Overlook Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Overlook Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 6, 2025

  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 . […]

• No harm, potential for more than minimal, widespreadF812May 6, 2025

  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. […]

• No harm, potential for more than minimal, patternF881May 6, 2025

  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. […]

• No harm, potential for more than minimal, patternF883May 6, 2025

  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… […]

• No harm, potential for more than minimal, patternF658Jun 14, 2024

  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. […]