Inspection Reports for Oakland Grove Health Care Center

The visit was complaint-related based on a report submitted to the Rhode Island Department of Health alleging neglect of a resident requiring a neck brace and concerns about residents experiencing foodborne illness due to freezer malfunction.

The facility failed to meet professional standards of quality by not applying a physician-ordered neck brace for a resident with a neck fracture, and failed to maintain the walk-in freezer in a safe operating condition, resulting in partially thawed food items.

The facility was found deficient in multiple areas including failure to treat residents with respect and dignity, incomplete care plans, inadequate follow-up on physician appointments, improper wound care, medication errors, and improper storage and labeling of medications.

The complaint investigation was substantiated based on record review, resident and staff interviews, and observations. Resident ID #2 physically abused Resident ID #1 on 7/22/2025, causing injury. The facility lacked evidence of adequate prevention and monitoring measures.

The facility failed to protect a resident from physical abuse by another resident, resulting in a wrist fracture. Additionally, the facility failed to ensure proper physician orders and monitoring for a splint applied to the injured resident's wrist, contrary to their own policy.

The complaint was substantiated based on record review and staff interview. The resident requested hospital transfer for pain but was refused due to lack of physician order. The resident called 911 and was transported to the hospital where fractures were diagnosed.

The facility failed to honor the resident's request for hospital transfer despite the resident's repeated requests and a subsequent 911 call. The resident was later diagnosed with fractures after hospital evaluation. The Director of Nursing acknowledged the expectation to contact a physician for pain complaints but could not provide evidence that the resident's request was honored.

The complaint investigation was triggered by two community-reported complaints submitted on 12/2/2024 alleging Resident ID #1 was hospitalized four times in less than a month and did not receive prescribed antibiotic therapy after hospital discharge. The resident was found non-responsive by a family member and required hospitalization again.

The facility failed to ensure residents received treatment and care according to physician orders, specifically regarding antibiotic therapy and monitoring of an indwelling foley catheter for Resident ID #1. Additionally, the facility failed to maintain the resident's medical record according to professional standards and failed to implement an effective infection prevention and control program, including proper use of enhanced barrier precautions and equipment sanitation.

The complaint investigation was triggered by a reported medication error on 10/5/2024 where Resident ID #1 was administered Clozaril 125 mg intended for Resident ID #2. The resident exhibited severe adverse effects including altered mental status, requiring hospital transfer and critical care. The Nurse Practitioner and Director of Nursing Services confirmed lack of immediate evaluation and failure to follow facility medication administration policies.

The facility failed to meet professional standards of quality by not immediately evaluating Resident ID #1 after a suspected medication error occurred. Resident ID #1 was administered Clozaril intended for another resident, resulting in serious adverse effects requiring hospital transfer and critical care. The facility did not provide evidence of timely evaluation or follow-up after the error.

The complaint investigation revealed that Resident ID #1 reported non-consensual sexual activity by Resident ID #2 on multiple occasions between 9/27/2024 and 9/29/2024. Staff were made aware of Resident ID #1's discomfort on 9/29/2024 but failed to identify it as abuse or initiate an investigation. Resident ID #1 was treated in the emergency room for potential sexual assault and related injuries. The facility did not prevent further abuse or conduct a timely investigation.

The facility failed to keep a resident free from sexual abuse and did not appropriately respond to or investigate allegations of abuse. Resident ID #1 reported non-consensual sexual activity by Resident ID #2, and staff failed to recognize or act on the resident's expressed concerns, resulting in actual harm.

The facility failed to ensure proper documentation and adherence to physician orders for intake and output monitoring for multiple residents, maintain acceptable nutritional status with appropriate weight monitoring and reweighs, provide appropriate care for residents with feeding tubes, deliver trauma-informed and culturally competent care for a resident with PTSD, and implement an effective infection prevention and control program including COVID-19 precautions and enhanced barrier precautions for residents with infections.

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 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.

The complaint was community reported and submitted on 2024-06-26 to the Rhode Island Department of Health. It involved multiple concerns about the care received by Resident ID #1, including missed medication doses.

The facility failed to ensure that a resident received the prescribed medication Humira on three occasions, and there was no evidence that the physician was informed of the missed doses. Staff acknowledged the missed doses and the expectation to notify the physician was not met.

Complaint investigation triggered by a community reported complaint alleging failure to monitor weight and rule out blood clots in a resident with increased left leg swelling and history of DVT. The complaint was substantiated with findings of actual harm.

The facility failed to ensure appropriate treatment and care according to professional standards and the resident's care plan, specifically failing to monitor and identify changes in the resident's condition, follow physician's orders for weekly weights, and timely order an ultrasound to rule out DVT. This resulted in actual harm to the resident who required transfer to an acute care hospital for mechanical thrombectomy.

The complaint investigation revealed that Resident ID #1 physically abused Resident ID #5 by placing hands around Resident ID #5's neck on 5/9/2024. Resident ID #1 was hospitalized and diagnosed with a urinary tract infection. Resident ID #5 sustained a bruise and superficial nail mark. The Director of Nursing Services acknowledged the abuse and was unable to provide evidence that Resident ID #5 was kept free from abuse.

The facility failed to protect residents from physical abuse when Resident ID #1 was observed with hands around Resident ID #5's neck. Resident ID #1 was sent to the hospital and Resident ID #5 was moved to a different room after sustaining a bruise. The Director of Nursing Services was unable to provide evidence that Resident ID #5 was kept free from abuse.

The investigation was complaint-related, focusing on the facility's infection control practices for Resident ID #1 with an MDRO. The complaint was substantiated as the facility failed to place the resident on contact precautions timely and lacked proper signage and PPE use until corrective actions were taken.

The facility failed to implement appropriate contact or enhanced barrier precautions for Resident ID #1 with an ESBL MDRO infection, resulting in delayed initiation of contact precautions and inadequate signage and PPE use until the issue was brought to the facility's attention and corrected.

The complaint investigation was triggered by allegations that Resident ID #4 was sexually abused by Resident ID #1, and Resident ID #2 physically abused Resident ID #3. The facility failed to prevent these abuses and failed to report the sexual abuse allegation timely to the State Agency.

The facility failed to keep residents free from sexual and physical abuse, failed to timely report suspected abuse, and failed to develop and implement baseline care plans addressing inappropriate sexual behaviors for a resident. Multiple observations and interviews confirmed inappropriate sexual interactions between residents and inadequate staff interventions.

The facility was found deficient in timely reporting of abuse and injuries, adherence to physician orders, medication administration errors, resident care including ADL assistance and positioning, respiratory care, food safety practices, and call light accessibility for residents.

The complaint investigation was substantiated with findings that the facility failed to timely report abuse and injuries, failed to meet professional standards of care, and had multiple deficiencies in resident care and safety.

The facility failed to timely report alleged abuse and injuries of unknown origin, did not follow physician's orders or specialist recommendations timely, failed to provide necessary care for residents' activities of daily living including bathing and positioning, had medication administration errors, failed to provide appropriate respiratory care, and had food safety violations including lack of beard restraints and unlabeled food containers. Additionally, a resident's call light was placed out of reach.

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.

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.

The complaint investigation found that the facility failed to follow physician's orders and maintain accurate documentation for one resident. The complaint was substantiated based on record review, resident and staff interviews, and surveyor observations.

The facility failed to meet professional standards of quality by not following physician's orders for one resident, including failure to apply TED stockings, compression sleeves, and offload heels as ordered. Documentation was also found to be inaccurate, with a nurse signing off on orders that were not completed. Staff and administration acknowledged these failures but could not explain why the orders were not followed or documented correctly.

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.

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 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.