Coventry Operations Ri Llc Dba Respiratory And Reh
Coventry Operations RI LLC DBA Respiratory and Reh in Coventry, RI — inspection on May 26, 2026.
Found 2 citations. 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
adjust ventilator settings without first speaking to a provider.2b.
Record review revealed Resident ID
jeopardy to resident health or dependence on respirator (ventilator) status.Review of a care plan focus area dated [DATE] revealed safety that Resident ID #3 is ventilator dependent with an intervention to use the ventilator for respiratory support per the physician's order.Review of a physician's order dated [DATE] revealed in part, the
interview on [DATE] at approximately 1:40 PM of Resident ID #3, in the presence of Staff C, Resident ID #3 was noted lying in his/her bed connected to his/her ventilator.
Further, his/her ventilator settings were observed, and s/he was noted to be receiving only room air, and was not receiving the 3 liters of oxygen, as prescribed.During a surveyor interview immediately following the above observation with Staff C, she was unable to provide evidence that Resident ID #3 had his/her ventilator settings set to include the 3 liters of oxygen, as prescribed.During a surveyor interview on [DATE] at 12:53 PM with the DNS, she was unable to provide evidence that the facility provided necessary respiratory care and services in accordance with professional standards of practice and per the facility's policies.Cross reference F 842
415078 05/26/2026
Coventry Operations RI LLC Dba Respiratory and Reh 10 Woodland Drive Coventry, RI 02816
in accordance with accepted professional standards.
clinical record review and staff interview, the facility failed to maintain complete and accurate
resident reviewed for non-invasive ventilation (NIV, a machine that provides breathing support using an external mask or other component, eliminating the need for an invasive surgical airway or breathing tube), Resident ID #1.
Findings are as follows:Review of a complaint received by the Rhode Island Department of Health on 5/19/2026 alleges, in part, that Resident ID #1 had been receiving the incorrect ventilator settings.
Record review revealed Resident ID #1 was admitted to the facility in March of 2026 with diagnoses including, but not limited to, duchenne or [NAME] muscular dystrophy (a severe, progressive genetic disorder characterized by the wasting away of skeletal, heart, and respiratory muscles), dependence on respirator (ventilator) status, and chronic respiratory failure.
Review of the care plan revealed a focus area dated 3/5/2026 indicating that Resident ID #1 has an alteration in respiratory status and is ventilator dependent.
Further, the care plan revealed that s/he receives ventilation support using non-invasive ventilation via mouthpiece ventilation equipment during the daytime.
Additionally, s/he uses nasal pillows [soft inserts that fit directly into the nostrils to provide pressurized air from the ventilator machine via a flexible tube to help keep the airway open, improve breathing, and prevent an individual from not breathing] at nighttime.
Further, interventions include, but are not limited to, ventilator check assessments to be conducted every six hours and to use the ventilator for respiratory support per the physician's order.Review of an undated facility policy titled, Non-Invasive Ventilator (NIV) Policy & Procedure states in part, .Purpose.Promote patient safety and improve respiratory support management.Procedure.Verify physician/provider order and prescribed settings.
Record review revealed Resident ID #1 utilized the following three ventilators while at the facility between 3/2/2026 through 3/14/2026:-Astral (daytime ventilator)-LTV (nighttime ventilator)-VOCSN (nighttime ventilator)
Record review revealed the following physician's order for the resident's LTV ventilator with the prescribed settings:-Tidal volume (VT, the amount of air inhaled or exhaled during a normal breath) 1100-Respiratory rate (RR, the number of breaths a person takes per minute) 14-Positive end-expiratory pressure (PEEP, the pressure in the lungs above atmospheric pressure at the end of exhalation that prevents the lungs from collapsing when breathing out) 6-Fraction of inspired oxygen (FiO2, refers to the oxygen concentration; room air is considered 21% oxygen) 21%-Pressure support (PS, a mode of mechanical ventilation that assists patients by providing a preset level of pressure during inhalation) 8
Record review revealed that the facility discontinued using the LTV ventilator and began using the VOCSN ventilator at nighttime beginning on 3/4/2026 through 3/14/2026.
Review of the March 2026 Treatment Administration Record revealed that staff continued to document that Resident ID #1 was receiving his/her LTV ventilator at the prescribed settings as denoted above, on the following dates, after it was discontinued on 3/4/2026:-3/4-3/5-3/6-3/8-3/9-3/10-3/11-3/12-3/14/2026During a surveyor interview on 5/22/2026 at approximately 11:25 AM with the Physician Assistant, he revealed that he expects staff to document accurately.During a surveyor interview on 5/22/2026 at 12:53 PM with the Director of Nursing Services, she was unable to provide evidence that the facility maintained accurate medical records for Resident ID #1.Cross reference F 695
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.