Riverview Healthcare Community

In the surveyor’s words

From the most serious findings on record at Riverview Healthcare Community, in the surveyor’s own words.

• Immediate jeopardy, patternF760May 8, 2024

  Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 7 of 8 residents reviewed receiving Coumadin (an anticoagulant medication that is used to prevent harmful blood clots from forming or growing larger), Resident ID #s 1, 4, 5, 6, 7, 8 and 9. Findings are as follows: 1. Record review revealed Resident ID #1 was admitted to the facility in March of 2024 with diagnoses including, but not limited to, atrial fibrillation (an irregular heartbeat often causing blood to flow inadequately through the heart) and long-term use of anticoagulants. […]

• Immediate jeopardy, isolatedF760Jun 17, 2026

  Based on clinical record review and resident and staff interviews, the facility failed to ensure residents were free from significant medication errors for 1 of 1 resident reviewed. The facility failed to ensure Resident ID #1's identity was verified prior to medication administration, resulting in Resident ID #1 allegedly receiving insulin prescribed for Resident ID #3. The facility's failure to follow medication administration practices, including verifying the resident's identity prior to medication administration, placed Resident ID #1 at risk for serious injury, serious impairment, serious harm or death. […]

• Immediate jeopardy, isolatedF628Nov 28, 2025

  Based on record review, resident representative and staff interview, the facility failed to ensure that accurate and appropriate information was communicated to the receiving health care provider during an emergent discharge for Resident ID #1. When Resident ID #1 experienced a change in condition requiring emergency transfer to an acute care facility, Licensed Practical Nurse (LPN), Staff A, incorrectly identified the resident. As a result, Resident ID #1 was transferred with another resident's identifiers and medical record, placing Resident ID #1 at risk for delayed and/or inappropriate treatment.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/24/2025, alleges that Resident ID #1 was sent to the hospital on [DATE]… […]

• Immediate jeopardy, isolatedF726Nov 28, 2025

  Based on record review and staff interview, the facility failed to ensure that licensed nurses possessed the necessary competencies and skills to meet resident needs. When Resident ID #1 experienced a change in condition requiring emergency transfer to an acute care facility, Licensed Practical Nurse (LPN), Staff A, incorrectly identified the resident. Consequently, Resident ID #1 was transferred with another resident's identifiers and medical record, placing Resident ID #1 at risk for delayed and/or inappropriate treatment.Findings are as follows:Review of a facility policy titled, Acute Condition Changes-Clinical Protocol dated March 2018, states in part, .before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to… […]

• Actual harm, isolatedF692Aug 27, 2021

  Based on surveyor observation, record review, staff and representative interview, it has been determined that the facility failed to ensure the residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and were offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 2 of 4 residents reviewed for nutrition, Resident ID's #23 and #136. Findings are as follows: 1. Resident ID #23 was admitted to the facility in April of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]