Overlook Nursing and Rehabilitation Center
For profit - Limited Liability company
100 Beds
EDEN HEALTHCARE
Data: November 2025
Trust Grade
53/100
#42 of 72 in RI
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Overlook Nursing and Rehabilitation Center has a Trust Grade of C, which means it is average compared to other facilities, sitting in the middle of the pack. It ranks #42 out of 72 nursing homes in Rhode Island and #24 out of 41 in Providence County, indicating it is in the bottom half of options available. The facility is showing a worrying trend, with the number of issues increasing from 3 in 2024 to 14 in 2025. Staffing is a relative strength, receiving a 4 out of 5 stars rating, with a turnover rate of 40%, which is slightly below the state average. However, the facility has faced some concerning incidents, such as a resident suffering a burn due to hot beverage temperatures and failures in food safety and infection control measures, highlighting significant areas for improvement alongside its strengths.
- Trust Score
- C
- In Rhode Island
- #42/72
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near Rhode Island's 48% average. Typical for the industry.
- Penalties ✓ Good
- $10,358 in fines. Lower than most Rhode Island facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Rhode Island. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
53/100
Bottom 42%
Needs review
3 → 14 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 14 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Rhode Island average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Rhode Island average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 40%
Near Rhode Island avg (46%)
Typical for the industry
Federal Fines: $10,358
Below median ($33,413)
Minor penalties assessed
Chain: EDEN HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 22 deficiencies on record
1 actual harm
May 2025
13 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, it has been determined that the facility failed to ensure that a resident's environment remains as free of accident hazards as possible for 1 of 1 resident reviewed who sustained a burn, Resident ID #27.
Findings are as follows:
Review of an article published by the Journal of Food Science, dated July 11, 2019, titled A Review of Hot Beverage Temperatures-Satisfying Consumer Preference and Safety states in part, .An appropriate range for service temperatures is 130 to 160 °Fahrenheit (F) .This recommendation balances a range of consumer preferences and safety .
Record review revealed the resident was admitted to the facility in December of 2024 with diagnoses including, but not limited to, chronic kidney disease, dependence on renal dialysis, and diabetes.
Record review of a Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status score of 14 out of 15, indicating intact cognitive function.
Record review a progress note dated 3/26/2025 revealed that at approximately 7:00 PM, the resident spilled hot chocolate on him/herself. His/her skin was assessed at approximately 8:00 PM and revealed redness with an intact blister on the outside of the left thigh. Skin prep and a border gauze was applied.
Record review of a progress notes dated 3/31/2025 at 12:08 PM states in part, .left thigh with a new area measuring 7.7 x 13.5 x 0.1 [centimeters] 30% dermis [middle layer of skin], 70% epithelial [outer layer of skin] no drainage or signs of infection. The resident stated [s/he] spilled hot cocoa on [him/herself] during a meal [s/he] was having with a friend who was visiting over the weekend .
Record review of a document titled, Integrated Wound Care dated 4/14/2025, revealed the resident had a left thigh burn measuring 7 by 12 centimeters (cm) and 0.1 cm deep noted with 30% scabbing. Additionally, the burn was noted as a second-degree burn (damage to the outer layer of skin and some of the underlying layer of skin).
During a surveyor interview with the resident on 5/1/2025 at 8:37 AM, s/he revealed that on the evening of 3/26/2025, a Nursing Assistant made him/her a cup of hot chocolate using a Keurig brand coffee maker located on the 1st floor kitchenette. Resident ID #27 indicated s/he had put the cup of hot chocolate on the edge of table, and it spilled onto his/her leg. S/he further revealed that the spilled hot chocolate on his/her thigh was very painful.
During a surveyor observation of the 1st floor kitchenette on at 5/1/2025 at 10:27 AM, revealed Nursing Assistant (NA) Staff F, warming a plated breakfast meal for a resident using the facility provided microwave.
During a surveyor interview with Staff F immediately following the observation, she revealed that she had been a NA at the facility for approximately 6 months and during this time she had not been provided education on safe temperatures when reheating meals for residents or serving hot beverages. She further revealed she was not aware of what temperatures are too hot and may be harmful.
During a surveyor interview on 5/5/2025 at 9:17 AM with the Staff Educator, she revealed that education of reheating or serving food and beverages was not provided to any staff member.
During a surveyor observation on 5/5/2025 at 1:47 PM in the presence of Licensed Practical Nurse, Staff A, an 8-ounce (oz) cup of hot water was obtained from the available Keurig brand coffee maker located in the first-floor kitchenette. The water temperature in the 8 oz cup was 180.3 F. Additionally, Staff A indicated the water was too hot to touch and acknowledged it would cause injury to skin.
During a surveyor interview on 5/5/2025 at 2:37 PM with the Administrator in the presence of the Director of Nursing Services, she acknowledged that Resident ID #27 had sustained a second degree burn from hot chocolate provided to him/her by the facility. She further indicated that she was aware that education had not been provided to reduce the risk of accidents associated with hot liquids.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on record review, staff, resident, and resident representative interview, it has been determined that the facility failed to inform the resident and/or resident's representative, in advance, of ...
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Based on record review, staff, resident, and resident representative interview, it has been determined that the facility failed to inform the resident and/or resident's 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, a medication prescribed to treat high blood pressure for 1 of 1 resident reviewed for the use of amlodipine, Resident ID #84.
Findings are as follows:
Review of the manufacturer's insert for amlodipine last revised in May of 2011, revealed the following possible side effects:
- Headache
- Swelling of the legs or ankles
- Tiredness, extreme sleepiness
- Stomach pain, nausea
- Dizziness
- Arrhythmia (irregular heartbeat)
- Heart palpitations (very fast heartbeat)
Additional review of the insert revealed that there is a potential risk of having a heart attack when first taking amlodipine.
Record review revealed the resident was admitted to the facility in April of 2025 with a diagnosis including, but not limited to, hypertension (high blood pressure).
Record review revealed the following progress notes:
- 4/18/2025 at 12:17 PM, authored by the resident's Physician, revealed that the resident was started on amlodipine 5 milligrams (mg) once daily for blood pressure control.
- 4/18/2025 at 1:40 PM, authored by Licensed Practical Nurse, Staff A, revealed that the resident's Physician reviewed his/her blood pressures and gave a new order for amlodipine 5 mg once daily.
Additionally, the above-mentioned notes failed to indicate that the resident, and/or his/her representative, was informed, in advance, of the addition of the amlodipine, the risks and benefits associated with the amlodipine, or the treatment alternatives prior to prescribing and administering the medication.
Review of a physician's order with a start date of 4/18/2025 and a disocontinue date of 4/28/2025 revealed to administer amlodipine 5 mg daily.
Review of the April 2025 Medication Administration Record (MAR) revealed that the resident was administered amlodipine 5 mg daily from 4/19 through 4/28.
Review of a progress note dated 4/26/2025 at 9:42 PM revealed that the resident's family member, who is listed as his/her emergency contact, expressed concerns to the staff that the resident is dizzy and requested to know what medication the resident was receiving. Additionally, it revealed that the resident's family member was unaware of the addition of the amlodipine and the family member would contact the resident's physician.
During a surveyor interview on 4/30/2025 at 12:59 PM with the resident and his/her representative, they revealed that neither of them were informed of the addition of the amlodipine to the resident's treatment plan.
During a surveyor interview on 5/1/2025 at 11:18 AM with Staff A, she revealed that she did not notify the resident or his/her representative regarding the amlodipine and indicated that she should have.
During a surveyor interview on 5/1/2025 at 4:33 PM with the Director of Nursing Services, she revealed that she would have expected the nurse to discuss the addition of the amlodipine to the resident's treatment plan with the resident and/or resident's representative prior to initiating treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 2 of 2 residents ...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident with an injury of unknown origin was thoroughly investigated for 2 of 2 residents reviewed for skin tears, Resident ID #s 19 and 27.
Findings are as follows:
Review of a facility policy titled, Abuse prohibition states in part, .Injuries of unknown origin .the source of the injury was not observed or the source cannot be explained by the resident .Investigations .obtain statements from witnesses, notify the appropriate administrative personnel so that a comprehensive internal facility investigation can be carried out .
1. Record review revealed that Resident ID #19 was readmitted to the facility in July of 2024 with a diagnosis including, but not limited to, Alzheimer's Disease.
Review of a progress note dated 4/26/2025 at 1:04 PM revealed that the resident presented with two new skin tears to his/her left upper extremity and s/he was unable to explain the origin of the skin tears.
Further record review failed to reveal evidence that an investigation had been conducted to determine the origin of the two skin tears.
During a surveyor interview on 5/1/2025 at 4:21 PM with the Director of Nursing Services (DNS), she acknowledged that the resident sustained an injury of unknown origin and was unable to provide evidence that an investigation was initiated and revealed that one should have been conducted.
2. Record review revealed that Resident ID #27 was readmitted to the facility in December of 2024 with a diagnosis including, but not limited to, chronic kidney disease.
Review of a progress note dated 4/28/2025 revealed that the resident sustained a 1 centimeter skin tear to his/her left knee and the area was cleansed and two steri strips were applied. Additionally, the note failed to indicate the origin of the skin tear.
Further record review failed to reveal evidence that an investigation had been conducted to determine the origin of the resident's skin tear to his/her left knee.
During a surveyor interview on 5/5/2025 at 9:09 AM with Licensed Practical Nurse, Staff A, she acknowledged the progress note on 4/28/2025 did not contain an origin for the resident's skin tear.
During a surveyor interview on 5/5/2025 at 2:37 PM with the DNS, she was unable to provide evidence that an investigation had been conducted to determine the origin of the resident's skin tear.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality and practices relative to 1 of 2 res...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality and practices relative to 1 of 2 residents reviewed for Abnormal Involuntary Movement Scale (AIMS) Assessments, Resident ID #23, and 1 of 1 resident reviewed that receives insulin without blood sugar monitoring in place, Resident ID #48.
1. Record review revealed Resident ID #23 was readmitted to the facility in August of 2022 with diagnoses including, but not limited to, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), and panic disorder.
Review of the resident's care plan revealed a focus area dated 6/1/2022 for psychotropic medication (a medication that affects behavior, mood, thoughts, or perception) use and to complete an AIMS Assessment as directed.
Review of a physician's order dated 5/17/2024 revealed to complete an AIMS Assessment on the 13th of every March, June, September, and December.
Record review revealed the last AIMS Assessment for the resident was completed on 8/12/2024.
Additionally, record review failed to reveal evidence that an AIMS Assessment was completed on 9/13/2024, 12/13/2024, or 3/13/2025, as ordered.
During a surveyor interview on 5/6/2025 at 11:29 AM with the resident's Nurse Practitioner, she revealed that she would expect staff to complete the AIMS Assessments as ordered.
During a surveyor interview on 5/6/2025 at 12:27 PM with the Director of Nursing Services (DNS), she acknowledged that an AIMS Assessment had not been completed since 8/12/2024 and would expect the assessments to be completed as ordered.
2. Record review revealed Resident ID #48 was readmitted to the facility in November of 2024 with a diagnosis including, but not limited to, diabetes mellitus due to an underlying condition with hyperglycemia (high blood sugar).
Review of the resident's care plan revealed a focus area dated 2/18/2025 indicating that s/he is at risk for potential complications related to diabetes and potential adverse effects of receiving insulin.
Review of a physician's order dated 1/27/2025 revealed to administer Semglee (insulin glargine-yfgn) 5 units subcutaneously (under the skin) once daily.
Review of a progress note dated 11/5/2024 at 2:06 PM revealed that the resident's hemoglobin A1C (a blood test that measures a person's average blood sugar levels over the past 3 months and provides insight in diagnosing and managing diabetes) was to be repeated in 3 months.
Record review failed to reveal evidence that the resident's hemoglobin A1C had been drawn following the above-mentioned progress note.
Review of progress notes dated 5/5/2025 at 11:50 AM and 12:44 PM, authored by the DNS, revealed that the resident had his/her hemoglobin A1C drawn on 11/1/2024 and his/her provider ordered a follow up hemoglobin A1C to be completed in 3 months. Additionally, new orders for labs were obtained and to be completed on 5/12/2025.
Record review revealed that a physician's order for a hemoglobin A1C test was entered for 5/12/2025, after it was brought to the facility's attention by the surveyor.
During a surveyor interview on 5/5/2025 at 11:37 AM with the DNS, she acknowledged that the last hemoglobin A1C completed for the resident was in November of 2024 and was unable to provide evidence that the resident's repeat hemoglobin A1C had been completed.
Cross reference F 842
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview, it has been determined that the facility failed to ensure that services p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident 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 2 residents reviewed for orthostatic blood pressures (a form of low blood pressure that happens when standing after sitting or lying down that may cause dizziness, lightheadedness, and fainting), Resident ID #23, and for 1 of 2 residents reviewed for physician referrals for appointments, Resident ID #52.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
1. According to [NAME] JJ. Antipsychotic pharmacotherapy and orthostatic hypotension: identification and management. CNS Drugs. 2011 Aug;25(8):659-71, states that, .Orthostatic hypotension is a common adverse effect of antipsychotics .monitoring for changes in postural blood pressure is important .
Record review revealed Resident ID #23 was readmitted to the facility in August of 2022 with Parkinson's disease with dyskinesia (involuntary, uncontrolled movements), dizziness and giddiness, bipolar disorder, and a history of falling.
Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition.
Review of the resident's care plan revealed that s/he is at risk for falls related to dizziness, potential medication side effects, effects of Parkinson's Disease, and the need for assistance with ambulation and transfers with interventions that includes to report changes in vital signs and complaints of dizziness.
Additional review of the resident's care plan revealed a focus area dated 6/1/2022 for psychotropic medications (medication that affects behavior, mood, thoughts, or perception).
Record review revealed the following physician's orders:
- 5/17/2024 Orthostatic vital signs every 3 months
- 8/22/2024 Seroquel (an antipsychotic medication) 25 milligrams (mg) give 25 mg at bedtime
- 10/3/2024 Seroquel 25 mg give 12.5 mg once daily
Review of the progress notes revealed the following:
- 12/15/2024: The resident had an unwitnessed fall in the bathroom
- 1/9/2025: The resident complained of dizziness after ambulating from bathroom
- 3/3/2025: The resident sustained a fall from his/her chair
- 3/10/2025: The resident stated that s/he was too dizzy to walk to the bathroom
Record review revealed that the resident had a change in orthostatic blood pressures as evidenced by the following quarterly fall assessments:
- 12/14/2024 No noted drop in blood pressure between lying and standing
- 3/14/2025 A drop of more than 20 mm/hg (millimeter of mercury; units of pressure for measuring blood pressure)
Record review failed to reveal evidence that the provider was made aware of the resident's change in orthostatic blood pressures.
During a surveyor interview on 5/1/2025 at 11:08 AM with the resident, s/he was asked if s/he gets dizzy when attempting to stand from a sitting or lying position and s/he replied, Oh, yeah.
During a surveyor interview on 5/6/2025 at 11:04 AM with Licensed Practical Nurse, Staff A, she revealed that the resident has a history of falls and dizziness. She further revealed that if the resident had a change in orthostatic blood pressures noted between the quarterly fall assessments, she would document it and notify the provider.
During a surveyor interview on 5/6/2025 at 11:29 AM with the resident's Nurse Practitioner, she revealed that she would expect to be notified of the change in orthostatic blood pressures and she would then review his/her blood pressures, medications, and fluid intake to ensure it is adequate, and reassess the resident.
During a surveyor interview on 5/6/2025 at 12:27 PM with the Director of Nursing Services (DNS), she revealed that she would expect the provider to be notified if the resident had a change in orthostatic blood pressures and was unable to provide evidence that the provider was made aware.
2. Record review revealed Resident ID #52, was admitted to the facility in March of 2023 with diagnoses including, but not limited to, spinal stenosis (a condition in which your spinal canal narrows, causing back pain and other nerve-related problems) and neurogenic bladder dysfunction (a urinary bladder condition caused by damage to the nerves that control bladder function).
Record review revealed the following physician's orders:
- Urology consult for possible suprapubic tube (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen) insertion due to history of difficulty maintaining indwelling catheter initiated on 3/19/2025
- MRI (a medical imaging technique) of the spine without contrast related to chronic back pain, initiated on 3/19/2025
Review of a progress note dated 3/19/2025, revealed the resident was seen by his/her physician and expressed interest in having an SP tube placed. Additionally, the note indicates the Physician educated the resident on risks and benefits of the SP tube and further indicated an appointment should be scheduled.
Review of a progress note dated 4/17/2025 revealed a continued need to schedule an MRI for chronic back pain.
Record review failed to reveal evidence of an appointment with urology for the placement of an SP catheter or an MRI for chronic back pain had been scheduled for Resident ID #52.
During a surveyor interview on 5/1/2025 at 2:36 PM with the facility's Appointment Scheduler, Staff C, she revealed that she was unaware of the resident's need for a urology appointment or an MRI until it was brought to her attention by the surveyor.
During a surveyor interview on 5/1/2025 at 2:46 PM with Licensed Practical Nurse, Staff D, she revealed that an appointment for urology or an MRI had not been made. Additionally, she revealed that if the resident refused to go to an appointment, then a note would be put in his/her medical record.
During a surveyor interview on 5/5/2025 at 11:21 AM with the DNS, she was unable to provide evidence that appointments for a urology consult or an MRI had been scheduled as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on surveyor observation, 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 servic...
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Based on surveyor observation, 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 1 of 1 resident observed for wound care, Resident ID #52.
Findings are as follows:
Record review revealed the resident was admitted to the facility in March of 2023 with diagnoses including, but not limited to, spinal stenosis (a condition in which your spinal canal narrows, causing back pain and other nerve-related problems) and stage 4 pressure ulcer (the most severe pressure wound that may impact muscle, tendons, ligaments, and bone).
Review of a progress note dated 4/28/2025 revealed the resident has the following wounds:
- Stage 4 pressure ulcer to his/her coccyx (tailbone) measuring 3.5 centimeters (cm) X 2.5 cm X 1 cm.
- Stage 4 pressure ulcer to his/her right gluteal fold (visible crease that separates the gluteal region from the upper thigh) measuring 3.3 cm X 2 cm X 2 cm.
Record review revealed the following physician's orders for wound care:
- Coccyx stage 4 pressure ulcer, vashe soak (wound cleanser) for 10 minutes, apply collagen with silver and calcium alginate (absorbent wound treatment) to wound bed, pack with kerlix (highly absorbent wound dressing) and cover with super absorbent dressing daily.
- Right gluteal fold stage 4 pressure ulcer, vashe soak for 10 minutes, apply collagen powder to the wound bed then pack with calcium alginate and cover with silicone super absorbent dressing daily.
During a surveyor observation of wound care on 5/1/2025 at 10:24 AM with Registered Nurse (RN), Staff E, she applied the collagen powder on top of the calcium alginate and packed it into the resident's coccyx wound with her gloved fingers. She then was observed to pack a ball of kerlix into the wound with her gloved fingers and not an applicator. Directly following the application to the coccyx wound, Staff E was observed to apply collagen powder on top of the calcium alginate and then pack into the wound to the right gluteal fold with her fingers and not an applicator. Staff E did not change her gloves between packing the coccyx wound and the gluteal fold wound.
During a surveyor interview on 5/1/2025 at 10:50 AM with, Staff E, she acknowledged that she did not utilize an applicator to pack the wounds. Additionally, she acknowledged she did not change her gloves after applying the coccyx wound dressing and before applying the right gluteal fold wound dressing.
During a surveyor interview on 5/1/2025 at 11:02 AM with the Director of Nursing Services (DNS), she acknowledged that Staff E should have utilized an applicator to pack the wound and should have changed her gloves between wound treatments. Additionally, the DNS was unable to provide evidence that the facility provided wound care consistent with professional standards of practice, to promote healing, and prevent infection for Resident ID #52.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based 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 a fol...
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Based 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 a foley catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #35, and for 1 of 2 residents with a suprapubic catheter (SP tube, a medical device that drains urine from the bladder through a small incision in the abdomen) Resident ID #45. Additionally, the facility failed to assess for the removal of a urinary catheter for 1 of 1 resident reviewed requiring a trial void, Resident ID #39.
Findings are as follows:
Review of a facility policy titled, Foley Catheters dated 1/16/2024 states in part, It is the policy of this facility to ensure that the resident (s) with a foley catheter (or SP tube) have the proper documentation in place to support the usage and proper care of the foley catheter .A resident with a foley catheter (or SP tube) must have a physician order in place for the foley catheter. The order must include the size of the catheter and the balloon .The order must also include the diagnosis to support the reason for the foley catheter .
1. Record review revealed that Resident ID #35 was admitted to the facility in September of 2024 with a diagnosis including, but not limited to, obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system).
Review of a care plan dated 1/22/2025 revealed that Resident ID #35 has urinary retention with an intervention including, but not limited to, foley catheter care every shift.
During a surveyor observation on 5/1/2025 at 9:29 AM of Resident ID #35 revealed a foley catheter hanging from the left side of his/her bed.
Record review failed to reveal a physician's order for the foley catheter including the size of the catheter, the balloon size, or the diagnosis to support the use, per the facility policy.
During a surveyor interview on 5/1/2025 at 1:50 PM with Licensed Practical Nurse (LPN), Staff D, she acknowledged that there was not an order in place for Resident ID #35's foley catheter.
During a surveyor interview on 5/1/2025 at 1:56 PM with the Director of Nursing Services (DNS), she acknowledged that there was not an order in place for the foley catheter including the catheter size and balloon size, and/or a diagnosis for its use, per the facility policy.
2. Record review revealed that Resident ID #45 was readmitted to the facility in February of 2024 with diagnoses including, but not limited to, urinary tract infection and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems).
Review of a care plan dated 3/15/2021 revealed that Resident ID #45 utilizes an SP catheter for urinary retention and is at high risk for recurrent urinary tract infections.
Record review failed to reveal an order for the SP catheter including the size of the catheter, the balloon size, or the diagnosis to support its use, per the facility policy.
During a surveyor interview on 5/1/2025 at 4:20 PM with the DNS she acknowledged that there is not an order for use of the SP catheter including the catheter and balloon size and a diagnosis for its use, per the facility policy.
3. Record review revealed that Resident ID #39 was admitted to the facility in August of 2024 with diagnoses including, but not limited to, obstructive uropathy and urinary retention.
Record review revealed a physician order dated 11/21/2024 for a foley catheter.
Review of a progress note dated 1/14/2025 revealed that Resident ID #39 saw a urologist who provided a recommendation to have a trial void in one week.
Record review revealed a physician's order with a start date of 1/22/2025 to remove the foley catheter for a trial void and if s/he does not void in 8 hours to reinsert the foley catheter.
Record review failed to reveal evidence that a trial void was attempted or failed.
During a surveyor interview on 5/5/2025 at 2:18 PM with the DNS, she was unable to provide evidence that a trial void was attempted for Resident ID #39 as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 ...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 resident reviewed for oxygen use, Resident ID #7.
Findings are as follows:
According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed .
Record review revealed the resident was readmitted to the facility in May of 2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypercapnia (a condition where there are abnormally high levels of carbon dioxide in the blood that could be caused by conditions like COPD).
Review of the care plan revealed that the resident utilizes oxygen at 2 liters per minute (LPM).
Review of a physician's order dated 6/10/2024 revealed an order for oxygen 2 LPM every shift.
Review of the resident's carbon dioxide levels revealed that the s/he had increasingly elevated levels which can be attributed to COPD, as well as, individuals that utilize supplemental oxygen, as evidenced by the following:
- 12/12/2024 Carbon dioxide level (normal range 19-32): 31
- 2/19/2025 Carbon dioxide level: 33
- 4/4/2025 Carbon dioxide level: 35
Surveyor observations revealed the resident was not receiving the 2 liters of oxygen as ordered on the following dates and times:
- 4/30/2025 at 11:54 AM, noted at approximately 3.5 LPM
- 5/1/2025 at 9:22 AM, 2:33 PM, and 2:39 PM, noted at approximately 3.5 LPM
During a surveyor interview immediately following the above observation at 2:39 PM with Registered Nurse, Staff G, she acknowledged that the resident was not receiving the 2 liters of oxygen as ordered.
During a surveyor interview on 5/1/2025 at 4:30 PM with the Director of Nursing Services, she indicated that she would have expected the resident to receive oxygen at 2 LPM, as ordered.
Cross reference F 842
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based 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 ...
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Based 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 a urinary tract infection (UTI), Resident ID #45.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in February of 2024 with a diagnosis including, but not limited to, UTI.
Record review revealed the following progress notes:
-3/12/2025 at 12:43 PM: The resident was seen by the provider and is to start Bactrim (an antibiotic) 800 milligrams (mg) twice daily for 7 days (to equal 14 total doses)
-3/13/2025 at 10:48 PM: The resident continues Bactrim for a UTI
Review of a physician's order dated 3/12/2025 revealed Bactrim DS 800-160 mg administer 1 tablet twice daily for 7 days (to equal 14 total doses).
Review of the March 2025 Medication Administration Record revealed that the resident received a total of 17 doses of Bactrim from 3/12 through 3/20, thus receiving an additional 3 doses more than what the provider had prescribed.
During a surveyor interview on 5/5/2025 at 11:37 AM with the Director of Nursing Services, she revealed that she would have expected the resident to have received only 14 doses of Bactrim, as prescribed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and ...
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Based on record review and staff interview, it has been determined that the facility failed to accurately maintain the resident's medical record in accordance with accepted professional standards and practices for 1 of 1 resident reviewed for oxygen use, Resident ID #7, and 1 of 2 residents reviewed for Abnormal Involuntary Movement Scale (AIMS) Assessments, Resident ID #23.
Findings are as follows:
1. Record review revealed Resident ID #7 was readmitted to the facility in May of 2024 with a diagnosis including, but not limited to, chronic obstructive pulmonary disease (COPD).
Review of the care plan revealed that the resident utilizes oxygen at 2 liters per minute (LPM).
Review of a physician's order dated 6/10/2024 revealed oxygen at 2 LPM every shift.
Surveyor observations revealed the resident was not receiving the 2 liters of oxygen as ordered on the following dates and times:
- 4/30/2025 at 11:54 AM, noted at approximately 3.5 LPM
- 5/1/2025 at 9:22 AM, 2:33 PM, and 2:39 PM, noted at approximately 3.5 LPM
Review of the April and May 2025 Medication Administration Records (MARs) revealed that the resident was documented as receiving oxygen at 2 LPM on the above-mentioned dates and times, although the resident was observed by the surveyor receiving approximately 3.5 liters of oxygen.
Additional review of the May 2025 MAR revealed that Registered Nurse, Staff G, documented the resident as receiving oxygen at 2 LPM on 5/1/2025 on the 7:00 AM to 3:00 PM shift.
During a surveyor interview on 5/1/2025 at 2:39 PM with Staff G, she revealed that she noted that the resident was receiving oxygen at 3 LPM earlier that morning, and was unable to explain why she documented the resident as receiving oxygen at 2 LPM.
2. Record review revealed Resident ID #23 was readmitted to the facility in August of 2022 with diagnoses including, but not limited to, anxiety, bipolar disorder, post traumatic stress disorder (PTSD), and panic disorder.
Review of the resident's care plan revealed a focus area dated 6/1/2022 for psychotropic medications (medications that affects behavior, mood, thoughts, or perception) use and to complete an AIMS Assessment as directed.
Review of a physician's order dated 5/17/2024 revealed to complete an AIMS assessment on the 13th of every March, June, September, and December.
Record review revealed that an AIMS Assessment was documented as completed on the following dates:
- 9/13/2024
- 12/13/2024
- 3/13/2025
Further record review revealed the last AIMS Assessment was completed on 8/12/2024. Additionally, record review failed to reveal evidence that an AIMS Assessment was completed on 9/13/2024, 12/13/2024, or 3/13/2025, as documented.
During a surveyor interview on 5/1/2025 at 4:30 PM with the Director of Nursing Services, she was unable to provide evidence that the facility maintained medical records that are accurate and would expect such.
Cross reference F 695 and F 658
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based 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 antibiot...
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Based 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 3 of 3 residents reviewed for antibiotic use, Resident ID #s 1, 12, and 343. Additionally, the facility failed to develop or maintain and Antibiotic Stewardship Team.
Findings are as follows:
1. According to the Centers for Disease Control and Prevention (CDC) document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes states in part, .Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians .Requires prescriber's to document a dose, duration, and indication for all antibiotic prescriptions .
Review of a facility policy titled, Antibiotic Stewardship states in part, .The antibiotic stewardship program is directed toward the correct use of antibiotic- the five D's -right diagnosis, the right medication, the right dose, the right duration, and the right deceleration .
1a. Record review revealed that Resident ID #1 was admitted to the facility in December of 2024 with a diagnosis including, but not limited to, acute bronchiolitis due to respiratory syncytial virus (an acute viral infection of the lower respiratory tract).
Record review revealed a physician's order dated 4/29/2025 for ciprofloxacin suspension (antibiotic) 500 milligram (mg) per 5 milliliters (ml), administer 5 ml twice a day.
Review of the physician's order for ciprofloxacin suspension, failed to reveal evidence of the indication of use for the antibiotic per the CDC and the facility policy.
1b. Record review revealed that Resident ID #12 was readmitted to the facility in April of 2025 with a diagnosis including, but not limited to, aftercare following surgical amputation.
Record review revealed a physician's order dated 4/29/2025 for sulfamethoxazole-trimethoprim (antibiotic) 800-160 mg, administer 1 tablet twice a day.
Review of the physician's order for sulfamethoxazole-trimethoprim, failed to reveal evidence of the indication of use for the antibiotic per the CDC and the facility policy.
1c. Record review revealed that Resident ID #343 was readmitted to the facility in April of 2025 with a diagnosis including, but not limited to, pneumonia.
Record review revealed a physician's order dated 4/29/2025 for amoxicillin-pot clavulanate (antibiotic) 875-125 mg, administer 1 tablet twice a day.
Review of the physician's order for amoxicillin-pot clavulanate, failed to reveal evidence of the indication of use for the antibiotic per the CDC and the facility policy.
During surveyor interviews on 5/1/2025 at 9:25 AM and 11:40 AM, with the Director of Nursing Services (DNS), she revealed that all antibiotics should have the indication for use in the physician's orders. Additionally, she acknowledged the above-mentioned orders for Resident ID #s 1, 12, and 343, failed to list an indication for the use of the antibiotics. Furthermore, the physician's orders were updated after it was brought to the facility's attention by the surveyor.
2. Further review of a facility policy titled, Antibiotic Stewardship states in part, .the Antibiotic Stewardship Team as outlined below, will meet on a regular scheduled basis. Minutes will be recorded and maintained for review. The efficacy of work of program will be analyzed at least annually and goals re-established each year based on the annual analysis .
During a surveyor interview on 5/1/2025 at 9:20 AM, with the DNS, when asked about the antibiotic stewardship team and meeting minutes, the DNS revealed that the facility does not have an antibiotic stewardship team. Additionally, she acknowledged the policy states that the facility has an active antibiotic stewardship team and that they do not have one.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure the resident's medical record includes documentation that the resident either received the pneumococcal vaccination or did not receive the vaccination due to medical contraindications or refusal, for 3 of 5 residents reviewed, Resident ID #s 21, 32, and 37.
Findings are follows:
According to the Centers for Disease Control and Prevention (CDC), pneumococcal vaccination for all adults 19 through [AGE] years old who have certain chronic medical conditions or 65 years or older who have only received PPSV23 [type of pneumococcal conjugate vaccination], the PCV15 [type of pneumococcal conjugate vaccine] or PCV20 [type of pneumococcal conjugate vaccine] dose should be administered at least one year after the most recent PPSV23 vaccination. For adults 19 through [AGE] years old who have certain chronic medical indications who have only received PCV13 [type of pneumococcal conjugate vaccine], give 1 dose of the PCV20 at least 1 year after PCV13 or give 1 dose of PPSV23 at least 8 weeks after PCV13. For adults 65 years or older who have only received PCV13, give PPSV23 or PCV20 as previously recommended. Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to adults greater than or equal to [AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old.
1. Record review for Resident ID #21 revealed the resident was admitted to the facility in November of 2018. Record review of the resident's immunization records revealed that the resident completed his/her initial series including PCV13 and PPSV23. Record review failed to reveal evidence that resident was offered, received, or declined the PCV20 or PCV21.
2. Record review for Resident ID #32 revealed the resident was admitted to the facility in April of 2018. Record review revealed that the resident consented to the Pneumococcal vaccination in May of 2023. Record review of the resident's immunization records failed to reveal evidence that the PPSV23, or PCV20 was received or declined.
3. Record review for Resident ID #37 revealed the resident was admitted to the facility in March of 2019. Record review of the resident's immunization records revealed that the resident completed his/her initial series including PCV13 and PPSV23. Record review failed to reveal evidence that the resident was offered, received, or declined the PCV20 or PCV21.
During a surveyor interview on 5/1/2025 at 11:31 AM, with the Director of Nursing Services, she revealed that she contacted the Medical Director and those who have completed the pneumococcal vaccination series should be offered the PCV20 or PCV21. Additionally, she was unable to provide evidence that Resident ID #s 21, 32, and 37's medical records included documentation that indicates, at a minimum, if the residents either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal, until brought to the facility's attention by the surveyor.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standar...
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Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 kitchenettes observed.
Findings are as follows:
Record review of Rhode Island Food Code, 2022 Edition, Section 3-501.17 states in part, .READY -TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and help in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees Celsius or 41 degrees Fahrenheit or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .
Record review of the Rhode Island Food Code 2022 edition, section 4-602.11 states in part, .(C) NON_ FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .
1) During the initial tour of the kitchen in the presence of the Food Service Director (FSD), on 4/30/2025 at 9:55 AM, the following was observed in the main kitchen:
- a bag containing approximately one dozen pieces of fried chicken without a label or discard date
- a bag containing approximately 15-20 pieces of chicken patties in the freezer without a label or discard date
- package containing 5 frozen hamburger patties in the freezer without a label or discard date
- 3 bags of 2-3 pancakes wrapped in saran wrap in the freezer, without a label or discard date
- a large zip lock style bag in the freezer, containing approximately 3-4 pounds of shaved beef without a label or discard date, with ice formed on the inside of the bag.
During a surveyor interview on 4/30/2025 at 10:04 AM with the Food Service Director (FSD), he acknowledged the above-mentioned items did not have labels and or discard dates per the regulations.
2) Record review of the facility policy titled Use and Storage of Food Brought in by Visitors revised on 4/18/2024, states in part .food for residents .is to be labeled with the resident's name and date .discard those perishable items that appear unsafe or are older than 3 days .
During a surveyor observation on 5/1/2025 at 10:02 AM, of the 1st floor kitchenette, in the presence of the FSD, the following was observed:
- a container in the refrigerator labeled with only a resident's name, without a discard date
- a brown box in the freezer labeled with only a resident's name, without a discard date
During a subsequent interview with the FSD, he indicated that he would expect the above items to be labeled, dated or discarded date per the facility policy.
3) During a surveyor observation on 5/1/2025 at 10:13 AM, of the 2nd floor kitchenette, in the presence of the FSD, the following was observed:
- a large Ziplock style bag containing what appeared to be tacos without a label or discard date
- the refrigerator contained a clear plastic container containing an unidentified food substance that was thick, dark orange in color with a pasty texture without a label or discard date
- the oven was observed with residual burnt matter on the inside, dark in color scattered on the bottom
During a surveyor interview on 5/1/2025 at 10:16 AM with the FSD, he acknowledged the above observations. Additionally, he was unable to provide a cleaning schedule for the oven.
During a surveyor interview on 5/1/2025 at 11:06 AM with the Administrator, she revealed that it was her expectation that the above-mentioned items would have been labeled, dated or discarded as indicated per the regulations and per the facility policy.
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided mee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of quality relative to a post fall transfer for 1 of 1 resident reviewed for injury, Resident ID #1.
Findings are as follows:
Record review of a facility provided document titled Fall Protocol states in part, A fall is an unintentional CHANGE IN POSITION COMING TO REST ON THE GROUND, FLOOR OR ON THE NEXT LEVEL SURFACE .Assess ROM [Range of motion] of all extremities for changes .Once you are sure the PT [patient] is stable you may move the patient If the PT is not able to get up on their own, you will use the hoyer lift [a mechanical device used to transfer] and two assist to get back into bed .
Review of a community reported complaint submitted to the Rhode Island Department of Health on 3/28/2025 alleges in part, the resident often fell because [s/he] had been incontinent .so when [s/he] would stand up to walk [him/herself] to the bathroom [s/he] would have falls .
Review of a facility reported incident resulting in hospitalization received by the Rhode Island Department of Health on 3/28/2025 revealed that on 3/25/2025 at 10:50 PM, the resident experienced a fall with complaints of right hip pain. Additionally, the report revealed an x-ray was obtained on 3/27/2025 which showed a right hip fracture, and the resident was subsequently transferred to the hospital.
Record review revealed that the resident was admitted to the facility in October of 2024 with diagnoses including, but not limited to, severe dementia with behavioral disturbance, muscle weakness, numerous falls, and abnormalities of gait and mobility.
Review of a Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 4 out of 15, indicating the resident has severe cognitive impairment. Additionally, it revealed that the resident requires supervision/touching assistance of one staff to transfer from a sitting to a standing position.
Review of a progress note dated 3/26/2025 at 12:12 AM, authored by Registered Nurse (RN), Staff A, revealed the resident was observed in his/her doorway laying on the floor. Additionally, the progress note indicated that the resident was guarding his/her right leg and complaining of right hip and leg pain. Further, the progress note indicated the resident required staff assistance to stand.
Record review of a Safety events fall SBAR [Situation Background Assessment Recommendation] form completed on 3/26/2025 revealed the resident experienced a pain level of 7-severe pain-horrible, intense with painful and limited ROM at the time of his/her fall.
Record review revealed that a portable x-ray was completed at the facility on 3/26/2025 which resulted in a right hip fracture. The resident was subsequently transferred to the emergency room on 3/27/2025 due to his/her fracture.
Review of the hospital emergency room visit notes dated 3/27/2025, revealed that the resident was diagnosed with a right femur (thigh bone) fracture.
During a surveyor interview on 3/31/2025 at 2:54 PM, with RN, Staff A, she acknowledged that the resident experienced an unwitnessed fall on 3/25/2025 and upon assessment the resident was guarding his/her right extremity and was complaining of right hip and leg pain. Additionally, she revealed that the resident was assisted to a standing position from the floor with two staff members. Additionally, she revealed she was not aware of the facility's fall protocol to utilize a Hoyer lift if the resident is not able to stand independently.
During a surveyor interview with the Assistant Director of Nursing Services on 3/31/2025 at 2:47 PM she revealed that it would be her expectation that staff would utilize a Hoyer lift to assist a resident off the floor that is unable to get up on their own. Additionally, she acknowledged that the resident was experiencing severe pain and sustained a fracture to his/her right femur.
Jun 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents' advance di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it has been determined that the facility failed to ensure that residents' advance directives were consistent with the residents' electronic medical record (EMR) for 3 of 19 residents reviewed, Resident ID #s 2, 68 and 398. Additionally, the facility failed to ensure that the resident's advance directive was formulated for 1 of 4 new admissions reviewed, Resident ID #3.
Findings are as follows:
Review of a facility policy dated [DATE], titled, Advance Directives, states in part,
.This facility is required to comply with state and federal regulations .including the right to formulate Advance Directives .to see that the resident's wishes are properly documented and carried out .
1. All residents (or their responsible party) shall, upon admission, shall be asked about their advanced directives/wishes and educational materials which explain the right of the individual to make decisions concerning medical care including .the right to make advance directives which are to be carried out when and if the resident becomes incapable of making his/her wishes known .
5. If the resident does not have an advance directive, the resident or his/her responsible party will be asked as soon as possible after admission, to indicate the resident's code status by completing the code status form .
7. In the absence of a specified code status, or/an advance directive, the resident is to be considered a full code .all residents in cardiac arrest should receive resuscitation unless the resident has a valid 'Do Not Resuscitate (DNR) order .
10. A copy of the advance directive is to be maintained in the resident's record .
1. Record review for Resident ID #2 revealed s/he was re-admitted to the facility in May of 2024.
Record review revealed a MOLST (Medical Orders for Life Sustaining Treatment) dated [DATE] which indicates, Cardiopulmonary Resuscitation (CPR) Full Code.
Record review revealed a physician's order dated [DATE], indicating a code status of DNR.
Record review revealed the EMR code status banner, derived from the data entered onto the resident's face sheet, identified the resident as a DNR.
Additional, record review revealed an advance directive document, dated [DATE] from a previous admission, which indicated DNR.
During a surveyor interview on [DATE] at 2:52 PM with Licensed Practical Nurse (LPN), Staff A, when reviewing the above resident's record with her, she was unable to determine if the resident was truly a Full Code and further revealed she would refer to the MOLST for his/her code status.
2. Record review for Resident ID #3 revealed s/he was re-admitted to the facility in May of 2024.
Record review failed to reveal evidence of an advance directive or any indication of the resident's code status.
Record review revealed a physician's order dated [DATE] for Code Status with no further instructions.
Additional, record revealed an Advance Directive document dated [DATE] from a previous admission, which indicated DNR.
During a surveyor interview on [DATE] at 2:52 PM with LPN, Staff A, after reviewing the above resident's record with her, she was unable to provide evidence that upon admission the resident was able to formulate his/her advance directives. Further, she acknowledged the resident's advance directive from his/her previous admission dated [DATE], indicating a DNR. Additionally, she revealed that she would treat the resident as if s/he was a full code as she has nothing to verify his/her code status.
3. Record review for Resident ID #68 revealed s/he was admitted to the facility in May of 2024.
Record review revealed a MOLST dated [DATE], unsigned by the resident's healthcare provider, indicating Do Not Attempt Resuscitation/DNR. Further review of the MOLST indicated Do Not Intubate [DNI].
Record review of the EMR banner only identified the resident as a DNR and not DNI.
Additional, record review revealed a physician's order dated [DATE] for Code Status with no further instructions.
4. Record review for Resident ID #398 revealed s/he was admitted to the facility in July of 2024.
Record review revealed a MOLST dated [DATE], unsigned by the resident's healthcare provider, indicating Do Not Attempt Resuscitation/DNR and Comfort Measures Only. Further review of the MOLST did not indicate DNI.
Record review of the EMR banner identified the resident as a DNR/DNI.
Additional, record review revealed a physician's order dated [DATE] for Code Status with no further instructions.
During a surveyor interview on [DATE] at 2:52 PM with LPN, Staff A, when asked what she would refer to for the resident's code status in the event of an emergency, she revealed she would refer to the resident's MOLST.
During a surveyor interview with Registered Nurse, Staff B, on [DATE] at 2:33 PM, when asked what she would refer to for a resident's code status in the event of an emergency, she revealed she would refer to the resident's EMR banner.
During an interview on [DATE] at 10:30 AM with the Director of Nursing Services, she acknowledged that Resident ID #s 2 and 3 had an advance directive from a previous admission. However, it is expected that an updated advance directive would have been completed upon their re-admission. She also acknowledged that Resident ID #3 did not have documentation of an advance directive from their current admission. Furthermore, she was unable to explain why Resident ID #s 68 and 398 did not have a signed MOLST document. Additionally, she was unable to explain the above-mentioned inconsistencies between the MOLST documents, orders and EMR banners. Lastly, she revealed staff should always refer to the resident's paper document for code status instructions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food that accommodates resident allergies for 1 of 1 resident reviewed, Res...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide food that accommodates resident allergies for 1 of 1 resident reviewed, Resident ID #29.
Findings are as follows:
Record review revealed the resident was readmitted to the facility in March of 2023 with diagnoses including, but not limited to, dementia and anxiety.
Review of the resident's listed allergies revealed s/he has an allergy to blueberries.
During a surveyor observation on 6/11/2024 at approximately 8:15 AM, revealed a breakfast tray on Resident ID #29's bedside table with Resident ID #41's name on the diet ticket. Further surveyor observation revealed Resident ID #29 consumed all of the food on the tray that was given to him/her.
Review of the diet ticket revealed the following food was served to Resident ID #29:
.blueberry coffeecake .
During a surveyor interview on 6/11/2024 at 8:16 AM with Certified Medication Technician (CMT), Staff D, she acknowledged that Resident ID #29 was given the wrong breakfast tray and was served blueberry coffeecake, and that s/he has an allergy to blueberries.
During a surveyor interview on 6/11/2024 at 9:20 AM with the Cook, Staff E, in the presence of the Food Service Director, she revealed that if blueberry coffeecake was listed on the meal ticket, then that is what the resident received.
During a surveyor interview on 6/11/2024 at 9:23 AM with Nursing Assistant, Staff F, she acknowledged that she served the resident the incorrect breakfast tray.
During a surveyor interview on 6/11/2024 at 9:31 AM with the Director of Nursing Services, she acknowledged that the resident has an allergy to blueberries. Additionally, she revealed that Resident ID #29 should not have received another resident's breakfast tray.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following physician's orders for 1 of 1 resident with waffle boots (an off-loading device), Resident ID #60 and 1 of 1 resident receiving Nystatin powder (antifungal treatment), Resident ID #3.
Findings are as follows:
1. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
Record review revealed Resident ID #60 was admitted to the facility in February of 2023 with diagnoses including, but not limited to, weakness and the need for assistance with personal care.
Record review revealed a physician's order dated 3/14/2024 for bilateral waffle boots as tolerated, remove and reapply for care.
During a surveyor observation on 6/14/2024 at 10:29 AM, in the presence of Licensed Practical Nurse, Staff C, revealed the resident was lying in his/her bed without his/her waffle boots applied. Additionally, Staff C acknowledged that the resident's waffle boots had not been applied and she was unable to locate the resident's waffle boots.
Record review of the Treatment Administration Record (TAR) from 6/1/2024 to 6/13/2024 revealed the waffle boots were documented as unavailable for 18 out of 39 opportunities.
During a surveyor interview on 6/14/2024 at approximately 1:00 PM with the Director of Nursing Services (DNS), she was unable to explain why the waffle boots were not applied as ordered and had been documented as unavailable, as the resident's waffle boots were located in the laundry room after it was brought to the facility's attention.
2. According to Mosby's Fundamentals of Nursing Concepts, Process and Practice, 4th Edition, page 809, states in part, .a Registered Nurse checks all transcribed orders against the original order for accuracy and thoroughness .
Record review revealed Resident ID #3 was admitted to the facility in May of 2024 with diagnoses including, but not limited to, cerebral infarction (stroke) and diabetes mellitus.
Record review of an admission skin assessment dated [DATE], revealed skin alterations of dermatitis and moisture associated skin damage. Further review of the assessment revealed a description of the skin integrity conditions including, but not limited to, nystatin powder to his/her bilateral groin.
Record review revealed a physician's order dated 5/21/2024 for Nystatin powder to fungal rash twice daily for 30 days. Further review of the order failed to indicate the affected area for the treatment.
Record review of the May and June 2024 TARs revealed the treatment was signed off as administered, without an affected area indicated for treatment.
During a surveyor interview on 6/14/2024 at 2:16 PM with Licensed Practical Nurse, Staff A, when asked where she applies the resident's Nystatin powder, she revealed she applies the powder to the reddened areas under the resident's chest folds.
During a surveyor interview on 6/14/2024 at approximately 1:00 PM with the DNS, she acknowledged that the Nystatin powder order was incomplete and that the order should have indicated the affected area to apply the treatment.
May 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care plan was implemented for each resi...
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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that a person-centered comprehensive care plan was implemented for each resident, consistent with the residents rights set forth and includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment, for 1 of 1 residents reviewed for suicidal ideations, Resident ID #55.
Findings are as follows:
Record review revealed the resident was admitted to the facility in February of 2022 with diagnoses including, but not limited to, cerebral infarction (stroke), major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood.
Record review of a nursing progress note dated 4/24/2023 revealed the Consultant Psychiatric Registered Nurse (RNP) was notified of the resident's comments to his/her sister regarding wanting to die.
Record review of the 5/3/2023 consultant psychiatric RNP document states in part, .Pt [patient] believes [s/he] would be better off dead, states how [s/he] would attempt-cuts arteries in legs; past attempt x 1 in [his/her] 50's .[S/he] would use a sharp object to cut blood vessels in legs .
Review of the record revealed the resident was sent out to the hospital for an psychiatric evaluation on 5/3/2023.
Record review of the hospital continuity of care document, dated 5/3/2023, states in part, .Source: patient, EMS [emergency medical services] .presenting today for evaluation of suicidal statements. Patient reportedly telling staff at [his/her] SNF [skilled nursing facility] that [s/he] would like to hurt [him/herself], stating that [s/he] would cut [him/herself] with a knife if [s/he] could .have access to 1. Stating that [s/he] would do this in an effort to hurt [him/herself] .
Record review of the care plan, updated on 5/23/2023, revealed an intervention to restrict access to potentially harmful items, including but not limited to, knives.
During a surveyor observation of the lunch meal pass on 5/25/2023 at 12:25 PM, revealed Nursing Assistant, Staff A, carrying a meal tray that included a metal butter knife, into the resident's room and placed the tray on his/her bedside table. After assisting the resident with cutting his/her food, the NA left the room. Continuous surveyor observation of the resident during his/her meal revealed the resident had access to the knife until his/her meal tray was removed by staff, which was at 1:08 PM.
During a surveyor interview on 5/25/2023 at 12:30 PM with Licensed Practical Nurse, Staff B, she revealed she was unaware of a care plan indicating that the resident should not have access to potentially harmful items, such as knives.
During a surveyor interview on 5/25/2023 at 1:35 PM with the Social Worker, she indicated that she developed the care plan to include restrictions of potentially harmful items due to his/her recent threat to harm his/her self.
Additionally, attempts were made to contact the consultant psychiatric RNP for an interview on 5/25/2023, but she was unable to be reached, and a return phone call has yet to be received.
During a surveyor interview on 5/25/2023 at 1:00 PM with the Director of Nursing Services, she was unable to provide evidence that the interventions in the care plan to maintain Resident ID #55's safety were implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who uses psychotropic drugs receives gradual dose reductions (GDR) unless contrain...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that a resident who uses psychotropic drugs receives gradual dose reductions (GDR) unless contraindicated for 1 of 5 sample residents reviewed for psychotropic medications, Resident ID #45.
Findings are as follows:
Record review revealed the resident was admitted to the facility in January of 2023 with diagnoses including, but not limited to, schizophrenia and depression.
Record review revealed a physician's order dated 1/26/2023 for clozapine (a medication used to treat schizophrenia) 200 milligram (mg) at bedtime.
Record review of a psychiatric consultant note dated 4/27/2023, revealed a medication recommendation to consider GDR of clozapine and to reduce the bedtime dose to 150 mg for 14 days.
Record review revealed a physician's progress note dated 5/3/2023, which states in part, Patient seen and examined for GDR .agreed with gradual dose reduction of clozapine to 150 mg at bedtime .
Record review of the May 2023 Medication Administration Record revealed the clozapine 200 mg was administered at bedtime from 5/3/2023 to 5/24/2023, indicating the resident did not receive the ordered reduced dose for 22 days.
Record review failed to reveal evidence that the GDR was implemented for clozapine, until after it was brought to the facility's attention by the surveyor.
During a surveyor interview on 5/25/2023 at 11:23 AM with the Director of Nursing Services, she acknowledged the GDR had not been implemented and she would have expected the clozapine to be reduced to 150 mg at bedtime on 5/3/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately docume...
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Based on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, for 1 of 2 residents receiving oxygen therapy, Resident ID #132.
According to Brunner and Sudarth's textbook, Medical and Surgical Nursing, 7th Edition, 1992, p. 524, as with other medications, oxygen is administered with care, and its effects on each patient are carefully assessed. Oxygen is a drug and except in emergency situations is prescribed by a physician.
According to Basic Nursing, Mosby's, 3rd after administering a drug, the nurse records it immediately on the appropriate record form. Recording of the drug includes the name of the drug, dosage, route of administration, and the exact time of administration.
Findings are as follows:
Record review revealed the resident was admitted to the facility in May of 2023 with diagnoses including, but not limited to, peripheral vascular disease and anemia.
Record review revealed a physician's order dated 5/11/2023 for Oxygen 2-4 liters per minute PRN (as needed) for SOB (shortness of breath).
During surveyor observations on the following dates and times the resident was observed receiving oxygen therapy at 2.5 liters via nasal cannula:
-5/23/2023 at 10:23 AM and 1:10 PM
-5/24/2023 at 8:27 AM and 12:13 PM
-5/25/2023 at 11:02 AM
Record review of the May 2023 Medication Administration Record (MAR) failed to reveal evidence that the oxygen was documented as administered on the above-mentioned dates and times.
During a surveyor interview and simultaneous observation on 5/23/2023 at 11:09 AM with Licensed Practical Nurse, Staff D, she acknowledged the resident was receiving oxygen therapy and that the oxygen should have been documented as administered in the resident's record.
During a surveyor interview with the Director of Nursing Services on 5/25/2023 at 11:47 AM she was unable to explain why the oxygen that the resident was receiving was not accurately documented in his/her record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure a sanitary environment to prevent the transmission of infections, for 1 of 1 residents duri...
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Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure a sanitary environment to prevent the transmission of infections, for 1 of 1 residents during medication administration of an insulin pen injection, Resident ID #35.
Findings are as follows:
Review of the facility policy titled, Medication Administration states in part, .Insulin pens containing multiple doses of insulin are for single resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident. 12 .Prior to administering the insulin, the nurse will verify that the correct pen is used for that resident .
Review of the physician orders revealed an order dated 2/20/2023 for Insulin Lispro Injection insulin pen, 100 units per milliliter (a disposable single-patient-use prefilled pen containing insulin) per sliding scale.
During a surveyor observation on 5/25/2023 at 11:56 AM after obtaining Resident ID #35's blood sugar, Licensed Practical Nurse, Staff E retrieved Resident ID #45's insulin pen, prepared the insulin dose per the sliding scale to administer for Resident ID #35. Staff E then entered Resident ID #35's room to administer the insulin, at which time the error was brought to Staff E's attention by the surveyor prior to the resident receiving insulin from another resident's insulin pen.
During a surveyor interview immediately following the above mentioned observation, Staff E acknowledged that the insulin pen she was about to use to administer insulin to Resident ID #35 was not his/her pen, but was Resident ID #45's insulin pen. Additionally, she acknowledged that the insulin pens are resident specific and should not be shared.
During a surveyor interview on 5/25/2023 at 2:12 PM with the Director of Nursing Services, she revealed that she would expect insulin pens to be administered to the prescribed resident and not be used by any other resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to following physicia...
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Based on record review and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to following physician's orders for 3 of 18 residents reviewed, Resident ID #s 41, 60, and 282.
Findings are as follows:
According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states, The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients.
1. Record review revealed Resident ID #41 was admitted to the facility in April of 2023 with diagnoses including, but not limited to, fusion of spine in lumbar region and peripheral vascular disease (narrowing, blockage, or spasms in a blood vessel).
Record review revealed a physician's order with a start date of 4/19/2023 for heparin solution (medication that prevents formation of blood clots) 5,000 unit/milliliter subcutaneously (injection) every 8 hours.
Record review of the May 2023 Medication Administration Record (MAR) revealed the resident refused his/her 5:00 AM dose of heparin on 5/23 and 5/24.
Record review of the progress notes failed to reveal evidence that the physician was notified of the resident's refusals of the medication.
During a surveyor interview with the Director of Nursing Services (DNS) on 5/25/2023 at 2:21 PM, she acknowledged that the physician should be notified when a resident refuses a medication.
2. According to the facility policy titled, Medication Administration states in part, .16. If the medication was not administered because the medication was not available, the nurse MUST take steps to ensure timely delivery of the medication and document all steps taken in progress notes .
Record review revealed Resident ID #60 was admitted to the facility in March of 2023 with diagnoses including, but not limited to, type 2 diabetes mellitus and morbid obesity.
Record review revealed a physician's order with a start date of 3/10/2023 for Ozempic (medication that helps control blood sugar for people with type 2 diabetes) pen injector 2 milligram/dose subcutaneously once a week every Saturday.
Record review of the April and May 2023 MARs failed to reveal evidence that the resident was administered the Ozempic injection weekly, due to the medication being unavailable, on the following dates:
-4/22/2023
-4/29/2023
-5/6/2023
-5/13/2023
-5/20/2023
Record review of the nursing progress notes failed to reveal evidence that steps were taken to ensure timely administration of the medication.
Additionally, the record failed to reveal evidence that the physician was notified after the medication doses were not administered on the above-mentioned dates.
During a surveyor interview with the DNS on 5/24/2023 at 3:02 PM, she was unable to provide evidence that the physician was notified that the medication was unavailable for administration and not administered as ordered.
3. According to the facility policy titled, Weight Loss/Gain Protocol states in part .a significant weight discrepancy is defined as: 1. A weight change of 3 pounds or more in one week .significant weight loss/gain, nursing must notify; Physician, Dietician, DNS, Family/Responsible Party .
Record review revealed Resident ID #282 was admitted to the facility in April of 2023 with diagnosis including, but not limited to, alcoholic cirrhosis of liver with ascites (severe scarring of the liver that causes fluid buildup in the abdomen).
Record review revealed the following physician's orders with a start date of 4/28/2023:
-Weigh daily and call the physician for gain of 3 pounds or more in 1 day or 5 pounds in 1 week.
-Re-weigh the resident as needed if discrepancy of 3 pounds (gain or loss) were found and notify the physician.
Record review failed to reveal evidence that the resident's weight was obtained for 3 days on 5/20, 5/21, and 5/23/2023.
Record review of the progress notes failed to reveal evidence that the resident refused to be weighed or that the physician was notified of the weights that were not obtained on the above-mentioned dates.
During a surveyor interview with the DNS on 5/25/2023 at 11:26 AM, she was unable to provide evidence that the resident's weights were obtained on the above mentioned dates or that the physician was notified.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below Rhode Island's 48% average. Good staff retention means consistent care.
Concerns
- • 22 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $10,358 in fines. Above average for Rhode Island. Some compliance problems on record.
- • Grade C (53/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 53/100. Visit in person and ask pointed questions.
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About This Facility
What is Overlook Nursing And Rehabilitation Center's CMS Rating?
CMS assigns Overlook Nursing and Rehabilitation Center an overall rating of 3 out of 5 stars, which is considered average nationally. Within Rhode Island, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Overlook Nursing And Rehabilitation Center Staffed?
CMS rates Overlook Nursing and Rehabilitation Center's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the Rhode Island average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Overlook Nursing And Rehabilitation Center?
State health inspectors documented 22 deficiencies at Overlook Nursing and Rehabilitation Center during 2023 to 2025. These included: 1 that caused actual resident harm and 21 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Overlook Nursing And Rehabilitation Center?
Overlook Nursing and Rehabilitation Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EDEN HEALTHCARE, a chain that manages multiple nursing homes. With 100 certified beds and approximately 88 residents (about 88% occupancy), it is a mid-sized facility located in Pascoag, Rhode Island.
How Does Overlook Nursing And Rehabilitation Center Compare to Other Rhode Island Nursing Homes?
Compared to the 100 nursing homes in Rhode Island, Overlook Nursing and Rehabilitation Center's overall rating (3 stars) is below the state average of 3.1, staff turnover (40%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Overlook Nursing And Rehabilitation Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Overlook Nursing And Rehabilitation Center Safe?
Based on CMS inspection data, Overlook Nursing and Rehabilitation Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Rhode Island. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Overlook Nursing And Rehabilitation Center Stick Around?
Overlook Nursing and Rehabilitation Center has a staff turnover rate of 40%, which is about average for Rhode Island nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Overlook Nursing And Rehabilitation Center Ever Fined?
Overlook Nursing and Rehabilitation Center has been fined $10,358 across 1 penalty action. This is below the Rhode Island average of $33,182. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Overlook Nursing And Rehabilitation Center on Any Federal Watch List?
Overlook Nursing and Rehabilitation Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.