Inspection Reports for Coventry Skilled Nursing And Rehabilitation

Complaint was substantiated based on record review and staff interviews confirming failure to follow physician's orders for tube flushes as alleged in the complaint filed on 2025-11-14.

The facility failed to meet professional standards of quality by not following physician's orders for flushing the gastrostomy tube during medication administration and continuous feeding for Resident ID #1. Documentation and staff interviews confirmed that flushes were not administered as ordered.

The complaint alleged that Resident ID #5 sustained two falls and did not receive appropriate care for injuries, and that the facility was severely understaffed and lacked qualified staff.

The facility failed to provide effective CPR consistent with basic life support protocols, failed to follow physician orders for orthopedic follow-up, failed to prevent accidents due to inadequate supervision and staffing, failed to obtain proper physician orders and medication reconciliation upon readmission, failed to maintain sufficient nursing staff with appropriate skills, and failed to ensure residents were free from significant medication errors. These failures resulted in serious harm and death for some residents.

The investigation was triggered by a complaint and incident report submitted to the Rhode Island Department of Health regarding a medication error on 6/15/2025 where Resident ID #1 was administered Clozapine 200 mg and Geodon 80 mg intended for Resident ID #2. The resident was sent emergently to an acute care hospital by family after becoming unresponsive. The facility failed to notify the resident's physician and family timely and failed to monitor the resident appropriately.

The facility failed to properly identify the resident before medication administration, resulting in Resident ID #1 receiving Clozapine 200 mg and Geodon 80 mg in error. The resident was not monitored appropriately after the error, was allowed to leave the facility on a leave of absence (LOA) without family or provider being informed, and required emergency hospitalization and ventilation. Staff failed to notify the resident's physician and family in a timely manner, and the facility did not implement appropriate interventions or monitoring following the medication error.

Complaint investigation triggered by a community report alleging neglect and development of additional bed sores in a resident. The complaint was substantiated by findings of inadequate wound care and failure to follow physician orders.

The facility failed to ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards to promote healing, prevent infection, and prevent new ulcers. Specifically, wound evaluations were not completed upon admission and weekly as required, and negative pressure wound therapy was not applied as ordered.

Complaint investigation was triggered by a community reported complaint submitted to the Rhode Island Department of Health on 3/17/2025 alleging failure to obtain consent for antipsychotic medication for Resident #101. The complaint was substantiated as the facility failed to inform the resident's representative about the addition of Rexulti and associated risks.

Deficiencies were identified in multiple areas including informed consent for antipsychotic medication, accounting and records of personal funds, Medicaid/Medicare coverage notices, freedom from abuse and neglect, accuracy of assessments, care plan timing and revision, drug regimen review, infection prevention and control, and life safety code compliance. The facility failed to ensure timely kitchen hood suppression system servicing and automatic sprinkler system maintenance.

The complaint investigation found that the facility did not revise the care plan after the resident's fall on 2/11/2025 and failed to implement the intervention added on 2/13/2025 for frequent checks. Staff interviews on 3/21/2025 confirmed these deficiencies.

The facility failed to revise the care plan with new interventions after multiple unwitnessed falls sustained by Resident ID #21 between January and March 2025. Interviews with staff confirmed lack of evidence that fall risk interventions were implemented as required.

The complaint alleged that the resident was started on Rexulti in January 2025 without the resident's ability to consent and without family notification of risks or adverse reactions.

The facility failed to inform the resident's representative in advance about the addition and dosage changes of Rexulti, an atypical antipsychotic medication, and failed to provide written accounting of residents' personal funds quarterly for several residents. Additional deficiencies included failure to provide timely Medicare notices, neglect in ADL care for a resident, inaccurate resident assessments, failure to revise care plans after falls, failure to follow physician orders for daily weights, failure to communicate with dialysis centers, failure to act on pharmacist medication recommendations, failure to maintain infection control practices including enhanced barrier precautions, and failure to implement an effective antibiotic stewardship program.

The complaint investigation was triggered by community reports received on 7/27/2024 and 8/14/2024 alleging mold on air conditioner units, water leaking, mold on carpeting, and resident elopements including Resident ID #1 found at a local convenience store. The investigation found failures in environmental safety and resident supervision.

The facility failed to maintain a safe, clean, and homelike environment due to mold and black matter on air conditioners and exposed pipes. Additionally, the facility failed to ensure adequate supervision to prevent elopement for 3 residents identified as elopement risks, with multiple failures in care planning, intervention implementation, and staff training.

The complaint investigation was triggered by a community reported complaint submitted on 7/17/2024 alleging multiple residents did not receive their medications as ordered. The complaint was substantiated by record reviews and staff interviews indicating failure to administer medications and treatments as ordered for multiple residents.

The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically failing to administer medications and treatments as ordered for 7 of 9 residents reviewed. The surveyor could not provide evidence that Residents #1, 2, 3, 4, 5, 6, and 7 received their medications and treatments on the specified dates and times.

The complaint investigation revealed that Resident ID #1's wound care treatment was outdated and not completed per medical doctor orders, with dressing changes not done as ordered on 6/13/2024 and 6/18/2024. Resident ID #3's wound treatment was also not completed as ordered on 7/7/2024. Facility staff, including the Administrator and Director of Nursing Services, acknowledged these failures during interviews.

The facility failed to ensure that two residents with stage 4 pressure ulcers received necessary wound care treatments as ordered by the physician, including timely dressing changes and completion of wound care procedures, resulting in minimal harm or potential for actual harm.

The complaint alleged that on 5/22/2024 a nurse forcibly administered mouthwash to a resident with a tracheostomy without using suction, which is required for safe oral care in such residents. The complaint was substantiated by record review, staff interviews, and observation.

The facility failed to ensure safe and appropriate respiratory care for residents with tracheostomies, specifically in providing oral care with suctioning as required. Staff lacked training and competency in suctioning and oral care for residents who are NPO with tracheostomies, and the facility lacked policies and procedures for oral care in this population. Multiple residents were at risk due to these deficiencies.

The complaint alleged that treatments and medication administration were not completed as ordered on 5/20/2024, including failure to administer insulin and failure to provide ordered wound and catheter care.

The facility failed to ensure residents received treatment and care according to physician orders for multiple residents, including failure to administer prescribed suprapubic catheter care, failure to promptly identify and intervene during an acute change in condition for a resident with wounds, failure to provide necessary pressure ulcer care, and failure to prevent significant medication errors related to insulin administration.

The continued noncompliance citation was issued due to failure to ensure resident safety and provide adequate staffing, including an unlicensed person conducting assessments, treatments, and medications to five residents without proper supervision.

Most previous deficiencies were corrected; however, a new deficiency related to insufficient nursing staff was identified and recited due to continued noncompliance. Additionally, a life safety code deficiency regarding sprinkler coverage at the main entrance was found but has been resolved.

Complaint alleged that an unlicensed graduate nurse administered medications unsupervised on the N3 unit during the 11:00 PM - 7:00 AM shift on 5/4/2024-5/5/2024, and that a nurse was forced to work a 20-hour shift, violating state law limiting consecutive work hours to 12.

The facility failed to provide sufficient nurse staffing and allowed an unlicensed graduate nurse (Staff A) to work unsupervised, administering medications, treatments, and assessments to 34 residents. Additionally, a Registered Nurse (Staff C) worked 20 hours in a 24-hour period, exceeding legal limits. The facility was unable to demonstrate effective administration of resources to ensure resident safety and well-being.

The complaint investigation was triggered by community reports submitted to the Rhode Island Department of Health on 4/24/2024 and 4/26/2024 alleging neglect of Resident ID #5 and uncontrollable combative behaviors of Resident ID #4. The complaint for Resident ID #5 involved failure to administer medication and assess pain, while the complaint for Resident ID #4 involved failure to manage behavioral symptoms appropriately.

The facility failed to protect Resident ID #5 from neglect, specifically failing to administer timely medication and assess the resident's change in condition. Additionally, the facility failed to provide appropriate behavioral health care and services to Resident ID #4, who exhibited uncontrollable combative behaviors and did not receive adequate interventions or timely psychiatric consultation.

Complaint investigation was part of the survey to address concerns related to feeding tube management and resident care.

Deficiencies were cited related to tube feeding management, physician supervision, sufficient nursing staff, food safety, and life safety code violations including fire exit door and emergency lighting issues. The facility provided plans of correction including staff education, audits, and corrective actions.

The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically for two residents requiring assistance of two staff members for ADL care. Observations and staff interviews revealed inadequate staffing levels, delayed response to call lights, and staff frequently providing care alone despite the need for assistance.

The facility was found deficient in multiple areas including failure to ensure appropriate care and follow-up for a resident with a dislodged feeding tube, inadequate physician supervision for a resident with abnormal lab results, insufficient nursing staff to meet resident care needs, and improper food storage and sanitation practices in kitchenettes and resident refrigerators.

The complaint reported on 2/22/2024 alleged that Resident ID #1 was sent home with Resident ID #2's medications. The family member of Resident ID #1 confirmed receiving the wrong medications and notified the facility. Staff acknowledged the error, and the medications were returned. The facility failed to provide evidence of proper medication reconciliation or discard and reorder of the returned medications.

The facility failed to reconcile all pre-discharge medications with post-discharge medications for Resident ID #1 and failed to provide a complete discharge summary for Residents ID #6 and #9. Additionally, the facility failed to store medications properly and broke the chain of custody by giving Resident ID #2's medications to Resident ID #1 upon discharge.

The facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed with an indwelling catheter, as the urinary collection bag was observed resting directly on the floor without a privacy bag, contrary to CDC guidelines and facility policy. Staff and the Director of Nursing acknowledged the deficiency.

The complaint investigation found that Resident ID #1 was administered seizure medications (Keppra, Vimpat, Phenobarbital) and Lovenox injection intended for Resident ID #3. The nurse did not verify Resident ID #1's identity prior to administration. The resident's family was notified, and the medical doctor ordered monitoring and blood work, which was not completed on the day of the error. The Director of Nursing acknowledged the error and lack of evidence that Resident ID #1 was kept free from significant medication errors.

The facility failed to ensure residents were free from significant medication errors when a nurse administered medications intended for Resident ID #3 to Resident ID #1 without verifying the resident's identity. This error had the potential to cause serious adverse outcomes, including immediate jeopardy to resident health or safety.

The complaint alleged that Resident ID #1 had oozing bed sores and blisters due to lack of repositioning and inadequate wound care, failure to follow physician orders for heel protectors, failure to obtain outpatient PT/OT services after specialist referral, and failure to ensure physician review of abnormal lab values for Resident ID #4.

The facility failed to provide appropriate pressure ulcer care, ensure physician supervision for residents with changes in condition and abnormal lab values, and obtain specialized rehabilitative services as recommended. Specifically, there was failure to implement orders for heel protectors, failure to follow up on elevated medication lab levels, and failure to schedule outpatient physical and occupational therapy services.

The complaint investigation was triggered by a community report on 11/2/2023 alleging Resident ID #3 did not receive MiraLAX for 10 days, leading to the resident purchasing their own medication. The investigation confirmed missed medication doses for Residents #3, #4, and #5, with no evidence that the provider was notified. The facility ran out of MiraLAX for 10 to 14 days. The primary care physician and Director of Nursing were unaware of the missed doses.

The facility failed to meet professional standards of quality by not following physician's orders for medication administration for 3 of 4 residents reviewed (Residents #3, 4, and 5), resulting from a shortage of MiraLAX and lack of provider notification. Additionally, the facility inaccurately documented the use of a low air loss mattress for Resident #4, which was broken and not in use for weeks.

The facility failed to ensure that services met professional standards of quality by not following the physician's order to change the humidified air tubing weekly for one resident, as evidenced by observation, record review, and staff interviews.

Complaint investigation was part of the survey, referenced by ACTS Reference Number 88568.

Deficiencies were cited related to drug regimen errors, medication error rates exceeding 5%, improper storage and labeling of drugs and biologicals, food safety violations, and failure to ensure infection preventionist completed specialized training. No Life Safety Code deficiencies were identified.

The facility was found deficient in multiple areas including administration of unnecessary medications, medication errors exceeding acceptable rates, improper labeling and storage of drugs, food safety violations in the kitchen, and failure to ensure the infection preventionist completed specialized training.

The facility was determined not to be in compliance with several requirements, resulting in multiple deficiencies cited related to resident self-administration of medications, advance directives, comprehensive care plans, bowel/bladder incontinence, nutrition/hydration status, respiratory care, physician visits, medication errors, food procurement and safety, smoking policies, and quality assurance performance improvement.