AdviniaCare Oakland Grove LLC

In the surveyor’s words

From the most serious findings on record at AdviniaCare Oakland Grove LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jun 22, 2026

  Based on record review, surveyor observations, staff and resident interviews, the facility failed to provide an environment that remained as free of accident hazards as possible and failed to implement adequate supervision and interventions to prevent avoidable harm. Specifically, the facility failed to ensure safe water temperatures in resident-accessible hand sinks throughout all four resident care floors, exposing residents to the potential for serious burn injuries. In addition, the facility failed to ensure that Resident ID #2 received timely and appropriate post-fall assessment, monitoring, and interventions in accordance with facility policy following a fall, placing the resident at risk for undetected injury and potential worsening of condition. Findings are as follows:1. […]

• Immediate jeopardy, isolatedF760Oct 8, 2024

  Based 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 resident reviewed who was administered antipsychotic medication (Clozaril) which was intended for another resident (Resident ID #2), Resident ID #1. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 10/5/2024 indicated that Resident ID #1 was transferred to an acute care hospital due a change in his/her mental status related to a potential medication error. Review of the manufacturer's guidance, last revised September 2024, revealed that Clozaril (clozapine) is an antipsychotic medication used to treat severe psychotic disorders. […]

• Actual harm, patternF838Nov 4, 2022

  Based on record review and staff interview, it has been determined that the facility failed to identify the care required by the resident population considering the types of disease, conditions, physical and cognitive disabilities. Additionally, the facility failed to ensure that staff has competencies that are necessary to provide the level and types of care needed for the resident population at risk and/or have limited range of motion (ROM). Furthermore, the facility failed to have necessary resources including a dementia care coordinator. […]

• Actual harm, isolatedF580Jun 22, 2026

  Based on clinical record review, surveyor observation, and resident and staff interviews, the facility failed to immediately consult with the physician when a resident's condition significantly changed or when treatment required alteration for 2 of 2 residents reviewed, Resident ID #1 and #5. The facility failed to notify the practitioner of Resident ID #1's worsening respiratory status, fever, lethargy, and labored breathing while receiving hospice services, and failed to obtain a physician order or notify the practitioner regarding Resident ID #5's urinary retention requiring catheterization. These failures had the potential to delay medical evaluation and treatment and resulted in actual harm for Resident ID #5, who required hospitalization for urinary retention. […]

• Actual harm, isolatedF684Jun 22, 2026

  Based on clinical record review and staff interview, the facility failed to provide care and services in accordance with the resident's physician-approved hospice plan of care for 1 of 1 resident reviewed receiving hospice services, Resident ID #1. Specifically, the facility failed to ensure timely administration of physician-ordered Morphine Sulfate for the management of pain and shortness of breath despite repeated hospice recommendations, worsening clinical symptoms, and the medication being available within the facility. As a result, Resident ID #1 experienced prolonged unmanaged pain and respiratory distress, including worsening lethargy, labored breathing, tachypnea (rapid shallow breathing), tachycardia (rapid heart rate), and fever. […]