Inspection Reports for Riverview Rehabilitation & Healthcare Center

The inspection was conducted following a community reported complaint alleging insufficient nursing staff on the 11:00 PM - 7:00 AM shift on 9/19/2025, which raised concerns about resident safety and supervision on the subacute unit.

The facility failed to have sufficient nursing staff to ensure resident safety and meet care needs for 2 residents reviewed, with only one nursing assistant and one nurse working the shift for 24 residents, despite staffing minimums requiring more. Multiple falls and care deficiencies were documented for residents requiring frequent checks and assistance.

The complaint was submitted on 9/20/2025 alleging insufficient staffing on 9/19/2025 night shift with only one nursing assistant and one nurse for 24 residents, many of whom were fall risks requiring 15-minute checks and one-to-one supervision. The complaint also alleged management awareness of unsafe staffing.

The inspection was conducted in response to a community reported complaint alleging that Resident ID #1 was sent to the hospital with Resident ID #2's medical record, resulting in incorrect patient identification and failure to notify the correct physician and resident representative about a change in condition.

The facility failed to immediately consult with the correct resident's physician and inform the resident's representative when there was a change in condition for Resident ID #1, who was sent to the hospital with another resident's medical record. This resulted in Resident ID #1 being treated under the wrong identity for approximately two hours, placing the resident at risk for delayed or inappropriate treatment. Additionally, the facility failed to maintain consistent and accurate documentation of residents' transfer needs and failed to ensure licensed nurses possessed the necessary competencies to meet resident needs.

The complaint alleged that Resident ID #1 was sent to the hospital with Resident ID #2's medical record, resulting in incorrect patient identification and failure to notify the correct physician and resident representative about the change in condition. The complaint was submitted to the Rhode Island Department of Health on 11/24/2025.

The inspection was conducted to assess the facility's compliance with safety regulations, specifically focusing on ensuring the nursing home environment is free from accident hazards and provides adequate supervision to prevent accidents, with emphasis on maintaining safe water temperatures.

The facility failed to maintain safe water temperatures in resident areas, with multiple sinks on three floors exceeding 120°F, posing a risk of scalding. Interviews and observations confirmed that water temperatures were excessively hot, and the facility lacked evidence of timely reporting and correction of these hazards.

The inspection was conducted to assess compliance with professional standards of quality in nursing facility services, including wound care, use of medical devices, accident prevention, food safety, infection control, and call system functionality.

The facility failed to consistently follow physician orders for wound care, glucose monitoring, hand splint use, and hot pack application. There were deficiencies in providing assistive devices for smoking safety, food service safety violations, inadequate infection control practices related to contact precautions, and a non-functional resident call system that does not alert staff directly or centrally.

A recertification and complaint survey was conducted at Riverview Healthcare Community Nursing Home from 12/30/2024 through 1/3/2025 to determine compliance with 42 CFR Part 483, requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.

Deficiencies were identified related to professional standards of care, infection control, accident prevention, food safety, emergency preparedness, and life safety code compliance. Specific issues included wound care, use of Freestyle Libre sensors, smoking policy enforcement, food service violations, infection prevention, resident call system inadequacies, and emergency lighting deficiencies.

The survey included a complaint investigation with ACTS reference numbers 96910 and 98882. Findings were substantiated related to wound care, infection control, and resident safety.

The inspection was conducted to assess compliance with professional standards of care related to pressure ulcer treatment, respiratory care, medication administration, and medical record accuracy at Riverview Healthcare Community.

The facility was found deficient in providing appropriate pressure ulcer care, safe respiratory care, and ensuring residents were free from significant medication errors, particularly with Coumadin administration and INR monitoring. Additionally, there was a failure to maintain accurate medical records for skin observations.

The inspection was conducted in response to a community reported complaint received on 2024-04-09 alleging that Resident ID #1 was not receiving appropriate medical care at the facility.

The facility failed to ensure that daily weights were obtained for Resident ID #1 as ordered by the physician, with weights missing for 8 of 18 opportunities and 5 documented refusals. The resident gained 9.2 pounds between 4/2/2024 and 4/6/2024 without notification to the provider or completion of the required SBAR, and no interventions were implemented. Interviews with staff confirmed failure to notify the provider and that the resident was unaware of the daily weight requirement.

Complaint investigation triggered by a community reported complaint on 2024-04-09 alleging inadequate medical care for Resident ID #1. The complaint was substantiated by findings of failure to obtain daily weights and notify provider of weight gain.

An off-site desk audit was conducted on February 16, 2024, to review all previous deficiencies cited on January 25, 2024.

Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.

The inspection was conducted to assess compliance with healthcare regulations including care planning, pressure ulcer care, catheter care, pain management, medication administration, medical record accuracy, and infection prevention and control.

The facility failed to develop and implement baseline care plans within 48 hours of admission, provide appropriate pressure ulcer care, ensure proper catheter care and follow-up, administer pain management timely, prevent significant medication errors, maintain accurate medical records, and implement an effective infection prevention and control program for residents with multidrug-resistant organisms.

The annual Federal Life Safety Code survey and a Recertification Survey and Complaints Investigation Survey were conducted at Riverview Healthcare Community from 01/22/2024 through 01/25/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.

Deficiencies were cited related to baseline care plans, pressure ulcer treatment, pain management, bladder/bowel incontinence care, infection prevention and control, medication administration, and resident records. No Life Safety Code deficiencies were identified. The facility failed to develop baseline care plans within 48 hours of admission for some residents and failed to provide appropriate treatment and documentation for pressure ulcers and pain management. Infection control practices and medication administration also had deficiencies.

The inspection was conducted following complaints and reported incidents involving resident-to-resident sexual abuse and safety hazards related to smoking within the facility.

The facility failed to protect a resident from sexual abuse by another resident with cognitive impairment, and failed to ensure a safe environment free from smoking hazards for two residents. Observations and interviews confirmed incidents of inappropriate sexual contact and possession of smoking materials contrary to facility policy.

The complaint investigation was substantiated with findings that Resident ID #7 was sexually abused by Resident ID #8 on 7/25/2023. The facility was not aware of the incident until 7/27/2023 and could not provide evidence that Resident ID #7 was kept free from sexual abuse.

The inspection was conducted in response to community reported complaints alleging sexual abuse and failure to provide adequate care and services to residents, including issues related to abuse, treatment for constipation, hydration, and wheelchair accessibility.

The facility failed to protect residents from sexual abuse by Resident ID #1 involving two other residents, failed to provide services to maintain the highest practicable wellbeing for Resident ID #2 including timely wheelchair repair, appropriate treatment for constipation, and adequate hydration. Multiple interviews and record reviews confirmed these deficiencies.

The complaint investigation was triggered by community reports submitted to the Rhode Island Department of Health on 6/22/2023 and 6/23/2023 alleging sexual abuse by Resident ID #1 towards other residents and inadequate care for Resident ID #2 including broken wheelchair, poor hydration, and untreated constipation. The investigation included record reviews, staff interviews, and family member interviews confirming the allegations.

The inspection was conducted in response to a community reported complaint alleging resident-to-resident abuse and concerns about the cleanliness and safety of the facility environment.

The facility failed to timely report and thoroughly investigate an allegation of resident-to-resident abuse involving one resident. Additionally, the facility failed to maintain a safe, clean, and sanitary environment in multiple resident bathrooms, with observations of fecal matter and unclean conditions in several rooms.

The complaint investigation was triggered by a community report submitted on 5/25/2023 alleging resident-to-resident abuse where a resident was hit on the right arm by another resident. The facility failed to report the allegation timely and did not thoroughly investigate the incident. The resident was transferred to the hospital with diagnoses including acute metabolic encephalopathy likely due to psychological trauma from the altercation. The facility also failed to maintain cleanliness in resident bathrooms as reported in a complaint on 6/14/2023.

The inspection was conducted following a complaint alleging sexual abuse of a resident by a Physical Therapist Assistant (PTA) on 4/6/2023.

The facility failed to keep Resident ID #1 free from sexual abuse when the PTA intentionally touched the resident's chest. The resident reported the incident, and the PTA admitted the intentional contact. The facility was unable to provide evidence that it kept the resident free from sexual abuse.

Complaint investigation related to sexual abuse allegation against a Physical Therapist Assistant. The allegation was substantiated based on resident report and staff admission.

The inspection was conducted following a community reported complaint alleging neglect and abuse related to the care of a resident with urinary tract infections (UTIs). The complaint was received by the Rhode Island Department of Health on 2023-02-23.

The facility failed to ensure appropriate treatment and care according to medical orders for one resident with UTIs. Specifically, a urine sample ordered on 2023-02-16 was not collected until 2023-02-19 after the family inquired, and there was no documentation or notification to the physician regarding the delay. Interviews with staff confirmed failure to follow orders and lack of documentation.

Complaint received on 2/23/2023 alleging neglect and abuse of a resident with UTIs. The complaint was substantiated by findings that the facility failed to timely collect a urine sample as ordered and failed to notify the physician of the delay.

The inspection was conducted to investigate complaints regarding the facility's failure to provide appropriate treatment and care according to orders, resident preferences, and goals, specifically related to wound care, IV fluid administration, and medication administration for residents.

The facility failed to ensure proper surgical wound care for one resident, delayed implementation of wound treatment orders, failed to administer IV fluids according to physician orders for a resident with a PICC line, and did not ensure medication administration was free from significant errors for two residents, including failure to administer ordered medications and documentation lapses.

The complaint investigation revealed substantiated deficiencies related to wound care, IV fluid administration, and medication administration errors affecting a few to some residents.

The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication management, safety, and facility operations.

The facility was found deficient in multiple areas including failure to maintain a clean environment, incomplete care plans, failure to follow physician orders, inadequate pressure ulcer care, insufficient nursing staff, improper medication storage and labeling, failure to ensure drug regimens free from unnecessary drugs, inadequate dental care assistance, incomplete medical record documentation, and lack of accessible call systems for residents.