Riverview Healthcare Community
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Community
546 Main Street Coventry, RI 02816
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0628
F 0628 Level of Harm - Immediate 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
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Community
546 Main Street Coventry, RI 02816
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverview Healthcare Community
546 Main Street Coventry, RI 02816
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0726
F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
Event ID:
Facility ID:
If continuation sheet
Riverview Healthcare Community in Coventry, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Coventry, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Riverview Healthcare Community or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.