources director, responsible for submitting employee hours to CMS, was unaware of the error until the end of the quarter when a report was run. The facility's current PBJ policy indicated that staffing data was generated and submitted from their electronic timekeeping system according to CMS guidelines. Despite this policy, the failure to accurately log the DON's hours resulted in a lack of documented RN coverage, potentially affecting all 32 residents in the facility.
Failure to Timely Notify Physician of Pressure Ulcers
Penalty
Summary
The facility failed to timely notify the physician of new onset pressure ulcers for a resident, identified as R7, who was at risk for pressure ulcer development. R7 was cognitively intact and had a diagnosis of dementia, anxiety, depression, psychotic disorder, and malnutrition. Despite being at risk, R7 had no pressure ulcers at the time of the initial assessment. However, on 12/18/24, a faxed notification to the physician was sent two days after the discovery of open areas on R7's left and right hips, indicating a delay in communication. The physician agreed with the treatment plan proposed by the staff, which included wound care and nutritional support. Interviews and observations revealed that the medical director was not initially notified of R7's wound, and the facility's administrator expected nursing staff to follow the policy of notifying the provider immediately for new onset wounds. The wound care nurse and nurse practitioner later assessed R7's wounds, noting significant improvement with current treatments. The facility's policy required nursing staff to notify the provider for treatment orders, which was not adhered to in this case, leading to the deficiency.
Expired Sterile Water Used in Resident's Ventilator
Penalty
Summary
The facility failed to ensure that the ventilator equipment supply water for a resident with respiratory failure and COPD was not expired. The resident, who was cognitively intact, used a non-invasive mechanical ventilation system with oxygen therapy. During an observation and interview, it was identified that the sterile water bag attached to the resident's ventilator had expired four months prior. The licensed practical nurse (LPN) was unaware of the expiration and confirmed that the facility should not use expired sterile water. The resident had an extra water bag in the storage room, but it was also expired. The facility's active orders required nursing staff to order supplies every two months, inspect and clean the ventilator weekly, and change the oxygen tubing and water bag as needed. However, the Treatment Administration Record (TAR) did not include a directive for staff to check the expiration date on the water. Interviews with the resident and staff revealed that the water was changed a few days ago, but the expiration was not checked. The ventilator company was not informed of the expired water, and the administrator was unaware of the situation until the observation. The facility did not provide a policy for the ventilator machine upon request.
Failure to Address Grieving Resident's Psychosocial Needs
Penalty
Summary
The facility failed to adequately assess and meet the psychosocial needs of a resident grieving the death of a significant other. The resident, who was cognitively intact but diagnosed with dementia, anxiety, depression, and other disorders, was identified as being at risk for mood and behavior alterations. Despite this, the care plan did not include specific monitoring for the resident's ability to cope with the loss. The resident's behavior and participation in activities declined significantly following the spouse's death, indicating a need for enhanced psychosocial support. Interviews with staff revealed that while the social services designee frequently checked on the resident, these visits were not documented, and there was no formal assessment of the resident's psychosocial needs post-bereavement. The medical director and other staff acknowledged the resident's withdrawal and sadness but did not implement a structured plan to address these issues. The facility lacked a policy on bereavement services, and staff had not received guidance on assisting the resident with grieving, leading to a deficiency in providing necessary medically-related social services.
Failure to Use Appropriate PPE During Sterile Dressing Change
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was used during a sterile dressing change for a resident identified as R85. R85 was admitted for orthopedic aftercare with a diagnosis of infection in his left hip following an arthroplasty, and had a peripherally inserted central catheter (PICC) for antibiotic administration. The resident's care plan required staff to follow Enhanced Barrier Protections (EBP), which included wearing a mask, gown, and gloves during high-contact procedures. However, during an observation of a sterile dressing change performed by RN-B, it was noted that the nurse did not wear a gown, despite the requirement being clearly posted on a sign outside the resident's room. Interviews with RN-B and other staff members confirmed that the facility's policy required the use of a gown, mask, and gloves for any personal care involving close contact with residents on EBP. RN-B acknowledged the oversight, attributing it to nervousness during the observation. The infection preventionist and other staff members reiterated the importance of adhering to EBP guidelines to prevent the transmission of multi-drug-resistant organisms. The facility's policy mandates that signage be posted to indicate the necessary precautions and that staff receive training on EBP at hire and annually thereafter.
Deficiency in Pneumococcal Vaccination Documentation
Penalty
Summary
The facility failed to ensure that two residents, identified as R21 and R31, were offered and/or provided updated vaccinations for pneumococcal disease in accordance with CDC guidelines. R21, who was at higher risk due to renal failure and diabetes, had received previous pneumococcal vaccinations, but there was no documentation of shared clinical decision-making regarding additional vaccines. Similarly, R31, who had chronic respiratory conditions and was dependent on supplemental oxygen, also lacked documentation of shared clinical decision-making for further pneumococcal vaccination. Interviews with facility staff, including the administrator, health information manager, and infection preventionist, revealed that while the facility had a process for offering vaccinations and obtaining consent, there was a lack of documentation regarding discussions on shared clinical decision-making for additional pneumococcal vaccines. The facility's policy aimed to follow CDC and ACIP recommendations, but the absence of documented discussions for R21 and R31 indicated a deficiency in adhering to these guidelines.
Failure to Assess Proper Sling Size Leads to Resident Injury
Penalty
Summary
The facility failed to comprehensively assess and determine the appropriate type and size of a full body mechanical lift sling for a resident, leading to a significant accident. The resident, who had mild cognitive impairment and fluctuating behaviors, was dependent on staff for all transfers and toileting. Despite having a history of severe pain and discomfort impacting transfers, the resident's care plan did not specify the type or size of sling to be used, nor was there an assessment for the appropriateness of the specialty sling. On the day of the incident, staff used a toileting sling that was too large for the resident, who had a history of behaviors during lift transfers. During a transfer from the bed to the commode, the resident complained of shoulder pain and attempted to adjust their position, resulting in a fall from the sling and a subsequent shoulder fracture. Interviews with staff revealed that the resident frequently complained about the toileting sling and had a habit of trying to pull their arms through it, yet the staff continued to use the incorrect sling size due to a lack of clear guidance and documentation. The facility's investigation identified that the root cause of the fall was the use of an extra-large toileting sling instead of a large one, as well as the resident's actions of pulling their arms over the sling. Prior to the incident, staff determined sling size based solely on the resident's weight, without considering other factors such as the resident's behavior and physical condition. The facility's failure to assess the appropriateness of the sling and to provide clear instructions on sling usage contributed to the accident.
Removal Plan
- R1 was assessed using manufacturer's guidelines, and care plan was updated to add the correct sling size and NOT to use a toileting sling
- Other residents that used full body lifts and slings were assessed, and care plans updated as appropriate for correct sling size and type
- All staff education for sling sizing and where to find that information
- Mechanical lift competencies completed for all staff
- Safe Patient Handling policy was reviewed, and staff educated
- The electronic record transferring tasks were updated to include sling size and color
- Toileting slings were removed from service
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Redwood Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin Restorative Care Center | 10.8 mi | ★★★★★ | 13 | 0 |
| Wabasso Restorative Care Center | 12 mi | ★★★★★ | 23 | 0 |
| Gil-mor Manor | 12.5 mi | ★★★★★ | 3 | 0 |
| Olivia Restorative Care Center | 17.5 mi | ★★★★★ | 2 | 0 |
| Renville Health Services | 17.8 mi | ★★★★★ | 6 | 0 |
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