Overlook Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to review and revise the resident's care plan relative to 1 of 3 residents reviewed for falls, Resident ID #3.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.