Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Overbrook Center during CMS and state inspections, most recent first.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day when the scheduled day-shift RN called off and was not replaced. An LPN later verified that the required RN coverage was not met, affecting all 69 residents.
Resident treated rudely and without dignity: A cognitively intact resident with DM, bipolar disorder, anxiety, HTN, and depression reported that an NA on evening/night shift was loud and rude when she asked for pain medication and a shower. The resident said the NA told her she was not getting a shower because it was not her shower day and told her to wait for the nurse for pain medication, leaving her feeling downgraded; staff interviews and the concern form reflected the same complaints.
Failure to Document Quarterly Care Conferences and Attendance: The facility did not document quarterly care conferences or who attended them for multiple residents. Records showed that some residents were invited to care conferences or had limited meetings with SS, but the chart lacked evidence of quarterly interdisciplinary conferences, and the DON and SSD confirmed the documentation was incomplete. Residents with complex medical and psychiatric conditions, including COPD, CKD, CHF, bipolar disorder, schizoaffective disorder, and stroke history, were affected.
Failure to provide personal hygiene care affected two residents. One resident with multiple chronic conditions and an ADL deficit had several days of facial hair growth and long, dirty, jagged fingernails with debris under the nails despite needing max assist with hygiene and scheduled hair and nail care. Another resident with Parkinson's disease, dementia, and other diagnoses missed a scheduled shower; the shower was incorrectly charted as refused, but the resident said he did not get the shower and a CNA later admitted the refusal was marked in error.
An LPN signed off a PICC dressing change as completed even though it was not done as ordered. A resident with a PICC line was observed with an outdated dressing on the right arm, and the LPN later stated she forgot to complete the dressing after the resident asked her to wait until morning.
Pressure relief interventions were not implemented as ordered for a resident with multiple chronic conditions, including DM, CKD, CHF, malnutrition, anemia, COPD, and impaired mobility. The care plan and physician orders included heel elevation and soft boots while in bed, with checks each shift, but observations found the resident in bed without the soft boots in place, and the DON verified the boots were not being used as ordered.
Failure to Apply Ordered Contracture Maintenance Devices: A resident with CVA, left-sided hemiplegia, and contractures of the left hand and foot was ordered to wear a resting hand splint and AFO with specified ROM and skin care interventions. Observations showed the splint was not in place, the brace was left in a bucket on the nightstand, and a CNA confirmed the splint had not been applied for the ordered time, saying she thought night shift had done it.
Insufficient staffing led to delayed resident care, including missed or postponed showers, delayed transfers, and long waits for call light response. A resident missed a shower because staff were too busy, another resident who needed shower assistance was told there were too many other showers to complete, and staff said there were not enough aides on the unit to meet needs. Observations also showed residents waiting over an hour for help getting out of bed or into bed, while another resident reported waiting hours for incontinence care and call lights to be answered.
A facility failed to accurately document resident care for two residents. One resident with a PICC line had a dressing observed unchanged even though an LPN had signed off the MAR as if the dressing change was completed; the LPN later admitted the treatment was not done before signing. Another resident with multiple chronic conditions reported missing a shower, yet the shower record falsely showed a refusal, with no supporting progress note and an altered shower sheet; the CNA said the refusal was marked by accident and the DON verified the sheet had been changed.
An LPN administered insulin to a resident without wearing gloves, and another LPN sanitized gloved hands before connecting IV tubing for a resident receiving meropenem. The facility also failed to follow EBP for a resident with ESBL history and a moderate cognitive deficit, as CNAs provided care without gowns despite a posted EBP sign and orders for enhanced precautions.
The facility failed to provide the required 48-hour notice to residents before the end of their Medicare Part A skilled nursing services, affecting three residents. Additionally, the facility did not issue Advanced Beneficiary Notices (ABN) to residents who remained in the facility after their skilled services ended, assuming all charges would be covered by Medicare. The Business Office Manager confirmed the oversight, and the facility lacked a policy to guide staff on completing liability notices.
A resident with dementia and dependent on staff for ADLs did not receive timely nail care, as observed during a survey. The resident's care plan required regular nail maintenance to prevent skin injury, but observations showed long, jagged nails with debris and dried blood at the mouth, likely from scratching. An LPN confirmed the need for nail trimming and cleaning.
A resident with a history of stroke and other health issues developed a pressure ulcer on the left heel, which was not assessed weekly as required by the care plan. The facility's wound nurse confirmed a 15-day gap between assessments, and the DON acknowledged the lack of a policy for ongoing monitoring of pressure ulcers.
A facility failed to change a resident's oxygen tubing weekly as ordered by the physician. The resident, with respiratory conditions, had tubing dated two months prior, contrary to the care plan. The resident could not recall the last change, and the Unit Manager confirmed the oversight.
The facility failed to manage psychotropic medications properly for two residents. One resident received Ativan without a stop date, and another was prescribed Risperidone without an appropriate diagnosis. These deficiencies were confirmed by staff interviews.
RN Coverage Not Maintained for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week. Review of the facility schedule from 04/03/26 to 04/09/26 showed that on 04/05/26 the scheduled day shift RN called off and was not replaced with another RN. During an interview on 05/07/26 at 2:43 P.M., an LPN verified that the facility did not meet the required eight consecutive hours of RN coverage on 04/05/26. This deficiency was identified under Complaint Number 3006363 and had the potential to affect all 69 residents in the facility.
Resident Treated Rudely and Without Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity and was cared for in an environment that promoted quality of life. Resident #39 was admitted with diagnoses including diabetes, bipolar disorder, anxiety disorder, hypertension, and depression, and had a BIMS score of 15 indicating intact cognition. The resident required partial/moderate assistance with showers and reported that a nursing assistant on evening/night shift was loud and rude to her. Resident #39 stated that when she used her call light for pain medication, the nursing assistant responded that the nurse was on another hall and she would get it when she got it. The resident said an LPN later brought the pain pill and apologized for the nursing assistant’s behavior, stating she had heard the nursing assistant talked to other residents that way. The resident also reported that when she asked the same nursing assistant for a shower because she was going out to a church function and wanted her hair to look nice, the nursing assistant told her she was not on the shower list, had eight other showers to do, and could not do it. The resident stated she washed her own hair in the sink and felt bad and downgraded by the nursing assistant’s manner of speaking. She also reported a history of PTSD related to prior abuse and said loud noises and rude people were triggers for her. Staff interviews confirmed the resident reported the nursing assistant was rude, that the resident had asked for a shower on evening shift, and that the shower was documented as refused on dayshift. The facility’s concern form documented the resident’s report that the nursing assistant was rude when responding to her request for a shower and pain medication.
Failure to Document Quarterly Care Conferences and Attendance
Penalty
Summary
The facility failed to document that quarterly care conferences were conducted and failed to document who attended the meetings for three residents. The deficiency was identified during record review and interviews, and it involved Residents #2, #8, and #53. The facility census was 69.1. Resident #2 was admitted on 04/08/19 and re-entered on 05/20/2025 with diagnoses including COPD, diabetes, CKD stage 4, CHF, hypothyroidism, anemia, bipolar disorder, paroxysmal atrial fibrillation, PVD, schizoaffective disorder, mood disorder, major depressive disorder, and anxiety disorder. The annual MDS showed a BIMS score of 15, indicating intact cognition, and the resident required extensive assistance with toileting hygiene and bed mobility and was always incontinent of bowel and bladder. The social services quarterly/annual/significant change assessment noted that the resident and POA were invited to a care conference and declined, but the record contained no further documentation of a care conference or who attended. The resident did not recall a recent care conference, and the DON stated the care conference is documented in the assessments by discipline, but there was no information about the care conference or attendees. Resident #53 was admitted on 10/24/25 with diagnoses including cerebral infarction, diabetes, COPD, seizures, and migraines, and the MDS dated 03/27/26 showed intact cognition. A care conference summary dated 10/30/25 documented that social services met with the resident and sister, but it did not identify what staff were present. A later social services quarterly/annual/significant change assessment stated the resident and POA were invited and declined, but did not show that a care conference was still held or who attended. Resident #53 and her sister stated there had been only one care conference since admission and none since, and the DON confirmed there was no evidence that quarterly care conferences were held or documented, even if the resident or family declined to attend. Resident #8 was admitted on 05/17/25 with multiple diagnoses including COPD, cirrhosis of the liver, bipolar disorder with psychotic features, schizoaffective disorder, PTSD, pain, Raynaud's syndrome, HTN, HLD, disc degeneration, hepatitis C, anxiety disorder, osteoarthritis, GERD, obesity, tricuspid valve insufficiency, mood disorder, CHF, cervical disc degeneration, chronic gastric ulcer, PVD, anemia, and CKD. The record showed one care conference held with social services, the resident, and her son by phone, with only social services documented as attending, and a later care conference letter was sent to the guardian. The record contained no documented evidence that quarterly care conferences were held after the initial meeting, and the SSD confirmed she does not document quarterly care conferences in the medical record and not all disciplines attend all care conferences.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to ensure routine shaving and nail care were provided for Resident #6, who was admitted with multiple chronic conditions including CHF, CKD, diabetes, BPH, protein calorie malnutrition, major depressive disorder, anemia, cirrhosis, COPD, dysphagia, and atrial fibrillation. The care plan identified an ADL self-care deficit and stated the resident required maximum assistance with personal hygiene and showering twice weekly with hair and nail care per preference. Observations over several days showed the resident had several days of facial hair growth and fingernails that were long, jagged, dirty, and had a brown substance under the nails. The resident stated the nails needed to be cut, and an LPN later verified the facial hair growth and the condition of the fingernails. The facility also failed to provide a scheduled shower for Resident #4, who had diagnoses including Parkinson's disease, dementia, atrial fibrillation, anemia, chronic pulmonary embolism, hypertension, dysphagia, CKD, gout, osteoarthritis, fatty liver, chronic pain, insomnia, prostate cancer, cerebral aneurysm, depression, and diabetes mellitus. The care plan noted ADL deficits and that the resident required partial assistance with bathing, with a history of refusing showers at times. The resident told surveyors he did not receive his shower and stated, "I stink," and said the aide told him they were too busy to do showers. The shower record incorrectly documented the shower as refused, but there was no progress note showing refusal. The CNA later stated the resident had not refused the shower and that she had marked refusal by accident because she was in a hurry; another CNA stated she was not working on the date listed on the shower sheet and later ensured the resident received a shower after learning he had missed the scheduled one.
PICC Dressing Change Not Completed as Ordered
Penalty
Summary
The facility failed to ensure Resident #55’s PICC dressing was changed as ordered. Resident #55 was admitted with diagnoses including localization-related idiopathic epilepsy and epileptic syndromes with seizures of localized onset, paroxysmal fibrillation, and atherosclerosis atrial fibrillation. A physician order dated 04/25/2026 directed the dressing to the midline be changed weekly and as needed every night shift every Thursday until 05/05/2026 at 11:59 P.M. The MAR showed the dressing change was signed off as completed by the LPN on 04/30/2026, but during observation on 05/05/2026 the resident was seen with a PICC line dressing dated 04/24/2026 on the right arm. The LPN later stated the dressing change had been signed off but was not completed as ordered, explaining that she planned to do it in the evening, the resident asked her to wait until morning, and she forgot to complete it before signing off.
Pressure Relief Interventions Not Implemented as Ordered
Penalty
Summary
Failure to provide pressure ulcer care and prevent new ulcers from developing occurred when the facility did not ensure pressure relieving interventions were implemented as ordered for one resident. The resident had been admitted on 08/17/22 and readmitted on 06/18/24 with diagnoses including congestive heart failure, chronic kidney disease, diabetes mellitus, protein calorie malnutrition, anemia, cirrhosis of the liver, hypertension, ischemic cardiomyopathy, COPD, dysphagia, atrial fibrillation, and an acquired absence of the right foot. The care plan identified risk for pressure ulcer development related to decreased mobility and incontinence and included an air mattress, heel elevation, heel protector boots, and preventative treatments. The resident’s MDS showed a moderate cognitive deficit, substantial/maximal assistance needed for personal hygiene and bed mobility, and risk for skin breakdown with no current skin issues. Physician orders included skin prep to the right heel for skin breakdown prevention, heel elevation while in bed, and soft boots while in bed with placement checks every shift and documentation of any noncompliance. Review of progress notes from 05/04/26 to 05/05/26 showed no documented refusal of the soft boots. However, during observations on 05/04/26 and 05/05/26, the resident was in bed and the soft boots were not in place as ordered. The DON later verified that the soft boots while in bed were not in place as physician ordered.
Failure to Apply Ordered Contracture Maintenance Devices
Penalty
Summary
The facility failed to ensure contracture maintenance devices were in place as physician ordered for Resident #5, who had a history of cerebrovascular accident with left-sided hemiplegia, contracture of the left foot, and contracture of the left hand. The resident’s care plan directed staff to apply an ankle foot orthosis to the left lower extremity every morning for transfers and remove it every night, as well as to apply a hand roll and a resting hand splint to the left upper extremity with specified ROM and skin care interventions. The resident’s MDS indicated no cognitive deficit and impaired ROM on one side to both upper and lower extremities. The monthly physician orders included an order to encourage use of the resting hand splint with morning care, remove it after four hours, perform gentle passive ROM before application, and check skin after removal every shift. During observation and interview, the resident stated he was supposed to wear a hand brace and leg brace, but the aides never put it on, and the blue brace was seen in a bucket on the nightstand. Subsequent observations showed the resting hand splint was not in place, and a CNA later confirmed the splint had not been in place for the ordered four hours, stating she thought night shift had applied it.
Insufficient Staffing to Meet Resident Care Needs
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet residents’ total care needs and to have enough nursing staff available on each shift. Survey observations, interviews, and record review showed that residents who needed assistance with showers, transfers, toileting, and getting into bed were delayed because staff were busy with other tasks and there were not enough aides available to provide care when requested. One resident reported missing a scheduled shower and stated an aide told him they were too busy to do showers. Another resident, who required partial/moderate assistance with showers and had diagnoses including diabetes, bipolar disorder, anxiety disorder, hypertension, and depression, asked for a shower before going to a church function but was told she was not on the shower list and that the aide had eight other showers to do; she washed her own hair in the sink. Staff interviews confirmed that shower care was affected by staffing, with one LPN stating there was not enough staff to meet resident needs in the area of showers and that the building normally had two nurses and four aides on the evening/night shift, although five aides would be ideal. Additional observations showed residents waiting extended periods for assistance. One resident requesting help out of bed was told the aides were in rooms and would have to wait, and remained in bed for more than an hour. Another resident asking to be put to bed was told to wait because other aides were doing showers and also remained up for more than an hour before staff assisted. A resident who wished to remain anonymous reported routinely waiting for hours for call lights to be answered and needing to wait when incontinent because only two aides were available per side of the building. Resident #55 also stated there was not enough staff, especially nurse aides, and that call lights were not answered in a timely manner because staff were in a hurry.
Inaccurate Documentation of PICC Dressing Care and Shower Records
Penalty
Summary
The facility failed to accurately document resident care in the medical record for two residents. For one resident with a PICC line in the right arm, the dressing was observed dated 04/24/2026, while the MAR showed the dressing change had been signed off as completed on 04/30/2026. The resident confirmed the dressing had not been changed since it was applied on 04/24/2026. The LPN later stated the dressing change was signed off as completed even though it was not done as ordered, explaining that she intended to complete it later, the resident asked her to wait until morning, and she forgot to perform the dressing change but should not have signed off before the treatment was completed. For another resident with diagnoses including Parkinson's disease, dementia, atrial fibrillation, dysphagia, chronic kidney disease, and diabetes mellitus, the record showed a care plan for partial/moderate assistance with bathing and honoring the resident's choices and preferences. The resident stated he did not receive his shower and that staff said they were too busy. However, the shower documentation for that day recorded the shower as refused, and there was no progress note documenting a refusal. The shower sheet had been altered from one date to another, and the CNA who documented the refusal stated the resident had not refused the shower and that she had marked refusal by accident because she was in a hurry. Another CNA stated she did not work on the date in question and had later provided the resident a shower because he was upset he had missed it. The DON verified the shower sheet had been altered.
Infection Control Lapses With Glove Use and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control procedures related to glove use during medication administration and enhanced barrier precautions for a resident on EBP. For Resident #39, who had a physician order for Lispro insulin 15 units subcutaneously, an LPN administered the insulin injection to the resident’s abdomen without wearing gloves. The LPN later stated he was supposed to wear gloves but did not, and the DON confirmed staff were to wear gloves when administering insulin. The facility policy for subcutaneous insulin administration, dated 01/23, required staff to put on gloves prior to giving the injection. The facility also failed to follow its EBP procedure for Resident #6, whose record showed diagnoses including CHF, CKD, diabetes mellitus, COPD, atrial fibrillation, and other chronic conditions, and whose significant change MDS indicated a moderate cognitive deficit. The resident had physician orders for EBP due to a history of ESBL, with instructions to check placement of the sign and cart and stock every shift. During observation, a sign was posted on the door indicating EBP, but CNAs did not don gowns while providing care. In addition, while preparing IV meropenem for Resident #55, an LPN applied gloves, primed the IV tubing, used hand sanitizer on the gloves, and then connected the tubing to the resident’s IV; the DON confirmed the LPN should have changed gloves and that sanitizing gloves was not part of facility policy.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide residents with the required 48-hour notice of the end of their Medicare Part A skilled nursing services, affecting three residents. Resident #1 did not receive the notice until the same day her skilled services ended, and the notice lacked details about which services were ending and why. Additionally, the facility did not provide an Advanced Beneficiary Notice (ABN) to residents #1, #17, and #56, who remained in the facility after their skilled services ended, as required. The facility assumed all charges would be covered by Medicare, which was not the intended use of the ABN. The Business Office Manager confirmed that the facility did not provide the necessary ABN forms to the residents, acknowledging that the ABN allows residents to decide whether to continue receiving services while appealing the decision to end coverage. The facility's administrator admitted there was no policy in place to guide staff on completing liability notices when a resident's Medicare Part A services ended. This lack of policy and oversight led to the deficiency in notifying residents of their potential financial liability for services not covered by Medicare.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide timely and adequate nail care for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had diagnoses including senile degeneration of the brain and dementia, was assessed to be rarely or never understood and dependent on staff for personal hygiene. The care plan indicated the need for showers twice a week with hair and nail care, and to keep the resident's nails cut short to prevent skin injury. However, the resident's representative confirmed that the facility staff did not trim and clean the resident's fingernails, and the family had been unable to visit for almost three weeks due to medical issues. Observations during the survey revealed that the resident had long, jagged fingernails with dark brown debris underneath. The resident was seen eating with bare fingers, and later, a small area of dried blood was observed at the corner of the resident's mouth, likely caused by scratching or picking. An LPN confirmed the condition of the resident's nails and the presence of dried blood, indicating a failure to adhere to the care plan interventions for nail care and skin protection.
Failure to Conduct Weekly Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer was assessed weekly for signs of healing or infection, as required by the resident's plan of care. The resident, who had a history of stroke with hemiplegia, peripheral vascular disease, and other significant health issues, was admitted without any known pressure ulcers. However, a suspected deep tissue injury was identified on the resident's left heel, which was documented on a skin observation tool. Despite the care plan's requirement for weekly assessments, there was a 15-day gap between the initial assessment and the next documented assessment, with no evidence of an assessment during the week of 07/22/24. The facility's wound nurse, responsible for conducting weekly wound assessments, confirmed the lapse in documentation and could not explain the 15-day gap. The Director of Nursing acknowledged the absence of a policy guiding the ongoing monitoring of pressure ulcers through weekly assessments. This deficiency affected the resident's care, as the facility did not adhere to the established plan of care for monitoring the pressure ulcer's healing and potential infection.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of oxygen tubing for a resident. Resident #43, who was admitted with diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and muscle weakness, was affected by this deficiency. The resident's care plan included oxygen administration at two to four liters per minute by nasal cannula, with an active physician order to change the oxygen tubing weekly on the night shift. However, during an observation on 07/29/24, it was noted that the oxygen tubing had a piece of tape with a date of 05/30/24, indicating it had not been changed as per the order. The resident confirmed that staff changed the tubing but could not recall the last change. The Unit Manager confirmed the outdated tubing and stated it would be changed immediately.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper management of psychotropic medications for two residents, leading to deficiencies identified during the annual survey. For Resident #18, the facility did not include a stop date for an as-needed order of Ativan, an anti-anxiety medication. The resident, who was rarely or never understood and had diagnoses including senile degeneration of the brain and dementia, was receiving anti-anxiety medications without a specified duration of therapy. This oversight was confirmed by the Unit Manager during an interview. For Resident #25, the facility administered Risperidone, an antipsychotic medication, without an appropriate diagnosis. The resident, who had moderate cognitive impairment and multiple medical conditions, was prescribed Risperidone for unspecified dementia, which is not an acceptable diagnosis for this medication. This was verified by both a Registered Nurse and the Director of Nursing, who confirmed that Risperidone should be prescribed for an actual diagnosis rather than symptoms like agitation.
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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.
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Nursing homes near Middleport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Lakin | 3 mi | ★★★★★ | 0 | 0 |
| Arbors At Pomeroy | 8 mi | ★★★★★ | 1 | 0 |
| Pleasant Valley Healthcare Center | 8.8 mi | ★★★★★ | 3 | 0 |
| Holzer Senior Care Center | 13.9 mi | ★★★★★ | 0 | 0 |
| Abbyshire Place Health And Rehabilitation Center L | 14.6 mi | ★★★★★ | 2 | 0 |
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