Overbrook Center

Inspectors wroteBased 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.

Inspectors wroteBased on record review, resident interview, review of resident rights, and staff interview, the facility failed to ensure each resident was treated with respect and dignity and was given care in an environment that promoted enhancement of quality of life. This affected one of 20 sampled residents (Resident #39). The facility census was 69. Review of the record for Resident #39 revealed an admission date of 04/24/26 and diagnoses including diabetes, bipolar disorder, anxiety disorder, hypertension, and depression. Review of an admission Minimum Data Set completed on 04/29/26 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. It stated the resident required partial/moderate assistance with showers. Interview with Resident #39 on 05/04/26 at 3:13 P.M. [...]

Inspectors wroteBased on record review and interview the facility failed to document that quarterly care conferences were conducted and who attended the meetings. This affected three Residents (#2, #8, and #53) of three sampled for care conferences. The facility census was 69. 1. Review of Resident #2's medical record revealed an admission date of 04/08/19, a re-entry date of 05/20/2025 and diagnoses including chronic obstructive pulmonary disease, diabetes, chronic kidney disease stage 4, unspecified diastolic (congestive) heart failure, hypothyroidism, anemia, bipolar disorder, paroxysmal atrial fibrillation, peripheral vascular disease, schizoaffective disorder, unspecified mood disorder, major depressive disorder, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure routine shaving, nail care, and/or showers were provided for Resident #4 and #6. This affected two residents (#4 and #6) of three residents reviewed for activities of daily living (ADL). The facility census was 69. Findings Include:1. Review of the medical record for Resident #6 revealed an initial admission date of 08/17/22 with the latest readmission of 06/18/24. Diagnoses included congestive heart failure, chronic kidney disease, diabetes mellitus, benign prostatic hyperplasia, protein calorie malnutrition, major depressive disorder, acquired absence of right foot, anemia, cirrhosis of liver, ascites, hypertension, ischemic cardiomyopathy, retention of urine, chronic obstructive pulmonary disease, dysphagia, insomnia, and atrial fibrillation. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident #55's peripheral inserted central catheter (PICC) dressing was changed as ordered. This affected one (Resident #55) of one resident reviewed for PICC dressings. The census was 69.

Inspectors wroteBased on observations, medical record review and interviews, the facility failed to ensure pressure relieving interventions were implemented as ordered. This affected one resident (#6) of three residents reviewed for pressure ulcer. The facility census was 69. Findings Include: Review of the medical record for Resident #6 revealed an initial admission date of 08/17/22 with the latest readmission of 06/18/24. Diagnoses included congestive heart failure, chronic kidney disease, diabetes mellitus, benign prostatic hyperplasia, protein calorie malnutrition, major depressive disorder, acquired absence of right foot, anemia, cirrhosis of liver, ascites, hypertension, ischemic cardiomyopathy, retention of urine, chronic obstructive pulmonary disease, dysphagia, insomnia, and atrial fibrillation. [...]

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure contracture maintenance devices were in place as physician ordered. This affected one resident (#5) of one resident reviewed for range of motion (ROM). The facility census was 69. Findings Include:Review of the medical record for Resident #5 revealed an initial admission date of 07/30/16 with the latest readmission of 01/12/26. Diagnoses included cerebrovascular accident with left sided hemiplegia, chronic respiratory failure, diabetes mellitus, bipolar disorder, anemia, benign prostatic hyperplasia, hypertension, chronic obstructive pulmonary disease, anxiety disorder, diverticulosis of intestine, insomnia, hyperlipidemia, dysphagia, mood disorder, contracture of left foot, pseudobulbar affect, major depressive disorder and contracture of left hand. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate staffing levels to meet the total care needs of residents. This affected five residents (Resident #6, #39, #43, #44 and one anonymous resident) of 69 residents residing in the facility. Findings Include:1. On 05/04/26 at 9:53 A.M., an interview with Resident #4 revealed he was upset because he did not receive his shower on Saturday 05/02/26 and he stated, I stink. The resident stated, The aide said they were too busy to do showers. On 05/07/26 at 1:04 P.M., interview with Certified Nursing Assistant (CNA) #562 revealed she did not work at the facility on 05/02/26. She revealed she worked 05/04/26 and the resident was upset he had not received his scheduled shower on 05/02/26 so she ensured he had a shower on 05/04/26. 2. On 05/06/26 at 2:35 P.M.Resident #43 asked for assistance to get out of bed. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately document resident care in the medical record. This affected two residents (Resident #4 and #55) of 20 residents reviewed for accurate medical records. The facility census was 69.

Inspectors wroteBased on observations, record review, staff interview, and policy review, the facility failed to implement infection control procedures related to maintaining enhanced barrier precautions and glove use. This affected three of 20 sampled residents (Residents #6, #39, and #55). The facility census was 69.1. Record review revealed a physician's order for Resident #39 to receive insulin (Lispro) 15 units subcutaneous. Observations on 05/04/26 at 4:00 P.M. revealed LPN #519 to administer an insulin injection to Resident #39's abdomen. LPN #519 did not wear gloves to administer the injection. Interview with LPN #519 on 05/04/26 at 4:05 P.M. revealed he was supposed to wear gloves to give an injection but did not. Interview with the Director of Nursing on 05/05/26 at 1:25 P.M. confirmed staff were to wear gloves when administering insulin. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observations, staff and representative interviews, and record reviews, the facility failed to ensure timely and adequate nail care was completed for a resident who was dependent upon staff for Activities of Daily Living (ADLs). This affected one resident (#18) out of the three residents reviewed for ADL's during the annual survey. The facility census was 61.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer was assessed weekly for signs of healing/ infection as per the plan of care. This affected one resident (#59) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure oxygen tubing was changed according to physician orders. This affected one resident (#43) reviewed for respiratory care during the annual survey. The facility census was 61.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure orders for as needed psychotropic medications included a duration of therapy and additionally failed to ensure psychotropic medications were administered for appropriate indications. This affected two residents (#18 and #25) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 61.

Inspectors wroteBased on staff interview, resident interview, medical record review, and policy review, the facility failed to ensure that all allegations of abuse/mistreatment were reported immediately to the administrator of the facility. This affected one of 69 residents (Resident #15).

Inspectors wroteBased 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. The resident refrigerator issue affected all thirteen residents (Residents #2, #5, #11, #19, #30, #32, #39, #41, #52, #60, #65, #67 and #68) who had personal refrigerators in their rooms. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure new Pre-admission Screening and Resident Review (PASARR's) were completed for residents receiving new mental illness diagnoses after their admission into the facility. This affected six (Resident #14, #23, #28, #40, #46, and #65) of six residents reviewed for PASARR's.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to maintain proper hand hygiene while providing care services to Resident #48's gastrostomy tube and during dining observation. This affected one Resident (#48) of one resident reviewed for tube feeding and 23 residents receiving meals in their room on the 200 hall (Residents #4, #6, #10, #11, #18, #12, #14, #27, #30, #33, #34, #36, #41, #43, #44, #46, #53, #56, #65, #68, #69, #123, #124). The facility census was 76.

Inspectors wroteBased on medical record review, staff interview and facility policy and procedure review, the facility failed to notify a resident's physician of a change in condition related to a significant weight gain. This affected one (Resident #23) of 24 resident records reviewed. The census was 76.

Inspectors wroteBased on medical record review, review of self-reported incident (SRI), review of the facility investigation, staff interviews and facility policy review, the facility failed to ensure one resident (#73) was free from physical and verbal abuse. This affected one of one resident reviewed for abuse. The facility census was 76. Findings Included: Review of the medical record for Resident #73 revealed an initial admission date of 02/02/22 with the admitting diagnoses including chronic obstructive pulmonary disease, cervicalgia, generalized weakness, difficulty in walking, repeated falls, reduced mobility, chronic respiratory failure, low back pain, arthritis, asthma, hypertension, fecal impaction, hypothyroidism, hyperlipidemia and personal history of COVID-19. [...]

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident (#66) was free from restraints. This affected one of one resident reviewed for restraints. The facility census was 76. Findings Include: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the areas of active diagnoses, falls, and range of motion. This affected three (Resident #40, #46, and #63) of 24 residents reviewed for assessments.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident's (#233) baseline plan of care addressed Clostridium difficile infection (c-diff) and isolation to prevent the potential spread of c-diff. This affected one of 24 sampled residents. Findings Included: Review of the medical record for Resident #233 revealed an admission date of 10/20/22 with the admitting diagnoses of acute post-hemorrhagic anemia, hemorrhage of anus and rectum, atrial fibrillation diabetes mellitus, chronic kidney disease, congestive heart failure, hyperlipidemia, gastro-esophageal reflux disease, depression, anxiety, hypothyroidism and presence of cardiac pacemaker. [...]

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure a comprehensive care plan was developed for a resident with the diagnosis of schizo-affective disorder. This affected one (Resident #46) of 24 residents reviewed for care plans.

Inspectors wroteBased on interview and record review the facility failed to ensure the care plan of Resident #14 was revised with changes in physician's orders. This affected one Resident (#14) of five residents reviewed for respiratory concerns. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview and facility policy and procedure, the facility failed to follow physician orders in regard to obtaining daily weights . This affected one (Resident #23) of 24 resident records reviewed. The census was 76.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure a resident was seen by an ophthalmologist for treatment of cataracts as referred by the optometrist. This affected one (Resident #65) of three residents reviewed for vision/ hearing.

Inspectors wroteBased on observation, medical record review, and staff interview , the facility failed to ensure interventions were in place for pressure ulcers. This affected one (Resident #29) of five residents reviewed for pressure ulcers. The census was 76.

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident's (#40) contracture prevention devices were implemented as physician ordered. This affected one of five residents reviewed for limited range of motion. Findings Included: Review of the medical record for Resident #40 revealed an initial admission date of 04/07/21 with the admitting diagnoses of dementia, reduced mobility, schizoaffective disorder, allergic rhinitis, dysphagia, personal history of COVID-19, pseudobulbar affect, hypertension, obesity, anemia, polyneuropathy, anxiety disorder, bipolar disorder, major depressive disorder and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident was dependent on two staff for activities of daily living. [...]

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure dietary intake was accurately measured and documented and failed to ensure nutritional supplements were administered as ordered . This affected two Resident (#48 and #69) of seven residents reviewed for nutrition. The facility census was 76.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident oxygen was delivered at the flow rate ordered by the physician and respiratory equipment was stored properly. This affected two Resident (#14 and #31) of five residents reviewed for respiratory concerns. The facility census was 76.

Inspectors wroteBased on record review and interview the facility failed to ensure the physician responded with a rationale for no action taken on recommendations made by the pharmacist in the Medication Regimen Review (MRR). This affected two Residents (#28 and #67) of five residents reviewed for unnecessary medications. The facility census was 76.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident receiving an antipsychotic medication was monitored for resident specific target behaviors. This affected one (Resident #46) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review, staff interview and review of facility policy and procedure, the facility failed to ensure the facility medication error rates were not 5% or greater, with 30 opportunities for error and two actual observed errors resulting in a medication administration error rate of 6.67% . This affected two (Resident #2 and Resident #36) of three residents observed for medication administration. The census was 76.

Inspectors wroteBased on medical record review and staff interview, the facility failed to obtain laboratory tests ordered by the physician. This affected two (Resident #44 and #67) of five residents reviewed for unnecessary medications.