Coventry Respiratory Rehab: Ventilator Record Failures - RI
The patient, identified in inspection records only as Resident ID #1, was admitted to Coventry Operations RI LLC, doing business as Respiratory and Rehabilitation, in early March 2026. The admission diagnoses included Duchenne muscular dystrophy, a severe and progressive genetic disorder that destroys skeletal, heart, and respiratory muscles over time, along with chronic respiratory failure and documented dependence on a ventilator. The resident relied on mechanical breathing support around the clock, using a mouthpiece ventilator during the day and a separate machine through nasal pillows at night.
Three ventilators were involved in the resident's care between March 2 and March 14. The Astral handled daytime support. At night, staff initially used the LTV ventilator, then switched to the VOCSN beginning March 4.
The LTV had a physician's order specifying every setting: a tidal volume of 1,100, a respiratory rate of 14 breaths per minute, a positive end-expiratory pressure of 6, an oxygen concentration of 21 percent, and a pressure support level of 8. Those numbers mattered. For a patient whose respiratory muscles were failing, the ventilator was not supplemental equipment. It was keeping the resident alive.
When staff switched to the VOCSN on March 4, the LTV was discontinued. Nobody updated the treatment records to reflect that.
On March 4, March 5, March 6, March 8, March 9, March 10, March 11, March 12, and March 14, staff continued to document that Resident ID #1 was receiving the LTV ventilator at its prescribed settings. The machine wasn't in use on any of those dates. The documentation was wrong on nine separate occasions across eleven days.
The discrepancy surfaced through a complaint filed with the Rhode Island Department of Health on May 19, 2026, alleging the resident had been receiving incorrect ventilator settings. State inspectors arrived and reviewed the clinical record. What they found wasn't a question of whether the settings on the VOCSN were appropriate. It was that the facility's own treatment records said one thing was happening when something else entirely was.
The facility's own Non-Invasive Ventilator policy, which inspectors reviewed, stated its purpose plainly: promote patient safety and improve respiratory support management. The procedure required staff to verify physician orders and prescribed settings before documenting care.
When inspectors interviewed the physician assistant on May 22, he said he expects staff to document accurately.
When inspectors interviewed the Director of Nursing Services the same afternoon, she was unable to provide any evidence that the facility had maintained accurate medical records for this resident.
The care plan for Resident ID #1 required ventilator check assessments every six hours. Those checks were supposed to verify that the resident was receiving the correct support at the correct settings. Whether those checks were actually conducted during those eleven days, and whether anyone noticed the VOCSN was running while the LTV was being documented, the inspection report does not say. What the record does say is that the documentation produced by those checks, if they happened, was wrong.
For a resident with Duchenne muscular dystrophy, accurate ventilator records are not a paperwork formality. The condition progressively weakens the muscles responsible for breathing, which means the ventilator settings are calibrated to what remains of that function. A care team working from inaccurate records, or a covering clinician reviewing the chart in an emergency, would have had no reliable picture of what the resident was actually receiving.
The inspection, conducted on May 26, 2026, classified the violation as causing minimal harm or potential for actual harm. One resident was reviewed. One resident had documentation errors across nine treatment entries.
The Director of Nursing had no answer for the inspectors. The records stood as they were.
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 15, 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.
Three ventilators were involved in the resident's care between March 2 and March 14.
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.