Inspection Reports for Oak Hill Center for Rehabilitation and Nursing
RI, 02860
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
291% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 15, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, infection control, and rehabilitation services at Adviniacare Pawtucket Pleasant Rehab Center, LLC.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate treatment and care for residents with skin conditions, inadequate supervision and safety measures for residents at risk of elopement and smoking hazards, insufficient nursing staff competencies in infection control practices, failure to provide required specialized rehabilitative services, and failure to maintain an effective infection prevention and control program.
Deficiencies (5)
Failure to provide appropriate treatment and care according to orders and resident preferences, resulting in actual harm related to skin conditions for residents #111 and #3.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, including inadequate supervision of resident #31 at risk for elopement and failure to provide assistive devices for smoking safety.
Failure to ensure nurses and nurse aides have appropriate competencies to prevent transmission of communicable diseases and infections, specifically related to contact precautions for resident #2.
Failure to provide specialized rehabilitative services as required for residents #8 and #42 with decline in activities of daily living functional abilities.
Failure to provide and implement an infection prevention and control program, including staff not wearing appropriate personal protective equipment for resident #2 on contact precautions.
Report Facts
Residents reviewed for skin condition deficiencies: 3
Residents reviewed for rehabilitation deficiencies: 2
Staff interviewed regarding infection control competencies: 4
Open wound measurements: 5
Open wound measurements: 2
Open wound measurements: 13
Open wound measurements: 5
Superficial wound size: 3
Superficial wound size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Nursing Assistant | Named in observation and interview regarding failure to identify skin alterations on Resident #111's feet and failure to supervise Resident #31 outside. |
| Staff G | Licensed Practical Nurse | Named in observation and interview regarding unawareness of skin alterations on Resident #111's feet and failure to notify provider of open wound on Resident #3. |
| Assistant Director of Nursing Services | ADNS | Named in interviews acknowledging failures in skin care monitoring and infection control. |
| Director of Nursing Services | DNS | Named in interviews acknowledging failures in skin care assessments and therapy screening. |
| Staff I | Contracted Maintenance Worker | Named in observation and interview regarding escorting Resident #31 unsupervised outside. |
| Staff J | Licensed Practical Nurse | Named in interviews acknowledging failure to supervise Resident #31 and failure to enforce smoking safety. |
| Staff K | Nursing Assistant | Named in observation and interview regarding failure to follow contact precautions for Resident #2. |
| Staff L | Certified Medication Technician | Named in interview regarding misunderstanding of contact precautions. |
| Staff M | Licensed Practical Nurse | Named in interview regarding inability to answer questions on contact precautions. |
| Staff H | Assistant Director of Nursing Services and Infection Preventionist | Named in interviews confirming staff deficiencies in infection control competencies. |
| Staff A | Director of Rehabilitation | Named in interviews acknowledging failure to provide therapy services and screening. |
| Staff D | Licensed Practical Nurse | Named in interview regarding lack of resident ambulation and therapy. |
| Staff E | Nursing Assistant | Named in interview regarding resident's request to walk and uncertainty about therapy. |
| Staff P | Licensed Practical Nurse | Named in interview confirming Resident #2's contact precautions and expected PPE use. |
| Administrator | Named in interview acknowledging failures in supervision and smoking safety. |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 7, 2025
Visit Reason
The inspection was conducted to ensure that the nursing facility services meet professional standards of quality, specifically reviewing wound treatment orders for Resident ID #2.
Findings
The facility failed to ensure proper physician orders and treatment for wounds on Resident ID #2, including a non-pressure wound on the left anterior shin and an unstageable pressure wound on the left posterior calf. Dressings were applied without proper labeling and treatment orders were missing or not followed on several dates.
Deficiencies (2)
Failure to have a physician's order for the non-pressure wound on the resident's left shin and failure to label wound dressings with date and initials.
No treatment order in place for the resident's unstageable pressure ulcer on the left posterior calf on specified dates, and failure to follow wound physician's treatment recommendations.
Report Facts
Residents reviewed for wound treatment orders: 3
Dates with missing treatment orders: 4
Duration of wound treatment order: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding wound dressing application and lack of physician order. |
| Wound Nurse | Interviewed about transcription of wound physician's treatment orders and acknowledged missing orders and improper dressing labeling. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
The inspection was conducted in response to a community reported complaint submitted to the Rhode Island Department of Health on 2025-03-24 alleging that areas of the nursing home appeared to be under construction and in disrepair, and that a resident's room smelled overwhelmingly of urine despite reported cleaning efforts.
Complaint Details
Complaint was submitted on 2025-03-24 alleging disrepair and urine odor in resident rooms, with prior notification on 2025-03-14 and unresolved issues as of 2025-03-21.
Findings
Surveyor observations on 2025-03-26 revealed unsanitary conditions including black and pink matter in shower stalls, urine odors, and brown stains inside toilet bowls across multiple floors and resident rooms. Additional issues included a large hole in a bathroom wall, presence of flies, and clutter in common areas. Facility leadership acknowledged the issues and committed to remedying them.
Deficiencies (1)
Facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, with unsanitary conditions in resident bathrooms and shower rooms including black and pink matter, urine odors, and stained toilet bowls.
Report Facts
Date of complaint submission: Mar 24, 2025
Date of survey observations: Mar 26, 2025
Hole size: 12
Hole size: 15
Number of urinals: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged observations and committed to remedy issues | |
| Director of Nursing | Acknowledged observations and committed to remedy issues | |
| Maintenance Director | Acknowledged observations and committed to remedy issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 2, 2024
Visit Reason
The inspection was conducted following a community report complaint submitted to the Rhode Island Department of Health on 10/1/2024 regarding concerns about care for residents with indwelling catheters and medication administration.
Complaint Details
The complaint alleged that Resident ID #1 accidentally removed his/her foley catheter shortly after admission and was transferred to the hospital three days later for fever and infection. The complaint also included concerns about missed antibiotic doses and inadequate monitoring of urinary output.
Findings
The facility failed to provide appropriate treatment and services for two residents with indwelling catheters, including inadequate monitoring and documentation of urinary output, and failed to ensure residents were free from significant medication errors, including missed antibiotic doses leading to adverse health outcomes.
Deficiencies (2)
Failure to monitor and document urinary output accurately for residents with indwelling catheters, including failure to notify providers of low urinary output.
Missed doses of antibiotic Bactrim due to incorrect transcription of start date and failure to notify provider, resulting in resident's condition worsening and hospital transfer.
Report Facts
Urinary output: 0
Urinary output: 800
Urinary output: 200
Missed antibiotic doses: 4
Medication doses missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Authored progress note on 9/24/2024 verifying medications; unable to explain incorrect transcription of Bactrim order start date and did not notify provider about missed doses |
| Staff B | Licensed Practical Nurse | Interviewed regarding urinary output monitoring and medication administration; indicated she would notify provider for low urinary output and missed antibiotic doses |
| Director of Nursing Services | Director of Nursing Services | Interviewed and stated expectation that urinary output be documented and provider notified; did not acknowledge need to notify provider for low urinary output in Resident ID #1 |
| Administrator | Administrator | Interviewed regarding expectations for urinary output documentation and provider notification |
| Physician | Physician | Authored progress note on 9/26/2024 regarding resident's condition and antibiotic course |
Inspection Report
Deficiencies: 2
Date: Jul 19, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with providing necessary behavioral health care and services to residents, specifically reviewing trauma-informed care for Resident ID #40.
Findings
The facility failed to provide the necessary behavioral health care and services as ordered, including medication administration discrepancies for anxiety treatment. The resident was not receiving buspirone 15mg twice daily and hydroxyzine 25mg every 12 hours as needed, despite physician orders. Interviews revealed lack of awareness and failure to transcribe orders correctly, impacting the resident's mental health care.
Deficiencies (2)
Failure to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident ID #40.
Resident was not receiving buspirone 15mg BID and hydroxyzine 25mg BID PRN for anxiety as ordered.
Report Facts
PHQ-9 depression scores: 9
PHQ-9 depression scores: 12
PHQ-9 depression scores: 10
PHQ-9 depression scores: 15
PHQ-9 depression scores: 19
Medication start date: 2024
Medication start date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Interviewed on 7/18/2024 regarding medication transcription and behavioral health care |
| Psychiatric provider | Psychiatric provider | Interviewed on 7/19/2024 regarding medication orders and resident treatment |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jul 19, 2024
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility standards, including resident assessments, care quality, infection control, and medication administration.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to provide care according to professional standards, medication errors, failure to accommodate resident food preferences, inadequate infection prevention and control practices, and failure to maintain equipment cleaning protocols.
Deficiencies (8)
Facility failed to ensure accurate resident assessments for tobacco use and range of motion for several residents.
Failed to provide treatment and care in accordance with professional standards for assistance with meals for a resident.
Failed to provide appropriate care and documentation for a resident with an indwelling Foley catheter.
Failed to ensure appropriate care for a resident with a feeding tube, including checking tube placement before medication administration.
Failed to provide necessary behavioral health care and services to a resident with mental health diagnoses, including failure to administer ordered medications.
Medication error rate of 16.67% observed during enteral medication administration via gastrostomy tube.
Failed to accommodate resident food preferences for a resident who preferred sandwiches but was not provided them.
Failed to maintain an infection prevention and control program, including failure to implement enhanced barrier precautions for residents with MDROs, improper humidified oxygen storage, and inadequate cleaning of BiPAP equipment.
Report Facts
Medication error rate: 16.67
Medication administration opportunities: 30
Medication errors observed: 5
Urinary output documentation failures: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Observed administering medications via gastrostomy tube incorrectly and not checking tube placement. |
| Staff B | Licensed Practical Nurse | Acknowledged failure to provide resident with preferred sandwich. |
| Staff C | Nursing Assistant | Acknowledged feeding resident chicken instead of preferred sandwich. |
| Staff D | Licensed Practical Nurse | Acknowledged failure to document urinary output and improper humidifier storage. |
| Director of Nursing Services | Director of Nursing Services | Unable to provide evidence of accurate assessments, proper care, medication administration, infection control, and equipment cleaning. |
| Psychiatric provider | Psychiatric provider | Reported resident was started on clonidine and unaware of medication transcription errors. |
| Registered Dietitian | Registered Dietitian | Documented resident food preferences and acknowledged failure to provide preferred meals. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
The inspection was conducted in response to a community reported complaint submitted to the Rhode Island Department of Health on 2024-06-05 alleging that a resident was found in extreme pain with bruising and that the physician had not been notified.
Complaint Details
Complaint was substantiated based on record review and staff interviews indicating failure to notify the physician and unauthorized implementation of hospice recommendations.
Findings
The facility failed to ensure that services met professional standards related to notifying the physician of a change in condition and implementing hospice recommendations without physician approval for one hospice resident. Bruises were noted on the resident's genital area and thigh, hospice recommendations were implemented as physician orders without provider notification or authorization.
Deficiencies (1)
Failure to notify the physician of a change in condition and implementing hospice recommendations without physician approval for one hospice resident.
Report Facts
Residents Affected: 1
Date of complaint submission: Jun 5, 2024
Date of physician order for anticoagulant: Dec 15, 2022
Date of physician order to monitor side effects: Mar 15, 2024
Date of bruise progress note: Jun 1, 2024
Date of hospice visit note: Jun 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Hospice Nurse | Authored hospice visit note and gave recommendations |
| Staff B | Licensed Practical Nurse | Notified hospice nurse of bruising but did not notify physician; implemented hospice recommendations without provider authorization |
| Staff C | Nurse Practitioner | Expected provider notification and was unaware of resident's condition until 6/3/2024 |
| Director of Nursing Services | DNS | Unable to provide evidence of provider notification or authorization of hospice recommendations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 4, 2023
Visit Reason
The inspection was conducted in response to an anonymous community complaint submitted to the Rhode Island Department of Health on 10/4/2023 alleging that the facility was 'filthy' and 'abandoned'.
Complaint Details
The visit was complaint-related based on an anonymous community complaint alleging the facility was 'filthy' and 'abandoned'.
Findings
Surveyor observations revealed worn and dirty carpets with extensive dirt buildup on multiple floors, cracked and stained ceiling tiles, peeling paint, and large cracks in walls across several units. Facility leadership acknowledged the need for repairs and replacement of flooring and carpets.
Deficiencies (1)
Facility failed to provide a safe, functional, sanitary, and comfortable environment for residents related to the condition of floors, ceilings, and walls in 4 of 5 units observed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Operations | Interviewed and acknowledged the need for repairs and replacement of floors and carpets. | |
| Director of Nursing Services | Present during interview with Director of Operations acknowledging repair needs. | |
| Administrator in Training | Acknowledged observations of dirty and worn carpets needing attention. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 13, 2023
Visit Reason
The inspection was conducted in response to a community reported complaint submitted to the Rhode Island Department of Health on 2023-09-11 alleging unsanitary conditions and dirt on the floors, which is not suitable for residents fighting infections.
Complaint Details
Complaint was submitted on 2023-09-11 alleging floors were full of dirt and residues, and the facility was very dirty and unsanitary, not suitable for persons fighting infections.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment related to resident air conditioners, with 11 of 19 air conditioners observed on all three floors found to have buildup of dirt, black matter, white matter, and water accumulation. Facility staff acknowledged the air conditioners were dirty and needed cleaning, but evidence showed incomplete cleaning practices.
Deficiencies (1)
Failure to maintain clean air conditioners with buildup of brown, black, white, and fuzzy gray matter inside fan vents, on filters, and water accumulation on vents and windowsills in multiple rooms across all floors.
Report Facts
Air conditioners observed: 19
Air conditioners with deficiencies: 11
Date of complaint: Sep 11, 2023
Date of survey: Sep 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Acknowledged air conditioners were dirty and needed cleaning; interviewed on 2023-09-13 |
| Administrator | Administrator | Acknowledged air conditioners were dirty and needed cleaning; interviewed on 2023-09-13 |
Inspection Report
Routine
Census: 50
Deficiencies: 14
Date: Jun 19, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide residents access to petty cash, improper handling of resident funds upon death, failure to post survey results accessibly, inadequate notification of Medicaid/Medicare coverage changes, failure to provide bed hold policy upon hospital transfer, failure to meet professional standards in resident care and medication administration, improper dialysis management, delayed pharmacy recommendation responses, food safety violations, and inaccurate medical record documentation.
Deficiencies (14)
Failed to assure residents have ready and reasonable access to petty cash.
Failed to convey resident funds and final accounting within 30 days upon resident's death.
Failed to post survey results accessibly and protect resident identifying information.
Failed to provide proper notice of Medicaid/Medicare coverage changes and liability.
Failed to provide written bed hold policy upon hospital transfer or therapeutic leave.
Failed to ensure services met professional standards for offloading heels, chemotherapy precautions, blood glucose monitoring, expired insulin administration, contact precautions for C-Diff, AIMS assessment, and dialysis medication administration.
Failed to provide appropriate treatment and care according to orders for surgical wound infection.
Failed to provide safe and appropriate administration of IV fluids related to PICC line care.
Failed to provide safe, appropriate dialysis care and management including medication scheduling and fluid restriction monitoring.
Failed to ensure timely response to pharmacy recommendations over multiple months.
Failed to ensure food is palatable, prepared by standardized recipes, and served at safe temperatures.
Failed to procure food from approved sources and comply with Rhode Island Food Code including labeling, storage, glove use, and sanitation.
Failed to maintain accurate medical records and documentation of medication administration.
Failed to implement and maintain an effective, comprehensive, data-driven QAPI program addressing pharmacy recommendations and quality deficiencies.
Report Facts
Residents with funds handled: 50
Resident personal needs funds balance: 580.04
Resident personal needs funds balance: 2826.78
Residents transferred to hospital: 7
Missed pharmacy recommendations: 29
Missed pharmacy recommendations: 83
Missed pharmacy recommendations: 33
Residents unaware of survey results: 15
Residents identified in survey results binder: 8
Residents on pureed diet: 7
Fluid restriction documented consumption: 49040
Fluid restriction documented consumption: 3840
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Acknowledged resident's heels were not offloaded. |
| Staff B | Licensed Practical Nurse | Acknowledged resident's heels were directly on mattress. |
| Staff C | Licensed Practical Nurse | Administered insulin subcutaneously; revealed resident unaware of chemotherapy toilet precautions. |
| Staff D | Licensed Practical Nurse | Acknowledged missed medication documentation and fluid restriction documentation gaps. |
| Staff E | Registered Nurse | Acknowledged wound care documentation gaps and medication administration documentation errors. |
| Staff F | Licensed Practical Nurse | Acknowledged PICC dressing change frequency not followed. |
| Staff G | Certified Medication Technician | Revealed medication administration scheduling related to dialysis days. |
| Staff H | Nurse Practitioner | Expected timely pharmacy recommendation responses; unaware of quetiapine GDR recommendation. |
| Staff I | Cook | Observed preparing pureed turkey without standardized recipe. |
| Staff J | Dietary Aide | Observed without beard restraint and improper glove use. |
| Staff K | Dietary Aide | Observed improper sanitizing technique. |
| Administrator | Unable to provide evidence of QAPI program and unaware of food safety and dietary issues. | |
| Director of Nursing Services | Acknowledged multiple deficiencies including dialysis management, medication documentation, and PICC care. | |
| Food Service Director | Unaware of food safety violations and dietary aide practices. |
Inspection Report
Deficiencies: 2
Date: May 24, 2023
Visit Reason
The inspection was conducted to evaluate compliance with medication administration and storage regulations at Adviniacare Pawtucket Pleasant Rehab Center, LLC.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically a resident missing glaucoma medication for 7 days due to pharmacy delivery errors. Additionally, the facility failed to properly label and store medications on all medication carts, with multiple bottles of eye drops open and not dated as required.
Deficiencies (2)
Failure to ensure residents are free from significant medication errors, including a resident missing glaucoma medication for 7 days.
Failure to store and label drugs and biologicals in accordance with professional principles; multiple medication bottles open and not dated on medication carts.
Report Facts
Residents reviewed for medication administration: 4
Days medication missed: 7
Medication carts reviewed: 3
Bottles of Latanoprost Solution open and not dated: 3
Bottles of Travoprost Solution open and not dated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Practitioner (NP) | Interviewed regarding medication availability and awareness of missed medication |
| Staff B | Certified Medication Technician (CMT) | Present during medication cart observation on third floor and acknowledged medication should have been dated |
| Staff C | Certified Medication Technician (CMT) | Present during medication cart observation on second floor and acknowledged medication should have been dated |
| Staff D | Licensed Practical Nurse (LPN) | Present during medication cart observation on first floor and acknowledged medication should have been dated |
| Staff E | Certified Medication Technician (CMT) | Present during medication cart observation on first floor and acknowledged medication should have been dated |
| Director of Nursing Services | Interviewed regarding medication delivery errors and inability to provide evidence of compliance with medication storage standards |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 8, 2023
Visit Reason
The inspection was conducted following community reported complaints alleging that a cognitively impaired resident eloped from the facility, which is supposed to be locked down, and that police notification was delayed.
Complaint Details
The visit was complaint-related based on community reports submitted on 2/7/2023 alleging a resident went missing between 6:00 AM and 8:00 AM on 2/7/2023, police were not notified until after 2 hours, and the resident was found wandering approximately 18 miles away in Woonsocket at 12:47 PM. The resident was identified as high risk for elopement with dementia and other diagnoses.
Findings
The facility failed to ensure adequate supervision of a high-risk cognitively impaired resident who eloped from the facility, traveling approximately 18 miles by bus before being found 6.5 hours later. Staff failed to follow elopement prevention education, including silencing the wanderguard alarm without verifying the resident's presence, and did not implement interventions after prior wandering incidents.
Deficiencies (1)
Failed to ensure that a cognitively impaired resident received adequate supervision to prevent elopement from the facility.
Report Facts
Elopement assessment score: 14
BIMS score: 9
Time resident missing: 6.5
Distance traveled: 18
Dates of medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | LPN | Silenced the front door wanderguard alarm on 2/7/2023 without going outside as per facility education |
| Staff D | LPN | Administered medication to resident on 2/7/2023 and assisted in silencing the wanderguard alarm over the phone without going downstairs |
| Administrator | Provided timeline of events and acknowledged staff failures related to elopement | |
| Director of Nursing Services | Notified surveyor that resident was located and transported to hospital | |
| Licensed Practical Nurse Staff A | LPN | Reported involvement in search for missing resident |
| Licensed Practical Nurse Staff B | LPN | Reported involvement in search for missing resident |
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