Overlook Green.

“Direct care staff person A did not receive orientation on fire safety and emergency preparedness topics during their first work day, including the designated meeting place in case of fire, smoking safety procedures, location and use of fire extinguishers, and smoke detectors and fire alarms.”

“Direct care staff person A did not receive required orientation within 40 scheduled working hours on emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions.”

“Direct care staff persons B and C did not receive required annual training during the 2024 training year in fire safety completed by a fire safety expert and emergency preparedness procedures and recognition and response to crises and emergency situations. This is a repeat violation.”

“Training records for direct care staff persons B and C's 2024 annual trainings do not include the length of each course for infection control, Alzheimer's, incident reporting, and abuse reporting trainings.”

“Poisonous materials containing manufacturers' labels indicating to call a poison control center or doctor were not kept locked and inaccessible to residents.”

“An allegation of neglect was reported to staff on the morning of the inspection date but was not reported to the Department until after the 24-hour reporting requirement had passed. The incident involved direct care staff person A and a resident.”

“A resident who requires total physical assistance with toileting and bladder/bowel management rang the call bell numerous times requesting assistance with changing their brief, but the assigned direct care staff person A did not respond. The resident was left sitting in a soiled brief for several hours until another staff member provided care.”

“A resident requiring Hoyer lift transfers was transported through common areas of the facility while undressed and covered only with a sheet to access the shower room, failing to treat the resident with dignity and respect.”

“Resident's blood glucose readings ordered four times daily with sliding scale were not entered on the medication administration record (MAR), though the information was contained in the resident's Diabetic Log. Resident did not suffer ill effects.”

“Multiple residents' January 2024 medication administration records (MARs) were not initialed by staff for numerous medications on multiple dates and times, indicating medication administration documentation was not recorded at the time of administration.”

“On 11/24/23, with 52 residents, only one CPR/first aid certified staff was present 7:00 a.m.–11:00 p.m., and none from 11:00 p.m.–7:00 a.m. On 11/25/23, no certified staff from 3:00 p.m.–11:00 p.m., and only one from 11:00 p.m.–7:00 a.m. On 11/26/23, no certified staff from 3:00 p.m.–11:00 p.m. Facility failed to maintain at least one CPR/first aid certified staff per 50 residents at all times.”

“Direct care staff person A, hired after April 24, 2006, was providing unsupervised ADL services without successfully completing the Department-approved direct care training course or passing the competency test.”

“Direct care staff person B did not receive required 2022 annual training in care for residents with dementia and cognitive impairments, infection control and hygiene areas, and safe management techniques. Staff person C did not receive training in care for residents with dementia and cognitive impairments, and safe management techniques.”

“Direct care staff persons B, C, and D did not receive required 2022 annual training in emergency preparedness procedures and recognition/response to crises and emergency situations, and resident rights. Staff person D also did not receive falls and accident prevention training.”

“On 11/30/23, the enabler bar on resident #1's bed was not well-secured and could be lifted approximately 6 inches from the bed frame, creating entrapment and fall hazards.”