Inspection Reports for Oakland Grove Health Care Center
560 CUMBERLAND HILL ROAD, RI, 02895
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
60% occupied
Based on a September 2023 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 21, 2024
Visit Reason
An off-site desk audit was conducted on October 21, 2024, to review all previous deficiencies cited on September 12, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all previous deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 6
Sep 12, 2024
Visit Reason
A recertification and complaint survey was conducted at Oakland Grove Health Care Center from 09/09/2024 through 09/12/2024 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were identified related to failure to meet professional standards of care in intake and output monitoring, nutrition and hydration status maintenance, tube feeding management, trauma-informed care, infection prevention and control, and life safety code violations related to kitchen hood suppression system maintenance.
Complaint Details
The survey was a recertification and complaint survey with ACTS reference numbers 97424, 97055, and 97526. Deficiencies were identified as a result of the complaint investigation.
Deficiencies (6)
| Description |
|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards of practice related to intake and output monitoring for residents with catheters. |
| Failure to maintain acceptable parameters of nutritional status for residents, including failure to document weights and reweigh residents after significant weight changes. |
| Failure to ensure residents fed by feeding tubes receive appropriate treatment and services to prevent complications. |
| Failure to provide trauma-informed care to residents with history of trauma or PTSD, including failure to complete assessments and identify triggers. |
| Failure to establish and maintain an infection prevention and control program, including failure to screen employees and visitors for COVID-19 symptoms and failure to ensure staff wear appropriate PPE. |
| Failure to maintain the kitchen hood suppression system in accordance with National Fire Protection Association standards, with potential impact on 109 residents and staff. |
Report Facts
Residents reviewed for intake and output monitoring: 4
Opportunities for intake and output documentation: 27
Opportunities for intake and output documentation: 26
Opportunities for intake and output documentation: 30
Opportunities for intake and output documentation: 9
Residents reviewed for nutritional status: 3
Weight loss percentage: 8.59
Weight loss percentage: 11.89
Residents affected by kitchen hood suppression deficiency: 109
Residents tested positive for COVID-19: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Unable to provide evidence that intake and output orders were documented. |
| Staff C | LPN | Unable to provide evidence that intake and output orders were documented. |
| Staff F | Nurse | Revealed weights are done by nursing assistants and documented; unaware of weight gain for Resident #96. |
| Staff D | Licensed Practical Nurse | Revealed nurses document weights and note significant changes. |
| Staff G | Nurse Practitioner | Unaware of Resident #96's weight gain. |
| Staff H | Licensed Practical Nurse | Observed resident's head of bed elevation during feeding. |
| Staff J | Licensed Practical Nurse | Unaware of resident's history of trauma or potential triggers. |
| Staff A | Licensed Practical Nurse | Unaware of resident's trauma triggers. |
| Staff I | Social Worker | Unable to provide evidence of comprehensive trauma assessment. |
| Staff O | Receptionist | Informed survey team of COVID-19 outbreak. |
| Staff J | Nursing Assistant | Observed wearing two surgical masks instead of N95. |
| Staff K | Nursing Assistant | Observed failing to wear a gown during high-contact resident care. |
| Staff L | Unit Secretary | Indicated no screening for COVID-19 symptoms for weeks. |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 31, 2023
Visit Reason
An off-site desk audit was conducted on October 31, 2023, to review all previous deficiencies cited on September 28, 2023. A revisit survey was conducted on November 1, 2023, for all previous deficiencies cited on September 28, 2023, related to Re-certification/Licensure Life Safety Code survey.
Findings
All previously cited deficiencies have been corrected, and the facility is in compliance with all regulations surveyed. No new noncompliance was identified during the revisit survey.
Inspection Report
Complaint Investigation
Census: 107
Capacity: 178
Deficiencies: 10
Sep 27, 2023
Visit Reason
A Recertification Survey and Complaint Investigation survey were conducted from 09/25/2023 through 09/28/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The facility was found not in compliance with several requirements including reporting of alleged violations of abuse, neglect, exploitation, or mistreatment; meeting professional standards of quality related to physician orders and medication administration; activities of daily living care; quality of care related to specialized positioning devices; tube feeding management; respiratory care; medication administration; food safety; resident call system adequacy; and life safety code deficiencies related to emergency lighting.
Complaint Details
The complaint investigation was triggered by allegations of abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property. The facility failed to report alleged violations timely and failed to provide evidence of investigation and corrective actions for residents with identified concerns.
Deficiencies (10)
| Description |
|---|
| Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment within required timeframes. |
| Failure to meet professional standards of quality related to physician orders and medication administration for multiple residents. |
| Failure to provide necessary care and services to ensure residents' abilities in activities of daily living were maintained. |
| Failure to provide treatment and care in accordance with professional standards for residents with specialized positioning devices. |
| Failure to ensure residents fed through feeding tubes received appropriate treatment and services to prevent complications. |
| Failure to provide necessary respiratory care including tracheostomy and oxygen therapy according to professional standards. |
| Failure to ensure residents were free of significant medication errors. |
| Failure to ensure food safety standards were met including proper food labeling and employee hair restraints. |
| Failure to adequately equip the facility with a resident call system to allow residents to call for staff assistance. |
| Failure to maintain emergency lighting system in accordance with National Fire Protection Association standards. |
Report Facts
Capacity: 178
Census: 107
Residents reviewed: 7
Residents reviewed: 4
Residents reviewed: 2
Residents reviewed: 2
Residents reviewed: 7
Residents reviewed: 7
Residents reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Interviewed regarding missing resident property and investigation |
| Staff B | Registered Nurse | Interviewed regarding medication administration and air mattress settings |
| Staff C | Advance Practice Registered Nurse (APRN) | Interviewed regarding lab work transcription and completion |
| Staff D | Licensed Practical Nurse | Observed failing to apply skin prep and administering oxygen therapy |
| Staff E | Registered Nurse | Interviewed regarding transcription of orders and medication administration |
| Staff F | Maintenance Assistant | Interviewed regarding air mattress settings |
| Staff G | Licensed Practical Nurse | Interviewed regarding air mattress settings |
| Staff H | Certified Medication Technician (CMT) | Interviewed regarding resident shower refusal |
| Staff I | Nursing Assistant | Interviewed regarding positioning devices |
| Staff J | Licensed Practical Nurse | Interviewed regarding oxygen therapy |
| Staff K | Licensed Practical Nurse | Interviewed regarding oxygen tubing observations |
| Staff L | Advance Practice Registered Nurse | Interviewed regarding potassium medication transcription |
| Staff M | Dietary Staff | Observed without beard restraint |
| Staff N | Dietary Staff | Observed without beard restraint |
| Staff O | Dietary Staff | Observed without beard restraint |
| Staff P | Nursing Assistant | Interviewed regarding resident call light placement |
Inspection Report
Annual Inspection
Census: 133
Capacity: 178
Deficiencies: 9
Jul 6, 2022
Visit Reason
The annual Federal Life Safety Code survey and recertification survey were conducted to determine compliance with federal and state regulations for long term care facilities, including emergency preparedness and staff vaccination compliance.
Findings
Deficiencies were identified in multiple areas including comprehensive care plans, quality of care, free of accident hazards, drug regimen, medication errors, food safety, resident records, infection control, and life safety code related to kitchen hood suppression system. The facility failed to meet several regulatory requirements as evidenced by record reviews, observations, and staff interviews.
Deficiencies (9)
| Description |
|---|
| Facility failed to develop and implement comprehensive person-centered care plans for residents including measurable objectives and timeframes for oxygen use, falls, and wander guard. |
| Facility failed to ensure residents receive treatment and care in accordance with professional standards for skin conditions including lack of physician orders for wound treatment. |
| Facility failed to ensure resident environment remains free of accident hazards and adequate supervision to prevent accidents related to smoking and wander guards. |
| Facility failed to ensure resident drug regimen is free from unnecessary drugs, specifically anticoagulants. |
| Facility failed to ensure medication error rates are below 5%, with an observed error rate of 13.79%. |
| Facility failed to properly distribute and serve food under sanitary conditions, specifically milk served at improper temperature. |
| Facility failed to maintain resident records accurately and confidentially, including documentation of medication administration and TED stocking audits. |
| Facility failed to establish and maintain an infection prevention and control program including hand hygiene and PPE use during COVID-19 quarantine. |
| Life Safety Code deficiency: Kitchen hood suppression system was not maintained and was past due for service by more than 2 months. |
Report Facts
Census: 133
Total Capacity: 178
Medication error rate: 13.79
Medication error count: 4
Medication error opportunities: 29
Number of residents reviewed for skin conditions: 7
Number of residents reviewed for medication errors: 6
Number of residents reviewed for smoking supervision: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nedra Mullen | Infection Preventionist | Signed the plan of correction document |
Inspection Report
Annual Inspection
Census: 111
Capacity: 178
Deficiencies: 9
Apr 15, 2021
Visit Reason
The inspection was conducted as part of the annual Federal Recertification, annual State Licensure, annual Emergency Preparedness survey, and a Complaint Investigation to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to thoroughly investigate allegations of abuse and neglect, failure to develop and implement baseline and comprehensive care plans, medication administration errors, inadequate supervision for residents with suicidal ideation, failure to provide respiratory and dialysis care consistent with professional standards, and failure to ensure proper medication regimen reviews and psychotropic drug use monitoring.
Complaint Details
The complaint investigation was related to allegations that the facility failed to give a resident pain medication, replace dressing as needed, and feed the resident's roommate. The investigation found the facility failed to thoroughly investigate these allegations.
Deficiencies (9)
| Description |
|---|
| Facility failed to provide evidence that all alleged violations of abuse and neglect were thoroughly investigated. |
| Failure to develop a baseline care plan within 48 hours of admission for a resident with a right above the knee amputation. |
| Failure to provide services meeting professional standards of quality for residents receiving hemodialysis and respiratory care. |
| Failure to ensure adequate supervision for a resident with suicidal ideation, including failure to provide 1:1 supervision as required. |
| Medication administration errors including missed doses and failure to follow physician orders. |
| Failure to ensure proper documentation and timely signing of treatment administration records. |
| Failure to ensure medication regimen reviews were conducted and acted upon for residents. |
| Failure to ensure psychotropic drugs were used appropriately with required documentation and monitoring. |
| Failure to properly label and store drugs and biologicals, including expired medications and unlocked medication carts. |
Report Facts
Capacity: 178
Census: 111
Medication error rate: 13.89
Residents reviewed for drug regimen: 13
Residents reviewed for monthly pharmacy drug regimen: 8
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