Inspection Report
Re-Inspection
Deficiencies: 0
Jun 30, 2025
Visit Reason
A revisit survey was conducted on June 30, 2025, to verify correction of all previous deficiencies cited on May 1, 2025, during the Life Safety Code survey.
Findings
All deficiencies from the prior Life Safety Code survey have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 16, 2025
Visit Reason
A follow-up to a previous Recertification survey was conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Annual Inspection
Census: 89
Capacity: 100
Deficiencies: 12
May 6, 2025
Visit Reason
A recertification survey was conducted at Overlook Nursing Home from 4/30/2025 through 5/6/2025 to determine compliance with 42 C.F.R. Part 483 for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified in multiple areas including resident rights, abuse investigation, comprehensive care plans, quality of care, skin integrity, accident hazards, infection control, medication management, food safety, medical records, and immunizations. The facility failed to meet professional standards in these areas as evidenced by record reviews, staff interviews, and resident observations.
Severity Breakdown
SS=D: 9
SS=G: 1
SS=F: 1
SS=E: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to inform resident and/or representative in advance about addition of amlodipine medication and its risks and benefits. | SS=D |
| Facility failed to ensure thorough investigation of injuries of unknown origin for 2 residents. | SS=D |
| Facility failed to ensure services met professional standards for 2 residents including incomplete AIMS assessments and insulin monitoring. | SS=D |
| Facility failed to ensure quality of care related to orthostatic blood pressure monitoring and physician referrals for 2 residents. | SS=D |
| Facility failed to ensure prevention and treatment of pressure ulcers for 1 resident with stage 4 pressure ulcers. | SS=D |
| Facility failed to ensure free of accident hazards for 1 resident who sustained a burn from hot beverage. | SS=G |
| Facility failed to ensure proper bowel/bladder incontinence care and catheter management for multiple residents. | SS=D |
| Facility failed to ensure drug regimen free from unnecessary drugs for 2 residents. | SS=D |
| Facility failed to ensure food safety requirements related to storage, labeling, and preparation in kitchen and kitchenettes. | SS=F |
| Facility failed to maintain accurate, complete, and confidential medical records for residents including oxygen use and assessments. | SS=D |
| Facility failed to establish and maintain an antibiotic stewardship program. | SS=E |
| Facility failed to ensure influenza and pneumococcal immunizations were offered and documented for residents. | SS=E |
Report Facts
Census: 89
Total Capacity: 100
Deficiencies cited: 13
Dates of oxygen use observation: 3.5
Stage 4 pressure ulcer size: 3.5
Stage 4 pressure ulcer size: 3.3
Medication doses: 14
Medication doses: 17
Medication doses: 3
Medication doses: 14
Temperature of hot water: 180.3
Medication dosage: 5
Medication dosage: 25
Medication dosage: 12.5
Medication dosage: 500
Medication dosage: 800
Medication dosage: 160
Medication dosage: 875
Medication dosage: 125
Medication dosage: 1
Medication dosage: 2
Medication dosage: 3.5
Medication dosage: 10
Medication dosage: 7
Medication dosage: 12
Medication dosage: 0.1
Medication dosage: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in medication addition notification deficiency and medication administration observation |
| Director of Nursing Services | Interviewed regarding medication addition, abuse investigation, and antibiotic stewardship findings | |
| Staff E | Registered Nurse | Observed wound care and acknowledged improper wound packing technique |
| Staff F | Nursing Assistant | Observed warming and serving hot beverages without proper temperature education |
| Staff G | Nurse | Acknowledged resident not receiving ordered oxygen |
| Staff D | Licensed Practical Nurse | Interviewed about Foley catheter orders and medication administration |
| Administrator | Interviewed regarding food safety labeling and cleaning schedule | |
| Food Service Director | FSD | Interviewed and observed regarding food safety and labeling deficiencies |
Inspection Report
Renewal
Census: 89
Capacity: 100
Deficiencies: 12
May 6, 2025
Visit Reason
A recertification survey was conducted from 4/30/2025 through 5/6/2025 to determine compliance with 42 C.F.R. Part 483, Long Term Care Facilities, State licensure, and emergency preparedness surveys at Overlook Nursing and Rehabilitation Center.
Findings
Deficiencies were identified related to residents' rights, investigation of abuse allegations, professional standards of care, quality of care, skin integrity, accident hazards, respiratory care, food safety, medication administration, antibiotic stewardship, and immunizations. The facility submitted plans of correction for each deficiency with specific corrective actions and responsible parties.
Severity Breakdown
Level D: 10
Level E: 2
Level G: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to inform resident and/or representative in advance about medication risks and benefits related to amlodipine. | Level D |
| Failure to thoroughly investigate injuries of unknown origin for 2 residents. | Level D |
| Failure to meet professional standards for Abnormal Involuntary Movement Scale (AIMS) assessments and insulin blood sugar monitoring. | Level D |
| Failure to ensure quality care related to orthostatic vital signs, physician referrals, and fall risk assessments. | Level D |
| Failure to prevent pressure ulcers and provide appropriate wound care for a resident with stage 4 pressure ulcers. | Level D |
| Failure to maintain a safe environment free of accident hazards related to hot beverage temperatures causing a burn. | Level G |
| Failure to provide proper care and documentation for residents with foley catheters and urinary incontinence. | Level D |
| Failure to provide respiratory care consistent with professional standards for a resident requiring oxygen and tracheostomy care. | Level D |
| Failure to ensure food safety including proper labeling and storage of food items in kitchen and kitchenettes. | Level D |
| Failure to maintain accurate and confidential medical records for residents. | Level D |
| Failure to provide appropriate antibiotic stewardship including documentation and monitoring of antibiotic use. | Level E |
| Failure to provide and document influenza and pneumococcal immunizations or refusals for residents. | Level E |
Report Facts
Census: 89
Total Capacity: 100
Dates of Survey: May 6, 2025
Number of Deficiencies: 13
Temperature Range: 130-160
Pressure Ulcer Size: 3.5 x 2.5 x 1 cm
Oxygen Flow Rate: 2
Medication Dosage: 5
Antibiotic Dosage: 800
Medication Administration Count: 17
Fall Assessment Score: 15
Burn Size: 7 x 12 x 0.1 cm
Temperature of Hot Chocolate: 180.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dion A Pendleton | Administrator | Signed Plan of Correction on 05/28/2025 |
| Staff A | Licensed Practical Nurse | Authored physician order notes and interviewed during survey |
| Staff E | Registered Nurse | Observed wound care and interviewed during survey |
| Staff F | Nursing Assistant | Observed warming breakfast meal and interviewed during survey |
| Staff G | Registered Nurse | Documented oxygen administration during survey |
| Staff D | Licensed Practical Nurse | Interviewed regarding foley catheter care and oxygen therapy |
| Director of Nursing Services | Director of Nursing (DNS) | Interviewed and responsible for executing plans of correction |
| Administrator | Interviewed regarding hot beverage burn incident |
Inspection Report
Annual Inspection
Census: 89
Capacity: 100
Deficiencies: 13
May 1, 2025
Visit Reason
A recertification survey was conducted at Overlook Nursing and Rehabilitation Center from 4/30/2025 through 5/6/2025 to determine compliance with 42 C.F.R. Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified in multiple areas including residents' rights to be informed about treatment decisions, injury investigations, discharge processes, professional standards of care, quality of care, food safety, life safety code compliance, and infection prevention. The facility submitted plans of correction for all cited deficiencies.
Deficiencies (13)
| Description |
|---|
| Facility failed to inform resident and representative in advance about medication risks and treatment alternatives related to amlodipine. |
| Facility failed to thoroughly investigate injuries of unknown origin for residents with skin tears. |
| Facility failed to ensure proper documentation and notification for resident transfers and discharges. |
| Facility failed to meet professional standards of care for residents requiring Abnormal Involuntary Movement Scale (AIMS) assessments and insulin monitoring. |
| Facility failed to ensure proper care and documentation for residents with pressure ulcers, including a stage 4 pressure ulcer. |
| Facility failed to ensure resident environment was free of accident hazards, resulting in a resident burn injury. |
| Facility failed to provide proper supervision and assistance devices to prevent accidents. |
| Facility failed to ensure residents received timely and appropriate antibiotic therapy and maintain an antibiotic stewardship program. |
| Facility failed to ensure residents received pneumococcal and influenza immunizations or proper education regarding immunizations. |
| Facility failed to maintain accurate and complete medical records, including oxygen therapy documentation. |
| Facility failed to ensure food safety requirements were met, including proper labeling and storage of food items. |
| Facility failed to maintain fire safety code compliance related to self-closing doors, exit signage, fire alarm testing, sprinkler system maintenance, and fire drills. |
| Facility failed to maintain electrical safety related to power cords and extension cords in patient care areas. |
Report Facts
Census: 89
Total Capacity: 100
Deficiencies cited: 13
Dates of survey: Survey conducted from 2025-04-30 to 2025-05-06
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dani Pendleton | Administrator | Signed plan of correction and administrative role in the facility |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 1, 2024
Visit Reason
An off-site desk audit was conducted on August 1, 2024, to review all previous deficiencies cited on June 13 and June 14, 2024, based on an acceptable plan of correction and supporting documentation.
Findings
All deficiencies from the previous inspections have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 86
Capacity: 100
Deficiencies: 8
Jun 12, 2024
Visit Reason
A Recertification Survey and Emergency Preparedness Survey were conducted at Overlook Nursing and Rehabilitation Center to determine compliance with federal regulations and state licensure requirements. Additionally, a Federal Life Safety Code survey was conducted.
Findings
Deficiencies were cited related to advance directives, comprehensive care plans, treatment orders, food allergies, life safety code violations including means of egress, portable fire extinguishers, fire drills, and emergency power system maintenance. The facility was found not in compliance with all regulations surveyed.
Deficiencies (8)
| Description |
|---|
| Failure to ensure residents' advance directives were consistent with electronic medical records and properly documented. |
| Failure to meet professional standards in comprehensive care plans for residents. |
| Failure to ensure treatment orders for devices such as waffle boots were properly followed and documented. |
| Failure to provide food that accommodates resident allergies, intolerances, and preferences. |
| Life Safety Code deficiencies related to means of egress including obstructed stairwells and exit doors. |
| Failure to maintain portable fire extinguishers in accordance with NFPA 10 standards. |
| Failure to provide evidence that fire drills were conducted quarterly on all shifts. |
| Failure to ensure emergency power supply system (EPSS) generator load tests were conducted monthly as required. |
Report Facts
Resident reviewed: 19
Opportunities: 39
Residents impacted: 86
Residents impacted: 86
Residents impacted: 86
Load tests reviewed: 12
Load tests failed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dori A. Pendleton | Administrator | Signed the Plan of Correction and report |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 6, 2023
Visit Reason
An off-site desk audit was conducted on July 6, 2023, to verify correction of all previous deficiencies cited on May 25, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 81
Capacity: 100
Deficiencies: 8
May 25, 2023
Visit Reason
A Recertification Survey was conducted at the facility from 05/23/2023 through 05/25/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys as well as a Compliance Vaccination Survey.
Findings
Deficiencies were cited as a result of the survey, including failures in developing and implementing comprehensive care plans, meeting professional standards for services provided, ensuring resident safety regarding potentially harmful items, proper medication administration, maintaining resident records, infection prevention and control, and life safety code compliance.
Deficiencies (8)
| Description |
|---|
| Failure to develop and implement a comprehensive person-centered care plan for Resident ID #55, including measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs. |
| Failure to ensure services provided meet professional standards of quality for residents ID #41, 60, and 282. |
| Failure to ensure Resident ID #55's safety by allowing access to potentially harmful items such as knives despite care plan restrictions. |
| Failure to ensure gradual dose reductions and proper administration of psychotropic drugs for Resident ID #45. |
| Failure to maintain complete and accurate resident records for Resident ID #132 receiving oxygen therapy. |
| Failure to ensure infection prevention and control program prevents transmission of infections, specifically during insulin pen injection for Resident ID #35. |
| Failure to maintain emergency lighting systems and electrical wiring in accordance with National Fire Protection Association codes, affecting residents and staff. |
| Failure to ensure nursing assistants employed at the facility have active licenses as required by state regulations. |
Report Facts
Census: 81
Total Capacity: 100
Deficiencies cited: 8
Number of nursing assistants without active licenses: 3
Number of residents reviewed for physician orders: 18
Number of residents receiving oxygen therapy: 2
Number of residents affected by electrical deficiencies: 5
Number of staff and visitors affected by electrical deficiencies: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rona A. Pendleton | Administrator | Signed Plan of Correction documents and identified as Administrator |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 8, 2022
Visit Reason
An off-site desk audit was conducted on June 8, 2022, to review all previous deficiencies cited on May 4 and May 5, 2022, including life safety code deficiencies, to verify correction.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Census: 74
Capacity: 100
Deficiencies: 8
May 4, 2022
Visit Reason
A Recertification and Complaints Investigation Survey was conducted from 05/02/2022 through 05/04/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness survey and a Compliance Vaccination Survey.
Findings
Deficiencies were found related to employee immunization and screening, quality of care including wound care, range of motion and mobility, physician supervision, and life safety code compliance regarding smoke and fire door maintenance and testing.
Severity Breakdown
M 215: 1
F 684: 2
F 688: 2
F 710: 2
K 761: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to obtain evidence of immunity for health care workers for tuberculosis and hepatitis B vaccination/testing for 4 out of 8 staff reviewed. | M 215 |
| Facility failed to ensure residents received treatment and care in accordance with professional standards for non-pressure related wound care for 1 of 2 residents reviewed (Resident ID #178). | F 684 |
| Facility failed to ensure a treatment order was initiated timely for a surgical wound identified on 4/15/2022 (Resident ID #178). | F 684 |
| Facility failed to ensure residents with limited range of motion received appropriate treatment to prevent further decline for 1 of 4 residents reviewed (Resident ID #49). | F 688 |
| Facility failed to ensure proper positioning and support for residents with limited mobility to prevent contractures and discomfort (Resident ID #49). | F 688 |
| Facility failed to ensure medical care was supervised by a physician for 1 of 2 residents reviewed relative to nutritional recommendations (Resident ID #44). | F 710 |
| Facility failed to ensure physician orders were implemented and communicated effectively to nursing and dietary staff. | F 710 |
| Facility failed to maintain smoke and fire doors in accordance with NFPA 101 Life Safety Code 2012 Edition; testing and maintenance documentation was not provided. | K 761 |
Report Facts
Census: 74
Capacity: 100
Staff reviewed for immunization: 8
Residents reviewed for wound care: 2
Residents reviewed for range of motion: 4
Residents reviewed for physician supervision: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Roni A. Pendleton | Administrator | Named in relation to Plan of Correction signature and interview regarding immunization documentation |
| Staff A | Interviewed regarding resident care and positioning for range of motion deficiency | |
| Staff B | Staff Nurse | Interviewed regarding physician notification of blood work recommendation |
| Staff C | Physician's Assistant | Interviewed regarding awareness of physician recommendations |
| Director of Nursing Services (DNS) | Director of Nursing | Responsible for implementing Plan of Correction and conducting audits |
| Maintenance Director | Interviewed regarding smoke and fire door maintenance and testing | |
| Dietitian | Interviewed regarding communication of recommendations to physician |
Inspection Report
Annual Inspection
Census: 70
Capacity: 100
Deficiencies: 4
Jan 27, 2021
Visit Reason
The annual Federal Life Safety Code survey and a Recertification Survey were conducted at Overlook Nursing and Rehabilitation Center to determine compliance with federal and state regulations, including fire safety, long term care requirements, emergency preparedness, and COVID-19 infection control.
Findings
Deficiencies were identified related to life safety code compliance involving generator maintenance and testing, personal funds management including failure to obtain written authorization for residents' funds, and improper storage and labeling of drugs and biologicals including expired medications. Plans of correction were submitted addressing these issues.
Severity Breakdown
SS=C: 1
SS=B: 1
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Electrical Systems - Essential Electric System Maintenance and Testing: Generator monthly test did not meet the 10-second criterion and lacked proper documentation of battery tests and electrolyte levels. | SS=C |
| Protection/Management of Personal Funds: Facility failed to obtain written authorization for residents whose personal funds were held, affecting 8 of 9 residents reviewed. | SS=B |
| Labeling of Drugs and Biologicals: Facility failed to store medications according to manufacturer instructions, including expired medications and improper disposal. | SS=E |
| Notice and Conveyance of Personal Funds: Facility failed to transmit a notarized statement upon the death of a Medicaid resident as required by state law. | — |
Report Facts
Census: 70
Total Capacity: 100
Residents with personal funds authorization issues: 8
Residents reviewed for personal funds: 9
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