Overbrook Center

In the surveyor’s words

From the most serious findings on record at Overbrook Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF609Jul 29, 2021

  Based on medical record review, facility self-reported incident (SRI) history, facility witness statements, personnel file review, facility Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy and procedure, and staff interviews, the facility failed to ensure an allegation of resident mistreatment by State tested Nursing Assistant (STNA) #1 was reported immediately, but no later than two hours after the allegation was made to a facility representative and to the State Agency (SA) as required. This resulted in likelihood of serious harm that is Immediate Jeopardy on 07/04/21 at 05:00 A.M. when STNA #106 observed STNA #1 pull her pants downs and show her genitalia to Resident #1 while using intimidating explicit language. […]

• Immediate jeopardy, widespreadF610Jul 29, 2021

  Based on medical record review, staff interviews, review of facility witness statements, review of the facility Self-Reported Incident (SRI) history, and review of the facility Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy and procedure, the facility failed to ensure allegations of resident mistreatment by State tested Nursing Assistant (STNA) #1 were immediately and thoroughly investigated. This resulted in likelihood of serious harm that is Immediate Jeopardy on 07/04/21 at 05:00 A.M. when STNA #106 observed STNA #1 pull her pants downs and show her genitalia to Resident #1 while using intimidating explicit language. The allegation was reported on 07/04/21 at 12:44 P.M. allowing STNA #1 to continue to work the rest of her shift on 07/04/21. […]

• No harm, potential for more than minimal, widespreadF727May 7, 2026

  Based on review of facility schedule, and interview the facility failed to ensure a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 69 residents residing in the facility. Findings Include:Review of the facility schedules from 04/03/26 to 04/09/26 revealed on 04/05/26 the scheduled dayshift RN had called off and was not replaced with an RN. On 05/07/26 at 2:43 P.M., an interview with Licensed Practical Nurse (LPN) #528 verified the facility had not met required eight consecutive hours of RN coverage for 04/05/26. This deficiency represents noncompliance investigated under Complaint Number 3006363.

• No harm, potential for more than minimal, widespreadF812Oct 31, 2022

  Based on observation, interview and facility policy review the facility failed to store, prepare, and serve food in a sanitary manner and resident refrigerator temps were not monitored and adjusted as needed for increased temperatures. The food storage issue had the potential to affect all 74 residents receiving food from the facility kitchen (Residents #48 and # 276 do not receive food from the kitchen). The preparing and serving of food issue had the ability to affect all ten residents (Residents #6, #20, #25, #28, #31, #32, #40, #46, #51, and #69) who received pureed corn and one Resident (#30) who received a meatloaf sandwich. […]

• No harm, potential for more than minimal, patternF582Aug 1, 2024

  Based on record review, review of Medicare (MCR) liability notice letters, and staff interview, the facility failed to ensure residents, whose skilled nursing services ended with days remaining, received at least a 48 hour notice of their skilled service ending prior to their last covered day. They also failed to ensure those residents, whose skilled service ended and remained in the facility, were provided an Advanced Beneficiary Notice (ABN) as required. This affected three residents (#1, #17, and #56) of three residents reviewed for liability notices. Findings include: 1. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with a readmitted [DATE]. […]