Riverview Healthcare Community
Riverview Healthcare Community in Coventry, RI — inspection on November 28, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the hospital, prompting her/him to call the facility for clarification.
When s/he contacted the facility, s/he was told that her/his relative was fine and eating Chinese food.During a surveyor interview on 11/25/2025 at 8:56 AM with Licensed Practical Nurse, Staff A, she acknowledged that at 2:35 PM she notified Resident ID #2's on-call provider about a change in condition, instead of notifying the provider for Resident ID #1, who was the resident actually experiencing the change.
This indicates she contacted the wrong provider for the wrong resident.
She further stated that she did not notify Resident ID #1's resident representative that the resident had been sent to the hospital.During surveyor interviews on 11/25/2025 at approximately 1:00 PM and 11/26/2025 at approximately 12:15 PM, with the Director of Nursing Services and the Administrator, they were unable to provide evidence that the facility immediately consulted with the resident's physician and informed the resident's representative when there was a change in condition.
The facility notified Resident ID #2's provider and not Resident ID #1's provider of the change in condition and failed to inform the resident's representative for Resident ID #1 of their transfer to the hospital.Cross reference F 628 and F
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Community
546 Main Street Coventry, RI 02816
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
her knowledge the family of Resident ID #1 would have consented to intubation if they had been contacted.The facility's failure to send accurate medical records and patient identifiers during an emergent transfer placed Resident ID #1 at risk for delayed and/or inappropriate treatment.
Given the resident's known history of severe respiratory compromise, this error had the potential to result in serious harm, injury, impairment, or death.Cross-reference F 726
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Community
546 Main Street Coventry, RI 02816
SUMMARY STATEMENT OF DEFICIENCIES
an intervention dated 8/10/2025 that the resident needs supervision for ambulation and uses a walker.
Record review of Resident ID #3's Kardex revealed, the resident needs supervision for ambulation and utilizes a walker.
Record review of a Safe Patient Handling (SPH) Evaluation dated 11/19/2025 revealed, Resident ID #3 requires a mechanical lift, and two staff members for transfers.
Record review of the Nursing Assistants (NA) unit assignment for 11/26/2025 revealed, Resident ID #3 requires the use of two staff members using a gait belt.During surveyor interviews on 11/26/2025 at 11:28 AM and 11:48 AM with the 2nd floor Unit Manager, she revealed that each resident has an assessment that is completed for their SPH, and it is then reflected on the NA's assignments.
She revealed that the nurse on the floor or NA who is handing out the assignments should be responsible for updating the SPH on the assignments.
Additionally, she acknowledged that Resident ID #3's SPH does not match on all forms of communication mentioned above and that Resident ID# 3's information should all match.During surveyor interviews on 11/26/2025 at 10:40 AM and 11:44 AM with the Director of Nursing Services, she acknowledged that Resident ID #s 2 and 3's SPH status was different in each above-mentioned location throughout the resident's record.
Additionally, she revealed that she would expect that each resident's SPH would reflect the resident's current status in their care plan.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Community
546 Main Street Coventry, RI 02816
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
record with Resident ID #1, indicating that for approximately 2 hours the hospital was treating Resident ID #1 as if s/he was Resident ID #2.
Furthermore, Staff A revealed that she did not call the hospital to give a verbal report on the resident she transferred to the hospital at the time of the transfer.During a surveyor interview on 11/25/2025 at 10:17 AM with the Director of Nursing Services, she acknowledged that the wrong resident's medical record was sent with Resident ID #1 to the hospital.
Additionally, she was unable to provide evidence that LPN, Staff A was competent with the Acute Condition Changes-Clinical Protocol when she transferred Resident ID #1 to the hospital with the wrong medical record or when reporting a change in condition to the wrong provider about the wrong resident.The facility's failure of Staff A to send accurate medical records and patient identifiers during an emergent transfer placed Resident ID #1 at risk for delayed and/or inappropriate treatment.
Given the resident's known history of severe respiratory compromise, this error had the potential to result in serious harm, injury, impairment, or death.Cross reference F 628
Facility ID: