Coventry Operations Ri Llc Dba Respiratory And Reh
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality related to following physician's orders for 1 of 3 residents reviewed regarding flushes for through a gastrostomy tube (a flexible tube that allows for the delivery of liquid nutrition and medications directly into the stomach), Resident ID #1.Findings are as follows:Review of a community reported complaint submitted to the Rhode Island Department of Health on 11/14/2025 alleges
in part, that staff was not consistent with following physician orders related to the resident's tube feeding and flushes. The complaint further revealed that the issues began approximately 4 weeks prior to the complaint being filed.According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed Resident ID #1 was readmitted to the facility in July of 2025 with diagnoses including, but not limited to, traumatic brain injury, dysphagia (difficulty swallowing), and gastrostomy tube.Record review revealed a physician's order dated 7/23/2025 to flush the feeding tube with 30 milliliters (mL) of water before and after each medication pass and at least 15 mL of water between each medication. This order was discontinued
on 11/14/2025.Record review of the October 2025 Medication Administration Record (MAR) revealed the resident has approximately 6 medications on day shift, 5 medications on evening shift and 2 medications on
the night shift.Record review of the October 2025 MAR between 10/1/2025 through 10/31/2025 revealed a total of 93 eight-hour shifts. The documentation regarding flushes during medication administration reveals that for 91 out of the 93 shifts only 30 mL of water were administered.Record review of the October 2025 MAR revealed an order dated 10/17/2025 for Jevity 1.2 Cal (a high calorie nutritional supplement) to be administered continuously via the gastrostomy tube at a rate of 80 mL/hour. It was signed off as administered continuously on the day, evening, and night shifts from 10/18/2025 until 10/28/2025.Record
review revealed a physician's order dated 8/20/2025 to flush the feeding tube with 30 mL of water prior to feeding and every 4 hours during continuous feeding and 30 mL at the end of each feeding.Record review of the October 2025 MAR between 10/18/2025 through 10/28/2025 revealed a total of 33 eight-hour shifts.
The documentation regarding flushes during continuous feedings reveals that for 31 out of the 33 shifts only 30 mL of water were administered, and for 1 out of the 33 shifts only 22 mL of water were administered.During a surveyor interview with Licensed Practical Nurse, Staff A, she revealed that when
she administers medication to the resident through the gastrostomy tube, she flushes the tube with 15 mL of water prior to medication administration and 15 mL of water after medication administration. She was unable to provide evidence that the above orders for flushes during medication administration or continuous tube feeding were administered per the physician's orders.During a surveyor interview with Physician, Staff B, he acknowledged that the flushes during medication administration and continuous tube feeding were not completed per the physician's order.
Residents Affected - Some
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Coventry Operations RI LLC DBA Respiratory and Reh in Coventry, RI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Coventry, RI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Coventry Operations RI LLC DBA Respiratory and Reh or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.