Coventry Respiratory & Rehab: Ventilator Setting Failure - RI
The resident, identified in inspection records as Resident ID #3, had been readmitted to the facility in April 2026 with diagnoses that included dependence on a ventilator for breathing. A physician's order on file at the facility specified a ventilator setting of 3 liters of oxygen. The care plan reflected that same requirement.
When a surveyor observed Resident ID #3 in his or her room at approximately 1:40 in the afternoon, the resident was lying in bed, connected to the ventilator. The machine was running. The oxygen was not.
Instead of 3 liters of oxygen, the resident was receiving room air.
A staff member identified as Staff C was present during the observation. When inspectors immediately asked her to account for the discrepancy between the physician's order and what the ventilator was actually delivering, she could not. She provided no evidence that the prescribed oxygen setting had ever been applied.
The facility is named Respiratory and Rehabilitation. Its name describes, as a core function, the care of patients whose lungs cannot sustain them on their own. Resident ID #3 was precisely that kind of patient. The ventilator was there because without it, and without the oxygen it was supposed to deliver, the resident could not breathe adequately alone.
Inspectors also interviewed the facility's Director of Nursing Services. She, too, was unable to provide evidence that the facility had delivered necessary respiratory care in accordance with professional standards or its own policies.
The inspection report does not say how long the ventilator had been set incorrectly. It does not say whether anyone noticed before the surveyor walked in. It does not say whether Resident ID #3 showed signs of distress, or whether staff had checked the settings during any prior shift. What the report does say is that when an outside inspector looked at the machine, it was wrong, and nobody in the building could explain why or show that it had ever been right.
Federal inspectors flagged a separate but related concern in the same report: that staff had been adjusting ventilator settings without first speaking to a provider. That finding, noted at the top of the inspection narrative, suggests the problem was not simply a single missed setting. It points toward a broader breakdown in how the facility managed the machines that its most fragile residents depend on to survive.
Immediate jeopardy is not a term regulators use loosely. It means inspectors determined that the facility's failure had placed residents in a situation where serious injury, serious harm, or death was likely unless corrected immediately. At a facility that specializes in respiratory care, a ventilator patient receiving room air instead of prescribed oxygen met that threshold.
The facility is located at 10 Woodland Drive in Coventry. Its inspection was completed May 26, 2026. The report was printed August 8, 2026.
Resident ID #3 was readmitted in April. By May, an inspector standing in the room was the one who caught it.
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 2026-05-26 including all violations, facility responses, and corrective action plans.
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: August 14, 2026 · Our methodology
Coventry Operations RI LLC DBA Respiratory and Reh in Coventry, RI was cited for violations during a health inspection on May 26, 2026.
A physician's order on file at the facility specified a ventilator setting of 3 liters of oxygen.
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.