Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Overlook Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions sustained a second-degree burn after spilling hot chocolate prepared with excessively hot water from a Keurig machine. Staff had not received training on safe temperatures for serving hot beverages, and the water temperature was measured at 180.3°F, above recommended safety guidelines. The administrator and staff educator confirmed that no education on this topic had been provided.
Surveyors found that food items in the main kitchen and two kitchenettes were not labeled or dated according to professional standards and facility policy, including fried chicken, chicken patties, hamburger patties, pancakes, and resident food brought from outside. Additionally, an oven was found with burnt residue and lacked a cleaning schedule. The FSD and Administrator acknowledged these deficiencies during interviews.
The facility did not ensure that antibiotic orders for three residents included the required indication for use, as outlined by CDC guidelines and facility policy. Additionally, the facility lacked an active Antibiotic Stewardship Team, despite policy requirements for regular meetings and program analysis.
Three residents' medical records lacked documentation showing whether they received, declined, or had a contraindication to the recommended pneumococcal vaccines, despite completion of initial vaccine series. The DON confirmed that this documentation was missing and only became aware of the issue after it was identified by a surveyor.
A resident was started on amlodipine for hypertension without being informed, and neither the resident nor their representative was notified about the medication, its risks, or alternatives. The omission was confirmed through record review and interviews with the resident, their representative, nursing staff, and the DON.
Two residents with significant medical conditions sustained skin tears of unknown origin, and the facility did not conduct or document investigations into the causes of these injuries. Both the DON and an LPN confirmed that no investigation was initiated or recorded, despite facility policy requiring such action.
The facility did not complete required AIMS assessments for a resident on psychotropic medications and failed to ensure timely hemoglobin A1C monitoring for a resident receiving insulin, as ordered by providers. These omissions were confirmed by the DON and relevant clinical staff.
Two residents did not receive care in accordance with physician orders: one resident with Parkinson's disease and a history of falls was not reported to the provider after a significant change in orthostatic blood pressure, and another resident with spinal stenosis and neurogenic bladder did not have required urology and MRI appointments scheduled. Staff interviews confirmed these omissions, indicating a failure to follow professional standards and physician directives.
A resident with stage 4 pressure ulcers received wound care from an RN who failed to use an applicator to pack the wounds and did not change gloves between treating two separate wounds. The DON confirmed these actions did not meet professional standards of practice, and there was no evidence that wound care was provided in a manner consistent with promoting healing and preventing infection.
Surveyors found that the facility did not have required physician orders specifying catheter size, balloon size, or diagnosis for two residents with urinary catheters, as mandated by facility policy. Additionally, there was no evidence that a trial void was attempted for a resident as ordered by a physician. The DON and an LPN confirmed the lack of required documentation.
A resident with COPD and respiratory failure was not provided oxygen therapy at the prescribed rate of 2 LPM, as surveyors observed the oxygen being administered at approximately 3.5 LPM on several occasions. Staff confirmed the discrepancy between the physician's order and the care provided.
A resident being treated for a UTI was prescribed Bactrim for 7 days, totaling 14 doses, but received 17 doses instead. The DON confirmed that the resident should have only received the prescribed amount.
The facility did not accurately maintain medical records for two residents: one was documented as receiving oxygen at the prescribed rate, but was observed receiving a higher rate, and another had AIMS assessments documented as completed when there was no evidence they were actually performed. Staff interviews confirmed the discrepancies in documentation.
A resident with severe dementia and a history of falls was manually assisted to a standing position by two staff members after an unwitnessed fall, despite exhibiting severe pain and being unable to stand independently. Facility protocol required the use of a Hoyer lift in such situations, but staff did not follow this procedure, and the resident was later diagnosed with a right hip fracture. Staff interviews revealed a lack of awareness of the protocol.
The facility failed to follow physician's orders for two residents. A resident with a physician's order for waffle boots was found without them, and the boots were documented as unavailable multiple times. Another resident had an incomplete order for Nystatin powder, which did not specify the affected area, yet the treatment was administered. The DON acknowledged the incomplete order.
The facility failed to ensure consistency between residents' advance directives and their EMR. A resident had conflicting code status documentation, while another lacked current advance directive evidence. Two residents had unsigned MOLST forms with discrepancies between the MOLST and EMR. Staff were instructed to refer to paper documents, but inconsistencies persisted.
A resident with a known allergy to blueberries was mistakenly served a breakfast tray containing blueberry coffeecake, intended for another resident. The error was confirmed through staff interviews, including a CMT, Cook, and Nursing Assistant, who acknowledged the mistake. The DON confirmed the resident's allergy and the error in serving the incorrect tray.
Resident Burned by Hot Beverage Due to Lack of Staff Training and Unsafe Temperatures
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, dependence on renal dialysis, and diabetes, who was cognitively intact, sustained a second-degree burn after spilling hot chocolate on their thigh. The hot chocolate was prepared by a nursing assistant using a Keurig coffee maker in the facility's kitchenette. The incident resulted in a burn measuring 7 by 12 centimeters and 0.1 centimeters deep, with 30% scabbing and involvement of both the dermis and epithelial layers of the skin. The resident reported significant pain from the burn. Investigation revealed that the water dispensed from the Keurig machine reached a temperature of 180.3°F, which exceeds the recommended safe serving range of 130 to 160°F for hot beverages. Staff interviews indicated that nursing assistants had not received education on safe temperatures for reheating or serving food and beverages, and the staff educator confirmed that such training was not provided to any staff members. The administrator acknowledged awareness of the incident and the lack of staff education regarding the risks associated with hot liquids.
Failure to Properly Label, Date, and Store Food Items in Kitchen and Kitchenettes
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to store and distribute food in accordance with professional standards for food service safety in both the main kitchen and two kitchenettes. Specifically, multiple food items in the main kitchen freezer, such as fried chicken, chicken patties, hamburger patties, pancakes, and shaved beef, were found without labels or discard dates as required by the Rhode Island Food Code. The Food Service Director (FSD) acknowledged that these items were not labeled or dated per regulations. Additionally, the facility policy requires food brought in by visitors to be labeled with the resident's name and date, and to discard perishable items older than three days, but items in the 1st floor kitchenette were only labeled with resident names and lacked discard dates. Further deficiencies were observed in the 2nd floor kitchenette, where a large bag of tacos and a container of an unidentified food substance were found without labels or discard dates. The oven in this kitchenette also contained residual burnt matter, and the FSD was unable to provide a cleaning schedule for the oven. Both the FSD and the Administrator confirmed during interviews that it was their expectation for all food items to be properly labeled, dated, or discarded according to regulations and facility policy.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Specifically, for three residents reviewed for antibiotic use, physician orders for antibiotics did not include the required indication for use, as mandated by both CDC guidelines and the facility's own policy. The residents involved had diagnoses such as acute bronchiolitis due to respiratory syncytial virus, aftercare following surgical amputation, and pneumonia. In each case, the physician's orders for antibiotics lacked documentation of the clinical indication, which was confirmed during interviews with the Director of Nursing Services (DNS), who acknowledged the omission. Additionally, the facility did not have an active Antibiotic Stewardship Team as required by its policy. The policy specified that such a team should meet regularly, maintain meeting minutes, and analyze the efficacy of the program annually. However, during interviews, the DNS confirmed that the facility did not have an antibiotic stewardship team in place, nor were there any meeting minutes available, despite the policy's requirements.
Failure to Document Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure that the medical records of three residents included documentation indicating whether the residents received the pneumococcal vaccination, or if not, whether it was declined or medically contraindicated. Specifically, for three residents admitted between 2018 and 2019, record reviews showed that while initial pneumococcal vaccine series (PCV13 and PPSV23) were completed, there was no evidence that the newer recommended vaccines (PCV20 or PCV21) were offered, administered, or declined. In one case, a resident consented to a pneumococcal vaccination, but there was no documentation that the vaccine was actually given or refused. During an interview, the DON confirmed that the facility had not documented whether these residents received or declined the updated pneumococcal vaccines, and was unable to provide such evidence until prompted by the surveyor. The lack of documentation was only identified after the surveyor brought the issue to the facility's attention.
Failure to Inform Resident and Representative of New Antihypertensive Medication
Penalty
Summary
A resident with a diagnosis including hypertension was admitted to the facility and subsequently prescribed amlodipine 5 mg daily for blood pressure control. Documentation in the resident's medical record, including progress notes and physician orders, confirmed the initiation and administration of amlodipine. However, there was no evidence that the resident or the resident's representative was informed in advance about the addition of amlodipine, its associated risks and benefits, or alternative treatment options prior to the medication being prescribed and administered. The manufacturer's insert for amlodipine lists several potential side effects, including headache, swelling, dizziness, and a potential risk of heart attack when first taking the medication. The deficiency was further substantiated by interviews with the resident, the resident's representative, and facility staff. The resident's family member, who serves as the emergency contact, expressed concern about the resident experiencing dizziness and was unaware of the new medication. Both the resident and the representative confirmed they had not been informed about the addition of amlodipine. Staff interviews revealed that the nurse responsible for administering the medication did not notify the resident or representative, and the Director of Nursing Services acknowledged that such notification was expected prior to starting the treatment.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were thoroughly investigated for two residents who sustained skin tears. For one resident with Alzheimer's Disease, documentation showed the presence of two new skin tears on the left upper extremity, with the resident unable to explain their origin. Record review did not reveal any evidence that an investigation was conducted to determine how these injuries occurred. During an interview, the Director of Nursing Services (DNS) acknowledged the lack of an investigation and confirmed that one should have been initiated. Similarly, another resident with chronic kidney disease sustained a 1-centimeter skin tear to the left knee, with the progress note lacking any explanation for the injury's origin. Further review of records did not show that an investigation was conducted to determine the cause of the skin tear. Interviews with both a Licensed Practical Nurse and the DNS confirmed that the documentation did not include the origin of the injury and that no investigation had been performed.
Failure to Complete Required Assessments and Lab Monitoring
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a history of anxiety, bipolar disorder, PTSD, and panic disorder, the care plan required regular Abnormal Involuntary Movement Scale (AIMS) assessments due to psychotropic medication use. A physician's order specified that AIMS assessments should be completed quarterly in March, June, September, and December. However, records showed that the last AIMS assessment was completed in August 2024, with no evidence of assessments being performed on the subsequent required dates. Both the resident's Nurse Practitioner and the Director of Nursing Services confirmed that the assessments had not been completed as ordered. For another resident with diabetes mellitus and hyperglycemia, the care plan identified risks related to diabetes and insulin administration. The resident was prescribed daily Semglee (insulin glargine-yfgn), and a provider's note indicated that a hemoglobin A1C test should be repeated in three months following a previous test. However, there was no evidence that the follow-up hemoglobin A1C was completed as ordered. The Director of Nursing Services acknowledged that the last A1C test was in November 2024 and could not provide documentation of a repeat test until after the issue was identified by the surveyor.
Failure to Follow Physician Orders for Orthostatic Blood Pressure and Medical Appointments
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for two residents. For one resident with Parkinson's disease, a history of falls, and on antipsychotic medication, the physician had ordered orthostatic vital signs to be taken every three months. The resident experienced multiple episodes of dizziness and falls, and a quarterly assessment revealed a significant drop in orthostatic blood pressure. However, there was no evidence that the provider was notified of this change, despite staff and the nurse practitioner stating that such changes should be reported. For another resident with spinal stenosis and neurogenic bladder dysfunction, the physician ordered a urology consult for possible suprapubic tube placement and an MRI of the spine. The resident expressed interest in the procedure, and the physician documented the need to schedule the appointments. Despite this, there was no evidence that either the urology or MRI appointments had been scheduled. Staff interviews confirmed that the appointment scheduler was unaware of the orders, and the LPN stated that no appointments had been made. In both cases, the facility did not follow through on physician's orders, either by failing to notify the provider of significant clinical changes or by not scheduling required medical appointments. These actions resulted in a failure to provide appropriate treatment and care according to the residents' needs and physician directives.
Failure to Follow Professional Standards During Pressure Ulcer Care
Penalty
Summary
A resident admitted with spinal stenosis and stage 4 pressure ulcers to the coccyx and right gluteal fold was observed to receive wound care that did not follow professional standards of practice. Physician orders specified the use of vashe soak, collagen with silver, calcium alginate, kerlix, and super absorbent dressings for the coccyx wound, and vashe soak, collagen powder, calcium alginate, and silicone super absorbent dressing for the right gluteal fold wound. During wound care, the RN applied collagen powder on top of calcium alginate and packed the coccyx wound with her gloved fingers, followed by packing kerlix into the wound, also with her fingers, instead of using an applicator as required. Immediately after treating the coccyx wound, the RN proceeded to treat the right gluteal fold wound without changing gloves, again using her fingers to apply and pack the wound dressing. The RN acknowledged during interview that she did not use an applicator and did not change gloves between wound treatments. The DON also confirmed that the RN should have used an applicator and changed gloves between wounds, and was unable to provide evidence that wound care was provided in accordance with professional standards to promote healing and prevent infection for the resident.
Failure to Ensure Proper Catheter Orders and Documentation
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to provide appropriate treatment and services for residents with urinary catheters. For one resident with a foley catheter, there was no physician order on file specifying the catheter size, balloon size, or diagnosis to support its use, despite facility policy requiring this documentation. Both the LPN and the Director of Nursing Services (DNS) confirmed the absence of the required order. Similarly, another resident with a suprapubic catheter did not have an order specifying the catheter size, balloon size, or diagnosis, as required by policy, which was also acknowledged by the DNS. Additionally, a third resident with a foley catheter had a physician order for a trial void following a urologist's recommendation, but there was no evidence in the records that the trial void was attempted or failed as ordered. The DNS was unable to provide documentation to show that the trial void had been carried out. These findings indicate lapses in following facility policy and physician orders regarding catheter care and documentation.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypercapnia was not provided respiratory care consistent with professional standards. The resident was readmitted to the facility with a care plan and physician's order specifying oxygen therapy at 2 liters per minute (LPM). However, surveyor observations on multiple occasions revealed that the resident was receiving oxygen at approximately 3.5 LPM, which was not in accordance with the prescribed order. Staff interviews confirmed the discrepancy, with a registered nurse acknowledging that the resident was not receiving the ordered amount of oxygen. The Director of Nursing Services also indicated that the expectation was for the resident to receive oxygen at the ordered rate. Laboratory results showed the resident had elevated carbon dioxide levels, which can be associated with both COPD and supplemental oxygen use. The failure to administer oxygen as ordered constituted a lack of adherence to professional standards of respiratory care.
Resident Received More Antibiotic Doses Than Prescribed
Penalty
Summary
A resident with a diagnosis including urinary tract infection (UTI) was readmitted to the facility in February 2024. Medical records show that the provider prescribed Bactrim 800-160 mg to be administered twice daily for 7 days, totaling 14 doses. However, review of the March 2025 Medication Administration Record revealed that the resident received 17 doses of Bactrim between 3/12 and 3/20, which is 3 doses more than what was ordered by the provider. During an interview, the Director of Nursing Services confirmed that only 14 doses should have been administered as prescribed.
Failure to Accurately Maintain Medical Records for Oxygen Administration and AIMS Assessments
Penalty
Summary
The facility failed to accurately maintain medical records in accordance with accepted professional standards for two residents. For one resident with chronic obstructive pulmonary disease (COPD), the care plan and physician's order specified oxygen at 2 liters per minute (LPM). However, surveyor observations on multiple occasions found the resident receiving approximately 3.5 LPM of oxygen, while the Medication Administration Records (MARs) inaccurately documented administration at 2 LPM. A registered nurse also documented the ordered rate despite observing a different rate earlier in the day and could not explain the discrepancy during an interview. For another resident with a history of anxiety, bipolar disorder, PTSD, and panic disorder, the care plan required regular Abnormal Involuntary Movement Scale (AIMS) assessments as directed by a physician's order. Although records indicated that AIMS assessments were completed on specific dates, further review revealed that the last actual assessment was completed prior to those dates, and there was no evidence to support the documented completion of the assessments. The Director of Nursing Services was unable to provide accurate records for these assessments during the surveyor interview.
Failure to Follow Fall Protocol and Professional Standards During Post-Fall Transfer
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in relation to the post-fall transfer of a resident with severe dementia, muscle weakness, and a history of numerous falls. According to the facility's fall protocol, if a resident is unable to get up independently after a fall, staff are required to use a Hoyer lift with two staff members to assist the resident back into bed. However, after an unwitnessed fall, the resident was found on the floor, exhibiting severe pain and guarding of the right leg. Despite these symptoms and the resident's inability to stand without assistance, two staff members manually assisted the resident to a standing position from the floor, rather than utilizing the Hoyer lift as required by protocol. Further review revealed that the resident was subsequently diagnosed with a right hip fracture following the incident, which was confirmed by a portable x-ray and hospital emergency room evaluation. Staff interviews indicated a lack of awareness of the facility's fall protocol, and the Assistant Director of Nursing Services confirmed that the expectation was for staff to use a Hoyer lift in such situations. The failure to follow established protocol and professional standards of care directly contributed to the deficiency cited in the report.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following physician's orders for two residents. Resident ID #60, who was admitted with diagnoses including weakness and the need for assistance with personal care, had a physician's order for bilateral waffle boots to be applied as tolerated. However, during a surveyor observation, the resident was found without the waffle boots, and staff were unable to locate them. The Treatment Administration Record indicated that the waffle boots were documented as unavailable for 18 out of 39 opportunities, and the Director of Nursing Services could not explain the discrepancy, although the boots were later found in the laundry room. For Resident ID #3, who was admitted with cerebral infarction and diabetes mellitus, there was a physician's order for Nystatin powder to be applied to a fungal rash twice daily. However, the order did not specify the affected area for treatment. Despite this, the treatment was signed off as administered in the Treatment Administration Records for May and June. During an interview, an LPN revealed that she applied the powder to the reddened areas under the resident's chest folds, which was not specified in the order. The Director of Nursing Services acknowledged that the order was incomplete and should have indicated the affected area for the treatment.
Inconsistencies in Advance Directives and EMR
Penalty
Summary
The facility failed to ensure that residents' advance directives were consistent with their electronic medical records (EMR) for several residents. For Resident ID #2, there was a discrepancy between the MOLST indicating Full Code and a physician's order indicating DNR, with the EMR banner also showing DNR. Staff were unable to confirm the resident's true code status. Resident ID #3 lacked evidence of an advance directive or code status upon readmission, despite having a previous DNR directive. Staff treated the resident as Full Code due to the absence of current documentation. For Resident ID #68, the MOLST was unsigned by the healthcare provider and indicated DNR/DNI, but the EMR only showed DNR. Similarly, Resident ID #398 had an unsigned MOLST indicating DNR and Comfort Measures Only, but the EMR showed DNR/DNI. The Director of Nursing Services acknowledged the inconsistencies and the lack of updated advance directives upon re-admission for some residents. Staff were instructed to refer to paper documents for code status, but inconsistencies between MOLST documents, orders, and EMR banners were evident.
Failure to Accommodate Resident Allergy
Penalty
Summary
The facility failed to provide food that accommodates resident allergies, specifically for a resident with a known allergy to blueberries. The resident, who was readmitted to the facility with diagnoses including dementia and anxiety, was mistakenly given a breakfast tray intended for another resident. This tray contained blueberry coffeecake, which the resident consumed. The error was identified during a surveyor observation, and staff interviews confirmed the mistake. A Certified Medication Technician acknowledged the error, and the Cook confirmed that the meal ticket listed blueberry coffeecake, which was served to the resident. The Nursing Assistant admitted to serving the incorrect tray, and the Director of Nursing Services confirmed the resident's allergy and acknowledged the mistake.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Bayberry Commons | 1.7 mi | ★★★★★ | 0 | 0 |
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| Matulaitis Rehabilitation & Skilled Care | 7.9 mi | ★★★★★ | 3 | 0 |
| Greenville Operations Ri Llc Dba Greenville Skille | 8.5 mi | ★★★★★ | 16 | 1 |
| Cedar Haven Operations Llc Dba Lake Forrest Health | 8.5 mi | ★★★★★ | 18 | 2 |
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