Coventry Operations RI LLC DBA Respiratory and Reh

In the surveyor’s words

From the most serious findings on record at Coventry Operations RI LLC DBA Respiratory and Reh, in the surveyor’s own words.

• Immediate jeopardy, patternF805Apr 14, 2026

  Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure a system was in place to prepare and serve fluids in a form designed to meet residents prescribed dietary needs. Specifically, the facility failed to ensure nectar thick liquids (mildly thick fluid consistency required to promote safe swallowing) were prepared according to physician's orders for 1 of 1 resident reviewed who was prescribed nectar thick liquids, Resident ID #21. Additionally, the current styrofoam cup supply, located on 4 of 4 units, was found to consist of 16 fluid (fl.) ounce (oz.) cups instead of the 12 fl. oz cups that were posted in the facility for staff to use for guidance and instructions when preparing thickened liquids. […]

• Immediate jeopardy, patternF726Oct 28, 2025

  Based on record review and staff interview, it has been determined that the facility failed to have sufficient nursing staff with the appropriate skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to the medication verification process for the readmission of Resident ID #1 that involved six staff members, Staff A, B, C, E, the Assistant Director of Nursing Services (ADNS), and the resident's physician, that resulted in a significant medication error for Resident # 1. […]

• Immediate jeopardy, patternF695Jun 6, 2024

  Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice for 15 of 15 residents reviewed with a tracheostomy (a medical procedure that involves creating an opening in the neck to place a tube into a person's trachea, or windpipe), relative to oral care with suctioning, Resident ID #s 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17. […]

• Immediate jeopardy, patternF725May 14, 2024

  Based on record review and staff interview it has been determined that the facility failed to provide sufficient nurse staffing to ensure resident safety and attain the highest practicable physical, mental and psychosocial wellbeing of each resident relative to 1 of 1 unlicensed person who was scheduled as a nurse on a unit unsupervised and who documented that she administered treatments and/or medications to 5 of 5 residents reviewed who had treatments and/or medications scheduled for the 11:00 PM - 7:00 AM shift, Resident ID #s 1, 2, 3, 4, and 5, and who documented in 34 of 34 residents' health records reviewed from a unit, Resident ID #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 and 34. […]

• Immediate jeopardy, isolatedF695May 26, 2026

  Based on surveyor observation, clinical record review, and staff interview, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for a resident who requires mechanical ventilation (a life-support therapy that assists or replaces natural breathing by delivering oxygen and removing carbon dioxide through a ventilator) who experienced chest pain and was sent via rescue to an acute care hospital for evaluation, Resident ID #1, who ultimately expired in transit to the hospital. […]