Coventry Operations Ri Llc Dba Respiratory And Reh
Coventry Operations RI LLC DBA Respiratory and Reh in Coventry, RI — inspection on November 19, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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.
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