Cycle 1
Health 2025-05-06 · Fire 2025-05-06
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Pascoag, RI
Overlook Nursing and Rehabilitation Center
3-star overall rating with 3-star inspections with $10,358 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
14 Rock Avenue, Pascoag, RI
(401) 568-2549
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eden Healthcare
Operator or chain grouping
Approved since
1989-03-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.46 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.25 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.30 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,048
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.99
Baseline 17.35% · Performance 20.51% · Measure score 1.99 · Achievement 1.99 · Improvement 0
Healthcare-associated infections
4.54
Baseline 6.56% · Performance 6.48% · Measure score 4.54 · Achievement 4.54 · Improvement 0.02
Total nurse turnover
6.49
Baseline 51.25% · Performance 37.14% · Measure score 6.49 · Achievement 6.49 · Improvement 4.84
Adjusted total nurse staffing
0.65
Baseline 3.32 hours · Performance 3.26 hours · Measure score 0.65 · Achievement 0.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 125 · Observed rate 7.2% · Lower 95% interval 6.67% |
| Discharge to community | 54.03% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 48.15% · Lower 95% interval 44.14% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 72 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 48% |
53.69%
5.7 pts worse
|
Numerator 24 · Denominator 50 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 25 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 72 · Adjusted rate 1.35% |
| Healthcare-associated infections requiring hospitalization | 6.48% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 4.11% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 11.2% |
8.2%
3 pts better
|
Numerator 14 · Denominator 125 |
| Staff flu vaccination coverage | 47.66% |
42%
5.7 pts better
|
Numerator 61 · Denominator 128 |
| Discharge function score | 64% |
56.45%
7.5 pts better
|
Numerator 32 · Denominator 50 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 38 · Denominator 40 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 57.58% |
25.2%
32.4 pts better
|
Numerator 19 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.7
1.4 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.2%
6.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.6% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.3%
2.1 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.6% |
3.6%
4 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.1% · Q3 9.5% · Q4 7.8% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
14.6%
10.3 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 4.5% · Q4 8.5% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.3%
1.2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.8% · Q3 6.3% · Q4 3.1% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
16.4%
0.1 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 16.4% · Q3 13.6% · Q4 14.9% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.8% |
23.6%
1.2 pts worse
|
16.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 21.6% · Q3 28.6% · Q4 27.3% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.6% |
17.0%
0.4 pts better
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 24.4% · Q3 12.3% · Q4 9.5% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
18.4%
2.9 pts better
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 19.0% · Q3 16.4% · Q4 15.9% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.2%
1.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.4% |
22.3%
5.9 pts better
|
19.8%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 23.9% · Q3 8.4% · Q4 16.8% · 4Q avg 16.4% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
4.7%
3.1 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.3% · Q3 10.4% · Q4 7.5% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
77.2%
13.8 pts better
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 91.5% · Q3 91.6% · Q4 89.0% · 4Q avg 91.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
15.8%
0.8 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.9%
0.3 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.3% |
78.2%
1.9 pts worse
|
79.7%
3.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
25.1%
2 pts better
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 20.5% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-14 · Fire 2024-06-14
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
6 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-06
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-05
F · Potential for more than minimal harm
2024-06-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-14
F · Potential for more than minimal harm
2024-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-14
F · Potential for more than minimal harm
2023-05-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-24
Inspection history
Recent health citations
G · Actual harm
2025-05-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-05
E · Potential for more than minimal harm
2025-05-06
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-05
E · Potential for more than minimal harm
2025-05-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-03-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-30
E · Potential for more than minimal harm
2024-06-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-14
D · Potential for more than minimal harm
2024-06-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-14
D · Potential for more than minimal harm
2024-06-14
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-07-14
D · Potential for more than minimal harm
2023-09-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-05-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-24
Penalties and ownership
What sits behind the stars
$10,358
2025-03-31
Fine
Fine · fine $10,358
Fine
Ownership
Gellis, Louis
5% Or Greater Direct Ownership Interest · Individual
Bannon, Janet
W-2 Managing Employee · Individual
Gellis, Louis
Corporate Officer · Individual
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