Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Retirement Community during CMS and state inspections, most recent first.
A resident with a history of CVA, right-sided hemiplegia, osteoporosis, COPD, obesity, and wheelchair dependence was transported in a facility van without a seatbelt applied, despite facility policy requiring all passengers to wear seatbelts. While returning from a medical appointment, the activity staff driver braked suddenly on a highway when encountering stopped traffic near a school bus, causing the unsecured resident to slide out of the wheelchair and fall onto the van floor. The driver continued driving a short distance back to the facility with the resident on the floor. On arrival, nursing staff found the resident alert and oriented with a forehead abrasion, a bleeding skin tear on the lower leg, and significant right arm pain; EMS transported the resident to the ED, where a proximal humerus fracture, large lower-leg skin tear, and forehead contusion were documented. Surveyors cited this as a failure to prevent accidents and to follow the facility’s transportation safety policy, resulting in immediate jeopardy.
The facility failed to handle soiled linens as contaminated and did not use appropriate barriers while sorting laundry, increasing the risk of infection. Housekeeping staff only used gloves and did not wear gowns or aprons, contrary to the facility's policy requiring personal protective equipment. This oversight placed residents at risk for infectious diseases.
A resident was transferred to the hospital without being provided with the required bed hold policy notice, as confirmed by facility staff. The resident, with a history of pleural effusion, cellulitis, Alzheimer's, and hypertension, was transferred due to worsening cellulitis and pain. The facility's failure to provide the bed hold policy notice placed the resident at risk of not being able to return to the facility.
Unsecured Wheelchair Transport Leads to Resident Injury in Facility Van
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly secured with a seatbelt while being transported in the facility’s van, resulting in the resident falling from the wheelchair onto the floor of the moving vehicle. The resident had multiple significant medical conditions, including a prior cerebral infarction with right-sided flaccid hemiplegia and hemiparesis, obesity, COPD, osteoporosis, osteoarthritis of both knees, dependence on a wheelchair, and long-term anticoagulant use. The resident’s MDS showed intact cognition with a BIMS score of 15 and documented dependence or substantial/maximal assistance for most ADLs, including transfers and mobility-related tasks. The care plan identified the resident as at risk for falls due to weakness and at greater risk of injury and fractures due to osteoporosis, and documented that the wheelchair was the primary mode of transport and that the resident required extensive assistance with transfers, including use of a sit-to-stand lift for all transfers as of the most recent updates. On the day of the incident, the resident was being transported back to the facility from a physician’s appointment in a facility transport van, seated in a wheelchair on a metal floor equipped with straps for wheelchair securement. Activity staff driving the van did not apply a seatbelt to secure the resident before driving, contrary to the facility’s written policy that all elders and passengers, including the driver, will wear a seatbelt at all times when the vehicle is in motion, without exception. As the van traveled on a highway and crested a hill, the driver encountered a stopped school bus in the opposite lane and multiple stopped cars in the same lane ahead, requiring the driver to apply the brakes quickly. Because the resident was not secured with a seatbelt, the sudden braking caused the resident to slide forward out of the wheelchair and fall onto the floor of the van behind the front seats. Following the fall, the resident remained on the floor of the van while the driver continued driving approximately a mile and a half back to the facility, stating there was no shoulder to pull over and that the resident could not be returned to the wheelchair. The resident later reported that she had not been wearing a seatbelt, that both she and the driver had forgotten to apply it, and that this had never happened before. Upon arrival at the facility, nursing staff found the resident lying on her back in the van, alert and oriented, with a small abrasion on the forehead, a bleeding skin tear on the left lower leg, and significant pain in the right upper extremity with movement. EMS was called, and the resident was transported to the hospital, where ED documentation confirmed a proximal right humerus fracture, a large skin tear of the lower leg, and a forehead contusion. The surveyors determined that the failure to secure the resident with a seatbelt in the transport van, in violation of facility policy and despite the resident’s known fall and fracture risk, resulted in injuries and constituted immediate jeopardy.
Removal Plan
- Suspended Activity Staff Z pending investigation
- Provided education regarding transportation safety to the facility’s only other driver
- Placed signs in the transport vehicles as visual reminders for residents and drivers to use seat belts
- Removed Activity Staff Z from driving duties
Inadequate Use of Barriers in Laundry Handling
Penalty
Summary
The facility failed to handle all soiled linens as contaminated and did not use appropriate barriers while sorting soiled laundry, which placed residents at increased risk for infectious diseases. During an observation of the laundry area, it was noted that the facility had a designated soiled and clean area, with washing machines on the soiled side and dryers and folding areas on the clean side. Housekeeping staff reported that they only used gloves when sorting soiled laundry and did not wear a gown or apron, acknowledging the potential for transferring soiled or infectious materials from their clothing to clean laundry. The facility's undated Laundry Protocols policy stated that staff should prevent the spread of infection by appropriately handling, storing, processing, and transporting linens. The policy also required the laundry room to be equipped with a handwashing sink, alcohol gel dispensers, and personal protective equipment, including impervious gowns and gloves. However, the facility did not adhere to these protocols, as evidenced by the lack of appropriate barriers used by housekeeping staff while sorting soiled laundry, thereby increasing the risk of infection spread among residents.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide Resident 25 with written information regarding the bed hold policy when they were transferred to the hospital. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 25, who had a history of pleural effusion, cellulitis, Alzheimer's disease, and hypertension, was transferred to the hospital after a nurse observed significant symptoms of cellulitis and pain. Despite the transfer, the facility did not provide the resident or their representative with a copy of the bed hold policy, which is required to inform them of the duration and conditions under which the resident could return to the facility. The facility's bed hold policy mandates that residents and their representatives receive both verbal and written copies of the policy at the time of admission and upon transfer to a hospital or therapeutic leave. However, the facility was unable to provide evidence that this policy was followed for Resident 25. Social Service X confirmed that the bed hold notice was not provided when the resident was transferred to the hospital. This oversight placed the resident at risk of not being permitted to return and resume residence in the nursing facility.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Overbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Grove Estates | 16.8 mi | ★★★★★ | 0 | 0 |
| Osage Nursing & Rehabilitation Center | 17.2 mi | ★★★★★ | 0 | 0 |
| Brewster Health Center | 17.6 mi | ★★★★★ | 0 | 0 |
| Providence Living Center | 18.4 mi | ★★★★★ | 52 | 1 |
| Legacy On 10th Avenue | 18.8 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.