Coventry Rehab: Incomplete Discharge Paperwork - RI
The resident, identified in inspection records only as Resident 4, had been admitted to Coventry Operations RI LLC, doing business as Respiratory and Rehabilitation, in March 2026. Their diagnoses included dementia, chronic obstructive pulmonary disorder, gastroesophageal reflux disorder, a history of venous thrombosis, and anxiety disorder. On the day of discharge, the facility's own physician's assistant documented in a progress note that the resident would need to follow up with six different providers: a primary care physician, a neurologist, a gastroenterologist, a pulmonologist, a vascular physician, and a psychologist.
None of that made it onto the discharge form.
The Continuity of Care Discharge/Transfer of Patient Form, which a resident representative signed the day Resident 4 went home, was missing the name and phone number of the discharging facility's contact person. It was missing the name of any physician who would follow the patient after discharge, whether that physician had been notified, and the phone number for the home care agency that had been arranged. The section instructing the resident when to call a doctor was blank. The section for follow-up appointments with phone numbers was blank.
The social worker who helped arrange the discharge, Staff C, told inspectors by phone on April 27 that she had set up home care services for the resident. She said she would have expected the form to be filled out completely. She could not explain why it wasn't.
The licensed practical nurse who assisted with the discharge, Staff B, acknowledged the same thing in a separate interview that morning. The form was not complete. The components were missing. She knew what should have been there.
The physician's assistant, Staff A, sat down with inspectors at 9:15 that morning and acknowledged that the form was missing the documentation. He said he would have expected it to include the list of physicians the resident needed to see. He had written that list himself, in the progress note, on the day the resident left.
The Director of Nursing Services, interviewed the same day, could not provide any evidence that the facility had given Resident 4 sufficient preparation for a safe discharge.
A complaint about the incomplete plan of care had been filed with the Rhode Island Department of Health on April 14, more than a week after the resident went home.
What the discharge form was supposed to do was straightforward: tell the resident and their family who to call, when to call them, and where to go. For a person with dementia going home with a new home care arrangement, that information isn't administrative paperwork. It's the mechanism by which six different specialists, each managing a distinct and serious condition, stay connected to a patient who has just left a supervised setting.
The PA had done his part. He wrote it down. A neurologist. A gastroenterologist. A pulmonologist. A vascular physician. A psychologist. A primary care doctor. Six names that never made it to the form the family took home.
Inspectors rated the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The complaint inspection was completed April 27, 2026.
Resident 4's family representative signed a form with blank lines where the answers were supposed to be, and took their family member home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Coventry Operations Ri LLC Dba Respiratory and Reh from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Coventry Operations RI LLC DBA Respiratory and Reh in Coventry, RI was cited for violations during a health inspection on April 27, 2026.
None of that made it onto the discharge form.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.