Home / Rhode Island / Coventry
10 Woodland Drive, Coventry, RI 02816 · Kent County · (401) 826-2000
210 certified beds, about 105 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1983
CMS Care Compare ratings, data as of September 1, 2026 · CCN 415078 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 14, 2026, inspectors cited 15 health deficiencies (the Rhode Island average is 9.3, the national average 9.2).
Of 80 health citations since November 2023, 18 were rated as actual harm or immediate jeopardy to residents (12 immediate jeopardy).
CMS lists 8 fines totaling $371,554 in the last three years; the largest was $120,182, and the latest is dated April 14, 2026.
Nurses and nurse aides worked 4.09 hours per resident per day, against 3.71 across Rhode Island and 3.86 nationally. Registered nurses accounted for 0.97 of those hours.
71.8% of nursing staff left within the year CMS measured (Rhode Island average 40.6%).
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 80 health citations on file.
Inspectors wroteBased on record review and staff interview, the facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment and maintain a plan to maximize recruitment and retention of direct care staff.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that a resident remained free from physical abuse for 1 of 3 residents reviewed, pertaining to Resident ID #2 when Resident ID #1 physically assaulted the resident by pushing him/her against a door and holding a butter knife to his/her neck.
Inspectors wroteBased 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. [...]
Inspectors wroteBased on clinical record review and staff interview, the facility failed to maintain complete and accurate resident medical records in accordance with accepted professional standards and practices for 1 of 1 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.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly discharge from the facility by communicating the appropriate information for 1 of 1 resident reviewed for a discharge to his/her home, Resident ID #4.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide a resident who is unable to carry out activities of daily living, the necessary services to maintain good grooming and personal hygiene for 1 of 3 residents who were reviewed for showers, Resident ID #4.
Inspectors wroteBased 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. [...]
Inspectors wroteBased on record review and staff interview, the facility failed to complete an annual performance review for every nurse aide (NA) at least once every 12 months, for 5 of 5 NAs' personnel records reviewed, Staff I, J, K, L and M.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that irregularities identified by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were acted upon for 4 of 4 residents reviewed with outstanding pharmacy recommendations from prior months, Resident ID #s 6, 29, 84, and 107.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure a resident's drug regimen is free from unnecessary drugs for 1 of 1 resident reviewed receiving Midodrine (a medication prescribed to treat low blood pressure), Resident ID #13.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interviews, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication storage rooms observed and 3 of 4 medication carts observed.
Inspectors wroteBased on surveyor observation, record review, and staff interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to 3 of 4 kitchenettes.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that resident records are complete and accurately documented for 1 of 1 resident reviewed for 15-minute checks, Resident ID #9; for 1 of 1 resident reviewed for hand splints, Resident ID #52; and for 1 of 1 resident reviewed with a physician's order to flush his/her Gastrostomy tube (G-tube, a medical device inserted through the abdomen directly into the stomach to provide long-term nutritional support, fluids, and medication) before and after each feeding, Resident ID #71.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interviews, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infection, relative to maintaining Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) for 1 of 1 resident observed on EBP, Resident ID #20. [...]
Inspectors wroteBased on record review and staff interview, the facility failed to develop, implement, and maintain an effective training program for annual training for existing employees consistent with their expected roles, relative to education per the facility assessment, for 10 of 11 employees reviewed, Staff I, J, K, L, M, T, Y, GG, HH, and II.
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that the resident's formulated advance directive would be followed, as there were inconsistencies between the paper medical record and the Electronic Medical Record (EMR), for 1 of 1 resident reviewed who had recently changed his/her code status, Resident ID #4.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to promote wound healing for 1 of 1 resident reviewed with actual pressure ulcers (localized injuries to the skin and/or underlying skin usually over a bony prominence), Resident ID #52.
Inspectors wroteBased on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 2 residents reviewed with contractures (the shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to become very stiff, which prevents normal movement), Resident ID #52.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances, at least quarterly for 6 of 6 residents reviewed, Resident ID #s 14, 55, 57, 71, 74, and 86.
Inspectors wroteBased on record review and staff interview, the facility failed to notify each resident, or resident representative, that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Social Security Income (SSI) resource limit for 2 of 2 residents reviewed with over $4000 in personal needs funds handled by the facility, Resident ID #s 14 and 74.
Inspectors wroteBased on record review and staff interviews, the facility failed to allow the resident or resident representative to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility relative to 1 of 1 resident reviewed whose resident representative requested his/her medical records, Resident ID #120.
Inspectors wroteBased 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.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide effective cardiopulmonary resuscitation (CPR) consistent with basic life support protocols to a resident who was found without a pulse or respirations, Resident ID #3. 1. Record review revealed Resident ID #3 was admitted to the facility in August of 2025 with diagnoses including, but not limited to, acute and chronic respiratory failure with hypoxia (low levels of oxygen in the blood) and a tracheostomy (a surgical procedure to create an opening through the neck into the windpipe to facilitate breathing). Record review revealed that Resident ID #3 was a full code indicating that s/he wishes to receive life saving measures including CPR, which consists of chest compressions and rescue breaths, if required, in the event of a medical emergency. Review of a progress note dated [DATE] at 7: [...]
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who received Metolazone (a diuretic medication prescribed to treat fluid retention by increasing urine production) not as intended, Resident ID #1.
Inspectors wroteBased 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. Additionally, the facility failed to have nursing staff with the appropriate skills set regarding the care and treatment of Resident ID #1 after s/he was found unresponsive on the floor. [...]
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards relative to falls for 1 of 3 residents reviewed, Resident ID #5. The facility failed to implement the resident's care plan, leading directly to an accident and injury to resident #5, who sustained a left distal tibia (large shinbone) and fibula (smaller shinbone) fracture.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to have sufficient nursing staff to assure resident safety and attain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to insufficient staffing for 1 of 3 residents reviewed for a fall, Resident ID #5.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 3 residents reviewed for a physician referral for an appointment, Resident ID #5.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident's physician completed a medication reconciliation upon readmission. This failure resulted resulted in a resident receiving the medication Metolazone (a medication prescribed to treat fluid retention) in error, Resident ID #1.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that resident's records are complete and accurately documented, relative to 1 of 1 resident reviewed who received Metolazone (medication to treat fluid retention) inaccurately, Resident ID #1.
Inspectors wroteBased on surveyor observation, record review, and resident representative and staff interviews, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, as because the facility failed to monitor a resident for side effects after s/he was administered significant antipsychotic medications in error, nursing failed to inform additional staff on the unit that an error had occurred in order to enable all staff to assist in the monitoring of the resident, the failure to notify a provider of the medication error timely, the failure to inform the resident's family of the error at all, and allowed a resident who required monitoring to leave the facility on a leave of absence (LOA), for 1 of 1 resident reviewed who required emergency medical transport, hospitalization, and ventilation (ventilators are lifesaving machines [...]
Inspectors wroteBased on surveyor observation, record review, and resident representative and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed who was administered psychiatric medications that were prescribed for another resident, who required emergency medical transport, hospitalization, and ventilation. Medical ventilators are lifesaving machines that can support breathing function in the body when diagnosed with critical health conditions. These intervention were necessary as a result of medication errors involving Resident ID #1.
Inspectors wroteBased on record review, resident representative and staff interviews, it has been determined that the facility failed to immediately consult with the resident's physician and inform the resident's representative when there was a need to commence a new form of treatment to deal with a problem for 1 of 1 resident reviewed who was administered medications in error, Resident ID #1.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure a resident with pressure ulcers (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents reviewed, Resident ID #1.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that each resident was given a written accounting of his/her deposits, withdrawals, and balances at least quarterly for 5 of 7 residents reviewed, Resident ID #s 36, 41, 58, 69, and 252.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing them of when changes in coverage are made to items and services covered by Medicare and/or the state medical plan related to the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage Form for 2 of 4 residents discharged from Medicare Part A Services that remained in the facility, Resident ID #s 64 and 402. Additionally, the facility failed to provide notice of Medicare Non-Coverage (NOMNC), in a timely manner for 2 of 4 residents reviewed who were discharged from a Medicare covered Part A stay with benefit days remaining, Resident ID #s 93 and 253.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident reviewed with a diagnosis of schizophrenia, Resident ID #66.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to failure to follow a physician's order for 1 of 1 resident reviewed for daily weights, Resident ID #23.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the irregularities identified by the Consultant Pharmacist during the monthly pharmacist Medication Regimen Review (MRR) were acted upon for 1 of 2 residents reviewed for admission medication reconciliation, Resident ID #93.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to enhanced barrier precautions (EBP; refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities), for 4 of 4 residents reviewed on EBP, Resident ID #s 15, 60, 74, and 92.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 5 residents reviewed for antibiotic orders, Resident ID #s 89 and 93.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to inform the resident's appointed representative, in advance, of the care to be furnished by the physician or other provider, of the risks and benefits of proposed care or treatment alternatives relative to the ordering of, and administration of, an antipsychotic medication for 1 of 2 residents reviewed for the use of Rexulti (an atypical antipsychotic medication), Resident ID #101.
Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to keep a resident free from neglect for 1 of 1 resident reviewed for activities of daily living (ADLs), Resident ID #452.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to implement and revise a care plan after each assessment for 1 of 2 residents reviewed for falls, Resident ID #21.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis (a treatment that removes excess fluid, waste, and toxins from the blood when the kidneys are no longer functioning properly) receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for communication with the dialysis center, Resident ID #64.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the resident's drug regimen is free from unnecessary drugs for 1 of 2 residents reviewed for admission medication reconciliation, Resident ID #93.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to document all required components of the facility-wide assessment. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement and maintain an effective, comprehensive, data-driven, Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. Additionally, the facility failed to make a good faith attempt to correct the identified concern of antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) and personal protective equipment (PPE) related to enhanced barrier precautions (EBP; refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities).
Inspectors wroteBased on record review staff and resident interview, it has been determined that the facility failed to ensure that the resident receives adequate supervision to prevent an elopement for 3 of 6 residents reviewed who were identified as an elopement risk, Resident ID #s 1, 2, and 4. Review of a community reported complaint received by the Rhode Island Department of Health on 8/14/2024 alleged that Resident ID #1 eloped from the facility over the weekend and was found at a local convenience store. [...]
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment relative to window air conditioners and exposed pipes in the hallway ceiling for 4 of 4 occupied facility units.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program, for existing staff, consistent with their expected roles, relative to education involving smoking per the facility assessment, for 5 of 5 staff reviewed, Staff A, D, E, F and G.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide mandatory training to their staff, that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance and Performance Improvement) program, for 3 of 5 staff reviewed, Staff A, D, and E.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide all staff with behavioral health training, for 3 of 5 staff reviewed, Staff, A, D, and E.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 7 of 9 residents reviewed, Resident ID #s 1, 2, 3, 4, 5, 6, and 7.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to keep residents free from significant medication errors for 4 of 4 residents reviewed, Resident ID #s 1, 2, 3, and 4.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 residents reviewed for pressure ulcers, Resident ID #s 1 and 3.
Inspectors wroteBased 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.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure licensed nurses had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans in accordance with the facility assessment for 3 of 3 nurses reviewed, Staff A, I, and J who worked on the Ventilator Unit.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, relative to promptly identifying and intervening during an acute change in a resident's condition, for 1 of 1 resident reviewed, Resident ID #1.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following a physician's order for 2 of 2 residents reviewed with an indwelling suprapubic catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #'s 7 and 8.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 residents reviewed for pressure ulcers, Resident ID #'s 4, 5 and 6.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 1 of 1 resident reviewed for insulin, Resident ID #2.
Inspectors wroteBased 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. [...]
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to 1 of 1 unlicensed person who was working as a Graduate Nurse, (GN), in the facility and was responsible for overseeing the care of 34 of the facility's residents during the 11:00 PM - 7:00 AM shift on 5/4/2024- 5/5/2024, Staff A.
Inspectors wroteBased on surveyor observation, record review, resident, and staff interview it has been determined that the facility failed to protect the resident's right to be free from neglect for 1 of 1 residents reviewed for neglect, Resident ID #5.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that a resident who displays or is diagnosed with a mental disorder receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for 1 of 1 residents reviewed who exhibited behavioral symptoms, Resident ID #4.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed who receives nutrition and medications via Gastrostomy Tube (G-tube- is a feeding tube that provides supplemental feeding, hydration, or medicine directly to the stomach), Resident ID #21.
Inspectors wroteBased on surveyor observation, resident and staff interview, it has been determined that the facility failed to properly store, distribute, and serve food in accordance with professional standards for food service safety relative to 3 of 5 kitchenettes, 1 of 2 resident room refrigerators, and the cleanliness of 3 of 4 kitchenette ice machines.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 1 resident reviewed for abnormal laboratory results, Resident ID #94.
Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide sufficient nursing staffing to ensure resident safety and attain the highest practicable, physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care relative to Activities of Daily Living (ADL) for 2 of 2 residents reviewed for ADL care needs, Resident ID #s 21 and 77.
Inspectors wroteBased on record review, resident representative interview, and staff interview, it has been determined that the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications, for 1 of 9 discharged residents reviewed, Resident ID #1, and failed to have a discharge summary that includes, but is not limited to, a recapitulation of the resident's stay, a final summary of the residents status at discharge and a reconciliation of the residents medications for 2 of 9 residents reviewed Resident ID #s 6 and 9.
Inspectors wroteBased on record review, resident representative interview, and staff interview, it has been determined that the facility failed to store medications in accordance with currently accepted professional principles for 1 of 10 residents reviewed relative to breaking the chain of custody of medications and administering said medications to a resident, Resident ID #2.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed with an indwelling catheter, Resident ID #1.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 residents reviewed who was administered seizure medications (Keppra, Vimpat, and Phenobarbital) and a blood thinning medication (Lovenox injection) intended for another resident, Resident ID #1.
Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to obtain specialized rehabilitation services for 1 of 1 resident reviewed relative to rehabilitative services, Resident ID #1.
Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 2 residents reviewed for pressure ulcers (a localized injury to the skin or underlying tissue due to pressure), Resident ID #1.
Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 2 of 5 residents reviewed for a change in condition and abnormal lab values, Resident ID #'s 1 and 4.
Inspectors wroteBased on record review, resident, and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 3 of 4 residents reviewed for medication administration, Resident ID #'s 3, 4, and 5.
Inspectors wroteBased on surveyor interview and record review, it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed for the use of a low air loss mattress, Resident ID #4.
19 fire safety citations on file: 9 on April 14, 2026, 3 on July 31, 2025, 2 on March 21, 2025, 5 on April 8, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| April 14, 2026 | Fine | $27,378 |
| April 14, 2026 | Fine | $59,065 |
| April 14, 2026 | Payment Denial | 39 days from May 7, 2026 |
| October 28, 2025 | Fine | $89,970 |
| August 22, 2024 | Fine | $47,990 |
| August 22, 2024 | Payment Denial | 4 days from September 13, 2024 |
| April 8, 2024 | Fine | $8,824 |
| April 8, 2024 | Fine | $120,182 |
| February 6, 2024 | Fine | $8,827 |
| December 26, 2023 | Fine | $9,318 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Rhode Island | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.09 | 3.71 | 3.86 |
| Registered nurses | 0.97 | 0.77 | 0.69 |
| All nursing staff on weekends | 3.71 | 3.34 | 3.42 |
| Nurse aides | 2.39 | ||
| Licensed practical nurses | 0.73 | ||
| Nursing staff turnover (share who left in a year) | 71.8% | 40.6% | 45.8% |
| Registered nurse turnover | 75.9% | 37.9% | 42.9% |
| Administrators who left | 2 |
CMS expects 4.31 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.25 on weekdays and 3.71 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 28.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.66 in April to June 2025 to 4.09 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.09 | 0.97 | 4.25 | 3.71 | 28.9% | 0 of 90 | 105 |
| Oct to Dec 2025 | 4.12 | 1.04 | 4.26 | 3.74 | 26.2% | 0 of 92 | 111 |
| Jul to Sep 2025 | 3.95 | 1.04 | 4.07 | 3.65 | 23.5% | 0 of 92 | 109 |
| Apr to Jun 2025 | 3.66 | 1.11 | 3.67 | 3.63 | 30.3% | 0 of 91 | 101 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Rhode Island, Jan to Mar 2026 | 3.67 | 0.69 | 3.82 | 3.30 | 5.4% | 1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Rhode Island, all employers | |||
| CNAs (nursing assistants) | $22.33 | $21.52 to $22.82 | 10,220 |
| LPNs and LVNs | $38.51 | $37.45 to $39.02 | 1,290 |
| Registered nurses | $48.39 | $39.35 to $51.49 | 10,090 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Rhode Island | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 31.9 | 19.6 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.9 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.4 | 2.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.4 | 3.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.8 | 2.0 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 26.0 | 16.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.2 | 4.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 19.2 | 22.5 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 26.4 | 24.3 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.0 | 14.6 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 1.7 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Coventry Operations Ri LLC Dba Respiratory and Reh's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (58.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
58.2% this home
No different from the national rate
US median of homes 51.5% · Rhode Island: 24 better, 1 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 78 eligible stays.
10.8% this home
No different from the national rate
US median of homes 10.7% · Rhode Island: 0 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 74 eligible stays.
6.8% this home
No different from the national rate
US median of homes 7.1% · Rhode Island: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 50 eligible stays.
60.0% this home
Median of homes: Rhode Island59.1% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 25 residents counted.
3.6% this home
Median of homes: Rhode Island0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 56 residents counted.
1.9% this home
Median of homes: Rhode Island2.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 56 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Rhode Island100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 5 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: COVENTRY OPERATIONS RI LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Mayflower Healthcare LLC | 5% or greater direct ownership interest | Organization | 100% | 05/23/2025 |
| Schwartz, Zev | Indirect ownership interest | Individual | 05/23/2025 | |
| Ohi Asset (ct) Lender, LLC | 5% or greater security interest | Organization | 01/01/2012 | |
| Schwartz, Zev | Managing control - governing body | Individual | 05/23/2025 | |
| Mayflower Healthcare LLC | Operational/managerial control | Organization | 05/23/2025 | |
| Adeoye, Morenike | Operational/managerial control | Individual | 05/23/2025 | |
| Juma, Robert | Operational/managerial control | Individual | 05/23/2025 | |
| Schwartz, Zev | Operational/managerial control | Individual | 05/23/2025 | |
| Tabe, Julius | Operational/managerial control | Individual | 04/01/2024 | |
| Ulubiyo, Israel | Operational/managerial control | Individual | 06/30/2025 | |
| Vespia, Donald | Operational/managerial control | Individual | 05/23/2025 | |
| Powerback Rehabilitation LLC | Adp of the SNF | Organization | 05/23/2025 | |
| Rgw Consulting LLC | Adp of the SNF | Organization | 05/23/2025 | |
| Adeoye, Morenike | Adp of the SNF | Individual | 06/16/2025 | |
| Juma, Robert | Adp of the SNF | Individual | 05/23/2025 | |
| Tabe, Julius | Adp of the SNF | Individual | 04/01/2024 | |
| Ulubiyo, Israel | Adp of the SNF | Individual | 02/10/2026 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Rhode Island. NursingHomeClear cannot take or act on complaints.