NORTHBROOK CENTER FOR REHABILITATION AND HEALING

575 LAMAR AVE, BROOKSVILLE, FL 34601 (352) 799-2226
For profit - Limited Liability company 120 Beds INFINITE CARE Data: November 2025
Trust Grade
48/100
#535 of 690 in FL
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Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Northbrook Center for Rehabilitation and Healing has a Trust Grade of D, indicating below-average performance with some concerns about care quality. It ranks #535 of 690 facilities in Florida, placing it in the bottom half, and #6 of 6 in Hernando County, meaning there are no better local options available. The facility's trend is worsening, with the number of issues increasing from 7 in 2023 to 10 in 2025. Staffing is average with a 3/5 star rating and a turnover rate of 46%, which is comparable to the state average. However, there are concerning incidents, such as a failure to properly store and label food, and a resident not receiving the prescribed mobility assistance, which raises questions about the overall quality of care.

Trust Score
D
48/100
In Florida
#535/690
Bottom 23%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
7 → 10 violations
Staff Stability
⚠ Watch
46% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
✓ Good
$20,770 in fines. Lower than most Florida facilities. Relatively clean record.
Skilled Nurses
○ Average
Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Florida. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
23 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 7 issues
2025: 10 issues

The Good

  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Florida average (3.2)

Below average - review inspection findings carefully

Staff Turnover: 46%

Near Florida avg (46%)

Higher turnover may affect care consistency

Federal Fines: $20,770

Below median ($33,413)

Minor penalties assessed

Chain: INFINITE CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 23 deficiencies on record

Mar 2025 10 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident #81's admission record showed the resident was most recently admitted on [DATE], with the diagnosis of pne...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident #81's admission record showed the resident was most recently admitted on [DATE], with the diagnosis of pneumonia with onset date of 1/23/2025. Review of Resident #81's physician order dated 1/23/2025 showed read, Levaquin Oral Tablet (Levofloxacin), Give 500 mg by mouth at bedtime for Pneumonia for 7 Days. Review of Resident #81's MDS dated [DATE] showed no infections were documented under Section I- Active Diagnoses. Active Diagnoses in the last 7 days. During an interview on 3/26/2025 at 1:35 PM, Staff K, MDS Registered Nurse, stated that Section I of MDS for Resident #81 was not correct and it should have listed Pneumonia. Review of the facility policy and procedure titled Summit Care Resident Assessment Instrument (RAI) MDS Compliance Policy with the last review date of 2/19/2025 showed it read, Purpose: This policy establishes procedures for completing the Minimum Date Set (MDS) 3.0 to ensure compliance with federal and state requirements, promote accurate resident assessments, and facilitate proper reimbursement under Medicare and Medicaid . Procedure . 3. Accuracy and Completeness: All sections of the MDS must be filled out accurately using input from relevant staff, including nursing, social services, therapy, and dietary departments. Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for 1 of 8 residents reviewed for nutrition, Resident #31, and 1 of 6 residents reviewed for medication management, Resident #81. Findings include: 1) During an observation on 3/25/2025 at 12:39 PM, Resident #31 was lying in bed, receiving Jevity 1.5 via tube feeding at 80 milliliters per hour. During an observation on 3/26/2025 at 7:30 AM, Resident #31 was lying in bed, receiving Jevity 1.5 via tube feeding at 80 milliliters per hour. Review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] showed it read, Section K- Swallowing/ Nutritional Status. K0710. Percent Intake by Artificial Route . 3. During Entire 7 Days. A. Proportion of total calories the resident received through parenteral or tube feeding: 1. 25% or less. Review of Resident #31's physician order dated 11/13/2024 showed it read, NPO [Nil Per Os which is a Latin phrase meaning nothing by mouth]-Nothing by Mouth diet, NPO texture, NPO consistency. Review of Resident #31's physician order dated 1/24/2025 showed it read, Enteral Feed Order two times a day for (Enhanced Barrier Precautions) Enteral: Pump Feeding: Administer jevity 1.5 per PEG [Percutaneous Endoscopic Gastrostomy] tube via pump. Rate: 80 mls/hour (80 milliliters per hour) for 20 hours/day down at 9 am up at 1 pm. During an interview on 3/26/2025 at 12:04 PM, the Registered Dietician stated, [Resident #31's name] gets all his caloric intake via the gastric tube feedings. During an interview on 3/26/2025 at 12:15 PM, Staff G, Certified Dietary Manager (CDM), stated, [Resident #31's name] receives all nutrition via the gastric tube. During an interview on 3/26/2025 at 1:59 PM, Staff K, MDS Registered Nurse, stated, After speaking with [the CDM's name] we have to correct the MDS entry because [Resident #31's name] received all caloric intake via the gastric tube.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure residents received their medication as ordered by the physician for 1 of 10 residents reviewed for medication administ...

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Based on observation, interview, and record review, the facility failed to ensure residents received their medication as ordered by the physician for 1 of 10 residents reviewed for medication administration, Resident #402. Findings include: During an observation on 3/26/2025 at 9:38 AM, Staff C, Licensed Practical Nurse (LPN), measured 2 grams of Dicoflenac Sodium topical gel (Voltaren) onto the medication ruler. Staff C applied 2 grams of the medication to the medication ruler and applied one gram to the left knee of Resident #402 and then one gram was applied to the right knee. Review of Resident #402 physician order dated 3/14/2025 showed it read, Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium (Topical), Apply to knees topically two times a day for pain. During an interview on 3/26/2025 at 9:36 AM with Staff C, LPN, when asked if Diclofenac gel is 1 gram per knee or 2 grams per knee, Staff C stated, Will need to call the APRN [Advance Practice Registered Nurse] to clarify. During an interview on 3/27/2025 at 10:20 AM, the Director of Nursing (DON) stated, I spoke with [the physician's name] yesterday. I am the person who put the order in the system. Voltaren 2 grams should be given to each knee. I will let the nurse know. Review of the facility policy and procedure titled Administering Medications with the last review date of 2/19/2025 showed it read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required timeframe.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure residents received care and services for central venous access devices in accordance with professional standards of pr...

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Based on observation, interview, and record review, the facility failed to ensure residents received care and services for central venous access devices in accordance with professional standards of practice for 1 of 3 residents reviewed for intravenous therapy, Resident #95. Findings include: During an observation on 3/24/2025 at 10:17 AM, Resident #95 was sitting at the edge of her bed. Resident #95 had a single lumen PICC (Peripherally Inserted Central Catheter) line on her right arm with a transparent dressing and a gauze underneath the dressing with no date. During an interview on 3/24/2025 at 10:17 AM, Resident #95 stated, The staff changed my dressing last Thursday [3/20/2025]. I am not sure why they did not date the dressing. Review of Resident #95's physician order dated 3/3/2025 showed it read, IV [Intravenous]: Central Line- PICC Line: Change transparent dressing every evening shift every Sat [Saturday] for preventative care. Review of Resident #95's Medication Administration Record (MAR) for March 2025 showed the last transparent dressing change was completed on 3/15/2025. Review of Resident #95's physician order dated 3/13/2025 showed it read, Vancomycin HCl Intravenous Solution (Vancomycin HCl) Use 1250 mg [milligrams] intravenously two times a day for right knee infection. During an interview on 3/27/2025 at 8:09 AM, the Director of Nursing stated, IV dressing should be labeled with the date that the dressing was changed. Dressing changes should be done every 7 days and if they have a gauze under the transparent dressing every 2 days. Review of the facility policy and procedure titled Infusion Devices and Procedures with the last review date of 2/19/2025 showed it read, Policy . Gauze dressings are changed every 2 days. Transparent semipermeable membrane (TSM) dressings are changed every 5-7 days.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide dietary services as ordered by physician for 3 of 8 residents reviewed for nutrition, Residents #31, #352 and #405. F...

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Based on observation, interview, and record review, the facility failed to provide dietary services as ordered by physician for 3 of 8 residents reviewed for nutrition, Residents #31, #352 and #405. Findings include: 1) During an observation on 3/25/2025 at 12:55 PM, Resident #352 was eating in his room. The meal tray included cranberry juice, dessert, mixed vegetables containing broccoli, carrots, and cauliflower, and an inside out chicken potpie. Review of Resident #352's meal ticket for 3/25/2025 did not show fortified foods listed. During an observation on 3/26/2025 at 7:54 AM, Resident #352 was eating in the room. The meal tray included cold cereal mixed with white milk, scrambled eggs, toast with jelly and juice. Review of Resident #352's meal ticket for 3/26/2025 did not show fortified foods listed. Review of Resident #352's physician order dated 1/14/2025 showed it read, Low Concentrated Sweets diet, Regular Texture, Thin Consistency, for Fortified Foods. During an interview on 3/26/2025 at 12:18 PM, the Registered Dietitian [RD] stated, [Resident #352's name] has orders for fortified foods. For breakfast, oatmeal is the fortified food served, and mashed potatoes would be served for lunch and dinner. Fortified foods add more calories. During an interview on 3/26/2025 at 12:19 PM, Staff G, Certified Dietary Manager, stated, [Resident #352's name] is on fortified foods and should be getting oatmeal for breakfast and mashed potatoes for lunch and dinner. I do not see fortified foods included in his meal ticket. It should be written on the meal ticket. 2) During an observation on 3/24/2025 at 1:30 PM, Resident #31 was lying in bed, receiving Jevity 1.5 via feeding tube at the rate of 80 milliliters per hour. During an observation on 3/25/2025 at 12:39 PM, Resident #31 was lying in bed, receiving Jevity 1.5 via feeding tube at the rate of 80 milliliters per hour. During an observation on 3/26/2025 at 7:10 AM, Resident #31 was lying in bed, receiving Jevity 1.5 via feeding tube at the rate of 80 milliliters per hour. Review of Resident #31's physician order dated 1/24/2025 showed it read, Enteral Feed Order two times a day for (Enhanced Barrier Precautions) Enteral: Pump Feeding: Administer jevity 1.5 per peg [Percutaneous Endoscopic Gastrostomy] tube via pump. Rate: 80 mls/hour for 20 hours/day down at 9 am up at 1 pm. Review of Resident #31's progress note dated 3/12/2025 showed it read, RD Note tolerating TF [Tube Feeding] meeting calorie needs due to wt [weight] decrease will recommend increase TF jevity 1.5 at 85 ml [milliliter] x 20= 1700 cc [cubic centimeter] 2550 cal [calories], monitor wts [weights] weekly thru March review. Review of Resident #31's physician orders showed no order for increasing tube feeding to 85 milliliters. During an interview on 3/26/2025 at 12:04 PM, the Registered Dietician stated, I leave recommendation sheets and we give a copy to the DON [Director of Nursing], CDM [Certified Dietary Manager] and Minimum Data Set nurse and so everyone is aware. I would be careful not to increase too much. Even with the recommendation not followed [Resident #31 name] went up two pounds. I am not sure what happened that it did not get changed. During an interview on 3/26/2025 at 12:15 PM, Staff G, CDM, stated, I received the recommendation and carried it out to all parties including nursing and director of nursing. Nursing or DON are the ones to put in the orders. I was not aware the feeding tube rate was not changed. During an interview on 3/27/2025 at 8:14 AM, the Director of Nursing stated, I do not believe the doctor was notified when the recommendations were made to increase the tube feeding rate. 3) During an observation on 3/26/2025 at 8:00 AM, Resident #405 received her breakfast which included eggs, toast, and coffee. During an observation on 3/26/2025 at 12:45 PM, Resident #405 received her lunch, which included cheese broccoli casserole, roll and soda for a drink. Review of Resident #405's meal ticket for 3/26/2025 showed no fortified foods listed. Review of Resident #405's physician order dated 2/7/2025 showed it read, NAS (No Added Salt) diet Regular texture, Thin consistency, for add Fortified Foods every meal. During an interview on 3/25/2025 at 2:30 PM, Staff G, CDM stated, The fortified foods were oatmeal with cinnamon, cereal and mashed potatoes with gravy. During an interview on 3/27/2025 at 8:16 AM, Staff G, CDM, stated, [Resident #405's name] should have been given oatmeal during breakfast and mashed potatoes during lunch as part of their fortified food order. Review of the facility policy and procedure titled Nutrition Interventions with the last review date of 2/19/2025 showed it read, Policy: Nutritional interventions will be implemented as recommended by the Dietary Manager, dietitian and/or Nutrition and Dietetics Technician Registered (NDTR) to ensure the best possible nutritional status for residents of the facility. Recommendations will be consistent with nutritional best practices and the industry standards of care.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were assessed before and after dialysis treatments...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were assessed before and after dialysis treatments for 1 of 1 resident receiving dialysis services, Resident #30. Findings include: Review of Resident #30's Dialysis Center-Facility Communication Form dated 2/28/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's Dialysis Center-Facility Communication Form dated 3/3/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's Dialysis Center-Facility Communication Form dated 3/5/2025 showed no arrival time and vitals signs documented under the section reading, Facility Nurse to complete upon return from Dialysis Review of Resident #30's records showed no Dialysis Center-Facility Communication Form for dialysis visit on 3/10/2025. Review of Resident #30's physician order dated 8/27/2025 showed it read, Dialysis: May go to Dialysis on Monday/[NAME] [Wednesday]/Friday at [Name of dialysis center] on [the dialysis center address and phone number] chair time 11 am pick up after 9a m ([phone number of transportation company]). During an interview on 3/27/2025 at 8:45 AM, Staff L, Licensed Practical Nurse (LPN), stated, There is a dialysis book we have to complete before and after [Resident #30's name] has dialysis. The dialysis book has a communication sheet we have to fill out before resident is sent to dialysis and when they return. During an interview on 3/27/2025 at 9:13 AM, Staff M, LPN, stated, [Resident #30's name] does not have a communication sheet done for 3/10/2025. On 3/3/2205, 3/5/2025 and 2/28/2025, the post dialysis communication sheet has no vitals recorded upon his [Resident #30] return. The dialysis communication form should be completely filled out and vitals should be taken. The form is filled out before sending the resident to dialysis and upon his return. There is no order. It is just an expectation that the staff know they have to complete the communication form for any dialysis resident in the building. During an interview on 3/27/2025 at 11:20 AM, the Director of Nursing (DON) stated, Nurses should do a dialysis communication assessment pre and post dialysis days for [Resident #30's name]. Review of the facility policy and procedure titled Care of the resident receiving Dialysis with the last review date of 2/19/2025 showed it read, Procedure . Pre-dialysis care: a. Nurse will complete top section of Dialysis Communication Form and sign/date . Post-dialysis care . b. Document evaluation by completing bottom section of the Dialysis Communication Form. Sign/date the form. File the completed form in resident's medical record.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation upon entry to the facility on 3/24/202...

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Based on observation and interview, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation upon entry to the facility on 3/24/2025 at 9:00 AM, the nurse staffing information posted at the front desk was dated 3/19/2025. During an interview on 3/24/2025 at 9:37 AM, the Administrator stated, Federal posting should be changed daily. The staffing coordinator will change it during the week and the weekend supervisor will be responsible for changing the posting. During an interview on 3/27/2025 at 8:45 AM, the Staffing Coordinator stated, I am responsible for placing the staffing information at the front desk during the week. The weekend supervisors change it on the weekends. The number was correct, but the date wasn't.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principl...

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Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 2 of 4 halls. Findings include: 1) During an observation on 3/24/2025 at 10:51 AM, Resident #19 was lying in bed. There was a Ventolin HFA inhaler on top of the resident's nightstand. During an interview on 3/24/2025 at 10:51 AM, Resident #19 stated, I use the inhaler myself. The nurses do not help me with it. During an interview on 3/24/2025 at 8:07 AM, the Director of Nursing stated, There is no resident in the facility at this time that self-administers medication. The nurse will do a self-administration evaluation and it would be recorded in [electronic health record program's name]. Medication should not be left unattended. Even if resident has a self-administration evaluation and is considered safe to administer, the nurse will bring the medication and recollect it and take it back to the cart. During an interview on 3/27/2025 at 10:30 AM, the Director of Nursing stated, [Resident #19's name] does not even have an order for this inhaler [holding the Ventolin HFA inhaler in her hand]. 2) During an observation on 3/25/2025 at 10:56 AM, there was a small clear plastic cup with multiple pills on the overbed table of Resident #91. During an interview on 3/25/2025 at 10:57 AM, Resident #91 stated, These are my medications. I will take them later. Review of Resident #91's medical records did not reveal an evaluation of Resident #91 for self-administration of medications. Review of the facility policy and procedure titled Medication Storage with the last review date of 2/19/2025 showed it read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health guidelines. Procedure: A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart of medication room that is accessible only to authorized personnel as defined by facility policy.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 2 of 6 residents reviewed for medication management, Residents #351 and...

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Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 2 of 6 residents reviewed for medication management, Residents #351 and #354, and 1 of 3 residents reviewed for gastric tubes, Resident #23. Findings include: 1) Review of Resident #354's physician order dated 3/6/2025 showed it read, Insulin Glargine Subcutaneous Solution 100 UNIT/ML [unit per milliliter] (Insulin Glargine) Inject 40 units subcutaneously in the morning for Hyperglycemia. Review of Resident #354's Medication Administration Record (MAR) for March 2025 showed no entries documented at 6:00 AM on 3/11/2025 and 3/19/2025 for administration of Insulin Glargine. During an interview on 3/24/2025 at 10:11 AM, Resident #354 stated that the staff gave her all her medications. During an interview on 3/26/2025 at 7:10 AM, Staff G, Licensed Practical Nurse (LPN), stated, I got distracted and did not document it. I really do not know what happened. During an interview on 3/27/2025 at 11:24 AM, the Director of Nursing (DON) stated, I expect nurses to document accurately. I do see the blanks on 3/11/2025 and 3/19/2025 for [Resident #354's name]. 2) Review of Resident #23's physician order dated 2/23/2025 showed it read, After meals related to dysphagia, oropharyngeal phase (R13.12); gastrostomy status (Z93.1), Enteral: Hold Bolus Feeding if eats less than 50% of meal. Administer Nepro/CarbSteady Oral Liquid per G-Tube [gastric tube] via bolus. Rate: 237 mL [milliliters] per feeding, 3 times per day. (Enhanced Barrier Precautions). During an interview on 3/26/2025 at 12:25 PM, the Registered Dietician stated, The staff are monitoring [Resident #23's name] intake and has orders for bolus if he eats less than 50% of his meal. During an interview on 3/27/2025 at 8:13 AM, the DON stated, It was a documentation error that needs to be corrected. It should read hold when Resident eats more than 50% not less. I think it got written backwards. During an interview on 3/27/2025 at 3:09 PM, Staff G, Certified Dietary Manager, stated, [Resident #23's name] order should have read if consumed less than 50 percent of the meal to give the bolus. 3) Review of Resident #351's physician order dated 3/3/2025 showed it read, Behavior Monitoring: Monitor for the following: 1. itching, 2. picking at skin, 3. restlessness/agitation, 4. hitting, 5. increase in complaints, 6. biting, 7. kicking, 8. spitting, 9. cursing, 10. racial slurs, 11. elopement, 12. stealing, 13. delusions, 14. hallucinations, 15. psychosis, 16. aggression, 17. refusing care, Document Y if any of the above observed, record code and also document in progress notes. Document N if none of the above occurred. Review of Resident #351's physician order dated 3/3/2025 showed it read, Abilify Oral Tablet 10 mg [milligram] (Aripiprazole), Give 1 tablet by mouth one time a day for depression. Review of Resident #351's physician order dated 3/3/2025 showed it read, Mirtazapine Oral Table 7.5 mg (Mirtazapine), Give 1 tablet by mouth at bedtime related to depression. Review of Resident #351's physician order dated 3/3/2025 showed it read, Paroxetine HCl Oral Tablet 40 mg (Paroxetine HCl), Give 1 tablet by mouth at bedtime related to depression. Review of Resident #351's Treatment Administration Record for March 2025 for behavior monitoring showed staff documented code 0 on 3/16/2025, 3/18/2025, 3/24/2025, 3/25/2025, and 3/26/2025 during 7-3 shift, and NA (Not Applicable) on 3/7/2025, 3/15/2027, 3/16/2025, and 3/25/2025 during 3-1 shift. During an interview on 3/27/2025 at 8:42 AM, Staff L, Licensed Practical Nurse (LPN), stated, When documenting behavior monitoring, you should never put NA. It is a yes or no question. If the resident does have any behaviors, there are numbers to code what behavior they had and what intervention you took to help with the redirection of the behavior. During an interview on 3/27/2025 at 9:07 AM, Staff M, Licensed Practical Nurse (LPN), stated, NA should never be used when documenting behavior monitoring. The staff should answer yes or no. During an interview on 3/27/2025 at 8:17 AM, the DON stated, The staff should be documenting accurately the resident's behavior. They should not document NA. They should answer N for No if the resident does not have any behaviors. It is a user error. Review of the facility policy and procedure titled Documentation, Clinical with the last review date of 2/19/2025 showed it read, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. Documentation in the medical record of each resident should provide: A. A complete account of the resident's care treatment and response to the care . 4. An ongoing record of the physical and mental status of the resident.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and used proper personal protective equipment during medication administration for 2 of 1...

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Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and used proper personal protective equipment during medication administration for 2 of 11 residents reviewed for medication administration, Residents #32 and #56, and while providing care for 2 of 4 residents reviewed for isolation precautions, Residents #302 and #405, to prevent possible spread of infection and communicable diseases. Findings include: 1) During an observation on 3/25/2025 at 8:30 AM, Staff B, Licensed Practical Nurse (LPN), was standing in front of the medication cart. Staff B scratched the side of her head with her right hand. Without performing hand hygiene, Staff B continued to pour medication into a medication cup. Staff B poured the medication into a clear medication sleeve and crushed the medication. Staff B grabbed two capsules from the top of the medication cart, and without donning gloves, opened each capsule and poured the medication into a small bowl. Staff B pushed her medication cart to Resident #32's door, performed hand hygiene before entering the room, and administered the medication to Resident #32. During an interview on 3/26/2025 at 2:50 PM, Staff B, LPN, stated, I know I should use gloves when touching any medication. Medication should not be touched with your hands, but no one has ever told me anything. During an interview on 3/27/2025 at 7:15 AM, the Infection Preventionist stated, Any time the staff touch their face, they should wash her hands and they should not be touching medication with their bare hands. During an interview on 3/27/2025 at 8:06 AM, with the Director of Nursing (DON) stated, Once the staff touched her head, she should have performed hand hygiene and then continued to pour medication. The nursing staff should not touch a capsule with her hand. The nursing staff should wash her hands and don gloves, then she should open the capsule and once she is done and removes her gloves, she should wash her hands again. Review of the facility policy and procedure titled Administering Medications with the last review date of 2/19/2025 showed it read, Policy Statement: Medication are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g., hand hygiene, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with the last review date of 2/19/2025 showed it read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations . b. After contact with resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile [Clostridium difficile]. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . c. before preparing or handling medications. 2) During an observation on 3/25/2025 at 8:35 AM, Staff D, Registered Nurse (RN), opened Gabapentin and Potassium Chloride capsules with bare hands for Resident #56. Staff D did not have gloves on during medication preparation. During an interview on 3/25/2025 at 9:05 AM, Staff D, RN, stated, I was only touching the outside of the capsule, so I did not think I needed to wear gloves to open the capsule. During an interview on 3/25/2025 at 9:15 AM, 400 Hall Nurse Manager stated, Gloves should be worn when opening capsules during medication pass. 3) During an observation on 3/25/2025 at 9:33 AM, the Wound Care Nurse, RN, provided wound care to Resident #302. The Wound Care Nurse did not have gown while providing wound care. There was an Enhanced Barrier Precautions (EBP) signage outside Resident #302's room. During an interview on 3/25/2025 at 9:40 AM, the Wound Care Nurse stated, I should have worn a gown. During an interview on 3/27/2025 at 3:15 PM, the DON stated, During wound care, staff should wear gown and gloves for a resident on Enhanced Barrier Precautions. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 2/19/2025 showed it read, Policy Statement: Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring the u se of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and g. wound care (any skin opening requiring a dressing). 4) During an observation on 3/26/2025 at 8:31 AM, Staff A, Certified Nursing Assistant (CNA), entered Resident #405's room to pass out the breakfast tray. Staff A did not wear gown before entering the room. There was a contact precaution signage and PPE supplies outside of Resident #405's room. During an interview on 3/26/2025 at 8:40 AM, Staff A, CNA, stated, I just got in a hurry to pass out breakfast trays and didn't even see the bin or the sign outside the door. Review of Resident #405's physician order dated 2/4/2025 showed it read, Contact Isolation: The resident is in isolation due to: C-Diff. The resident is in a room alone, and all items are brought to the resident (food, activities, meditation [Sic.], therapy) because the resident does not leave the room, every shift. During an interview on 3/26/2025 at 8:45 AM, the DON stated, If a resident is on contact isolation for C. Diff., staff is supposed to dress out in appropriate PPE before entering room. Review of the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting last updated in July 2023 showed it read, III.B.1. Contact Precautions . Healthcare personnel caring for patients on Contact Precautions wear gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received restorative services to maintain their mo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received restorative services to maintain their mobility for 1 of 3 residents reviewed for restorative services, Resident #16. Findings include: During an interview on 3/25/2025 at 9:20 AM, Resident #16 stated, I am not doing any physical therapy or walking program at this time. I want to start walking again. Review of Resident #16's physician order dated 12/16/2024 showed it read, Restorative Program: Ambulate using 2ww [2 wheeled walker], gait belt, close wc [wheelchair] follow, and close contact assistance up to 100 ft [feet], 3x [3 times] weekly . Order Status: Active. Review of Resident #16's Physical Therapy Discharge summary dated [DATE] showed it read, Discharge Recommendations and Status . Restorative Programs . Ambulation Program Established/Trained 100' CGA [Contact Guard Assist] using gait belt, close wc follow. During an interview on 3/27/2025 at 12:18 PM, the Director of Nursing confirmed Resident #16 had an order for restorative therapy in December of 2024 and stated, He was not picked up for restorative services in December. During an interview on 3/27/2025 at 1:11 PM, Staff I, Occupational Therapist, stated, They are supposed to follow the goals in the referral to continue their therapy goals. During an interview on 3/27/2025 at 2:00 PM, the Director of Nursing stated, We expect the restorative team to pick up residents who have an order. We do not have a directly related policy.
Dec 2023 7 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

2. During an observation of Resident #81's room on 12/11/2023 at 2:00 PM, the baseboard was not attached to the wall and was lying face down on the floor. There was a thick substance on the back side ...

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2. During an observation of Resident #81's room on 12/11/2023 at 2:00 PM, the baseboard was not attached to the wall and was lying face down on the floor. There was a thick substance on the back side of the baseboard and a moderate amount of flakey white debris on the baseboard and the floor surrounding the detached baseboard. The wall where the baseboard had been attached had missing paint and exposed drywall. (Photographic evidence obtained). During an observation of Resident #81 on 12/12/2023 at 1:15 PM, the baseboard was not attached to the wall and was lying face down on the floor. There was a thick substance on the back side of the baseboard and a moderate amount of flakey white debris on the baseboard and the floor surrounding the detached baseboard. The wall where the baseboard had been attached had missing paint and exposed drywall. During an observation of Resident #81 on 12/13/2023 at 12:30 PM, the baseboard was not attached to the wall and was lying face down on the floor. There was a thick substance on the back side of the baseboard and a moderate amount of flakey white debris on the baseboard and the floor surrounding the detached baseboard. The wall where the baseboard had been attached had missing paint and exposed drywall. During an interview on 12/13/2023 at 12:45 PM, the Regional Maintenance Director stated, That should not be like that. It is the responsibility of the maintenance department to fix. 3. During an observation of Resident #57's room on 12/11/2023 at 10:49 AM, there was an outlet on the wall without a cover. (Photographic evidence obtained). During an observation Resident #57's room on 12/13/2023 at 12:19 PM, the outlet on the wall had no cover. 4. During an observation of Resident #75's room on 12/11/2023 at 2:10 PM, there was an outlet on the wall without a cover. (Photographic evidence obtained). During an observation of Resident #75's room on 12/13/2023 at 12:20 PM, the outlet on the wall had no cover. During an interview on 12/13/2023 at 12:45 PM, the Regional Maintenance Director stated, That should not be like that [outlets that are not covered]. That is not safe. It is the responsibility of the Maintenance Department to fix. Review of the facility policy and procedures titled Environmental Services-Safe Environment last reviewed on 1/18/2023, reads, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Definitions . Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes resident's susceptibility to loss of body heat and risk of hypothermia or hyperthermia or and is comfortable for the residents. Based on observation, interview, and record review, the facility failed to ensure comfortable and safe temperature levels were maintained in 4 of 4 facility shower rooms, and failed to ensure a clean and homelike environment in 3 of 5 resident rooms. Finding include: 1. During an interview on 12/11/2023 at 10:06 AM, Resident #106 stated the facility shower rooms were cold and he passed on showers sometimes because the shower room was so cold. During an observation on 12/11/2023 at 10:23 AM, the ambient air temperature was 66.7 degrees Fahrenheit in the B Wing shower room directly across from the nurses' station. During an observation on 12/11/2023 at 10:25 AM, the ambient air temperature was 67.6 degrees Fahrenheit in the B Wing shower room located to the right side across from the nurses' station. During an observation of the A Wing shower room located to the left side across from the nurses' station on 12/11/2023 at 11:02 AM with the Administrator, the ambient air temperature was 66.2 degrees Fahrenheit. During an observation of the A Wing shower room located directly across from the nurses' station on 12/11/2023 at 11:04 AM with the Administrator, the ambient air temperature was 67.8 degrees Fahrenheit. During an interview on 12/13/2023 at 9:30 AM, the Administrator stated that the temperature range of 71 to 81 degrees Fahrenheit is a comfortable and safe temperature range expected to be maintained in the facility.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure residents were referred to the appropriate state designated authority for a Level II evaluation and determination for 1 of 3 residen...

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Based on record review and interview, the facility failed to ensure residents were referred to the appropriate state designated authority for a Level II evaluation and determination for 1 of 3 residents reviewed for Preadmission Screening and Resident Review (PASRR), Resident #68. Findings include: Review of Resident #68's admission record revealed the resident was diagnosed with bipolar disorder, schizophrenia, and anxiety disorder with onset date of 11/18/2023. Review of Resident #68's Level I PASRR dated 11/1/2023 reads, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #68's hospital progress note dated 10/31/2023 showed history of dementia, schizophrenia, and bipolar disorder. Review of Resident #68's psychiatry subsequent note dated 12/1/2023 showed the resident's chief psychiatric complaints included depression, anxiety, and schizoaffective disorder. During an interview on 12/13/2023 at 8:50 AM, the Social Services Director stated the facility did not have any documentation that indicated Resident #68's Level I PASRR had been revised to show a diagnosis of bipolar disorder, schizophrenia, or dementia and to initiate a Level II PASRR screening.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for notifying the physician of hypoglyce...

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Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for notifying the physician of hypoglycemic episodes for 1 of 3 residents reviewed, Resident #82. Findings include: Review of Resident #82's physician order dated 9/11/2023 reads, Insulin Glargine Subcutaneous Solution Pen-Injector 100 unit/ml [milliliter]. Inject 30 unit two times daily related to type II diabetes with diabetic neuropathy. Review of Resident #82's nursing progress note dated 10/30/2023 showed insulin was held due to low BS (blood sugar). Review of Resident #82's nursing progress note dated 11/5/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/6/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/21/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/23/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/25/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 11/26/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/1/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/5/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/10/2023 showed insulin was held due to low BS. Review of Resident #82's nursing progress note dated 12/12/9/2023 showed insulin was held due to low BS. Review of Resident #82's care plan dated 7/25/2023 showed the resident had diabetes mellitus. The interventions included administration of diabetes medication as ordered by doctor, and monitoring, documenting and reporting any signs of hypoglycemia. During an interview on 12/11/2023 at 12:30 PM, the Director of Nursing (DON) stated that if there was an occasion that physician orders were not followed for insulin due to a low blood sugar, the physician should be notified for orders to give or to hold the insulin. Review of the facility policy and procedure titled Nursing- Hypoglycemia/ Hyperglycemia last reviewed on 1/18/2023, reads, General Guidelines . 2. Check blood glucose level if signs or symptoms indicate possible hypoglycemia . 5. Notify physician of the hypoglycemic episode and/or effectiveness of treatment and recheck blood sugar as indicated by physician.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 12/11/2023 at 10:46 AM, Resident #49 was lying in bed, receiving oxygen via nasal canula at 4 liters...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 12/11/2023 at 10:46 AM, Resident #49 was lying in bed, receiving oxygen via nasal canula at 4 liters per minute (Photographic evidence obtained). During an observation on 12/12/2023 at 9:30 AM, Resident #49 was lying in bed, receiving oxygen via nasal canula at 4 liters per minute. Review of Resident #49's physician order dated 10/19/2022 reads, Oxygen @ [at] 2 L/Min [liters per minute] via NC [Nasal Cannula] continuous inhalation every shift related to Hypoxemia. During an interview on 12/13/2023 at 12:35 PM, Staff E, Licensed Practical Nurse (LPN), acknowledged that Resident #49's oxygen concentrator was set on 4 liters per minute. Review of the facility policy and procedures titled Nursing- Oxygen Administration last reviewed on 1/18/2023, reads, Purpose. The purpose of this procedure is to provide guidelines for oxygen administration. Procedure . 9. Adjust the delivery devise so that it is comfortable to the resident and the proper flow of oxygen is being administered. Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care services, Residents #52 and #49. Findings include: 1. During an observation on 12/11/2023 at 11:13 AM, Resident #52 was resting in bed, receiving oxygen via nasal cannula at 2 ½ liters per minute (Photographic evidence obtained). During an observation 12/12/2023 at 8:58 AM, Resident #52 was resting in bed, receiving oxygen via nasal cannula at 2 ½ liters per minute. During an observation 12/12/2023 at 1:48 PM, Resident #52 was resting in bed, receiving oxygen via nasal cannula at 2 ½ liters per minute. Review of Resident #52's admission record revealed the resident was admitted on [DATE] with the diagnoses including pleural effusion, heart failure, chronic obstructive pulmonary disease. Review of Resident #52's physician order indicated administration of Oxygen at 3 liters per minute via nasal cannula. During an interview on 12/12/2023 at 1:55 PM, Staff A, Registered Nurse (RN), stated, The setting looks a little less than 2 1/5 liters. I should have looked at the setting as part of my assessment. During an interview on 12/13/2023 at 8:17 AM, the Director of Nursing stated, My expectation is when the nurse does an assessment to do a head to toe and check the head of bed, check oxygen setting to make sure the resident is good.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure residents received adaptive equipment for eating for 1 of 4 residents reviewed, Resident #275. Findings include: Durin...

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Based on observation, interview, and record review, the facility failed to ensure residents received adaptive equipment for eating for 1 of 4 residents reviewed, Resident #275. Findings include: During an interview on 12/11/2023 at 10:29 AM, Resident #275's wife stated Resident #275 spilled his food as he tried to eat as he was not provided with his curved utensils as ordered. During an observation on 12/11/2023 at 12:37 PM, Resident #275 was attempting to feed himself broccoli and cauliflower blended vegetables. Resident #275 had a scoop plate and regular utensils. As Resident #275 attempted to place the food in his mouth with the regular utensils, food spilled onto his shirt. Review of Resident #275's order summary showed an order for adaptive equipment with meals including a scoop plate and left-hand curved utensil. During an interview on 12/12/2023 at 11:45 AM, the Dietary Manager (DM) stated that adaptive devices should be on the tray for residents as the physician ordered. The DM confirmed Resident #275 did not receive his utensils as ordered. Review of Resident #275's care plan dated 12/8/2023 showed the resident was nutritionally at risk with the interventions to include adaptive equipment as ordered. During an interview on 12/13/2023 at 12:33 PM, Staff D, Certified Nursing Assistant (CNA), stated, When passing trays to the residents, the staff are to ensure that adaptive equipment is provided as listed on the tray ticket per the physician order. No adaptive equipment was on [Resident #275's name] tray ticket or she would have gone to the dietary department and retrieved it. During an interview on 12/12/2023 at 11:17 AM, the Registered Dietician (RD) confirmed that Resident #275 had an order for a left-curved utensil and that she had added it to the care plan. Review of the facility policy and procedures titled Meal Service last reviewed on 1/18/2023 reads, Policy: The facility believes that all residents should be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. Residents will be properly roomed and their needs attended to during the meal services. Procedure . 7. Assistive devices will be provided as ordered.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure food was properly stored and staff followed professional standards for food service safety. Findings include: A walk-...

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Based on observation, interview, and record review, the facility failed to ensure food was properly stored and staff followed professional standards for food service safety. Findings include: A walk-through tour of the kitchen was conducted on 12/11/2023 at 9:15 AM with the Dietary Manager (DM). The walk-through of the walk-in cooler revealed a case of raw shell eggs stored over a case of opened raw bacon. A gallon milk container with approximately 8 cups of milk remaining in the container was stored in the cooler with an expiration date of 12/6/2023. There were 33 cups of an apple dessert stored in the cooler without a label or date. Four male dietary staff members with facial hair of a beard or mustache did not have a restraint or beard guard. During an interview on 12/11/23 at 9:35 AM, the DM identified the unlabeled cups as apple pies that were leftover. The DM stated that the products should be labeled according to the policy and all products should be covered and dated when stored. The DM confirmed that the container of milk had an expiration date of 12/6/2203 and should have been discarded on 12/6/2023. The DM confirmed that he and other dietary staff did not have on hair or beard restraints as per the policy. Review of the facility policy and procedure titled Food Storage last reviewed on 1/81/2023 reads, Procedure . 2. Refrigerators . d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage . f. Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. Review of the facility policy and procedure titled Employee Sanitation last reviewed on 1/18/2023 reads, Procedure . 3. Employee Cleanliness Requirements . b. Hairnets, headbands, caps, beard coverings, or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the call light system was properly within reach for 3 of 5 residents reviewed for call light system, Residents #77, #3...

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Based on observation, interview, and record review, the facility failed to ensure the call light system was properly within reach for 3 of 5 residents reviewed for call light system, Residents #77, #374, and #49 (Photographic evidence obtained). Findings include: During an observation on 12/11/2023 at 9:45 AM, Resident #77's call light system was on the floor, not within reach of the resident. During an observation on 12/11/2023 at 10:00 AM, Resident #374's call light system was hanging on his headboard, not within reach of the resident. During an observation on 12/11/2023 at 10:42 AM, Resident #49's call light system was attached to the blanket at the foot of the bed, not within reach of the resident. During an interview on 12/11/2023 at 11:00 AM, Staff B, Licensed Practical Nurse (LPN), stated, The CNAs [certified nursing assistants] are supposed to make sure the call light is reachable for the resident before they leave the room. During an interview on 12/11/2023 at 11:04 AM, Staff C, CNA, stated, I don't usually work on this floor, and I will check on the residents every 2 hours. During an interview on 12/14/2023 at 9:30 AM, the Director of Nursing stated that her expectation was to have the staff place the call light within reach of each resident before they leave the room. Review of the facility's policy and procedure titled Call light, Answering last reviewed on 1/18/2023 reads, Procedure . 5. Make the resident as comfortable as possible. Position the call light within easy reach of the resident.
Jun 2022 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents, Resident #55, received the Skilled Nursing Advance Beneficiary of Non-coverage (CMS-10055) to inform the r...

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Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents, Resident #55, received the Skilled Nursing Advance Beneficiary of Non-coverage (CMS-10055) to inform the resident of potential liability for payment and related standard claim appeal rights. Findings include: Review of Resident #55's census data information revealed Resident #55's services in the facility was covered by Medicare Part A, effective 2/2/2022. Review of Resident #55's coverage notice records revealed a Notice of Medicare Non-Coverage form that documented Resident #55's skilled nursing services would end on 4/5/2022. Review of the Beneficiary Protection Notification Review form completed by the Minimum Data Set Coordinator revealed the facility initiated Resident #55's discharge from Medicare Part A Services with benefit days remaining. Review of Resident #55's coverage notice records failed to reveal any documentation that Resident #55 had been provided with the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10055). During an interview on 6/29/2022 at 9:15 AM, the Minimum Data Set Coordinator confirmed that Resident #55 had remained in the facility and Resident #55's benefit days were not exhausted. She stated that Resident #55 should have been issued the Skilled Nursing Advance Beneficiary of Non-Coverage notices (CMS-10055) to inform her or her representative of potential liability for payment and related standard claim appeal rights, but the previous Social Worker had not provided the Skilled Nursing Advance Beneficiary of Non-Coverage notice (CMS-10055) to Resident #55 or her representative.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personal privacy during enteral gastrostomy tu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personal privacy during enteral gastrostomy tube feeding for 2 of 2 residents receiving ostomy care, Resident #92 and Resident #410. Findings include: 1. Review of Resident #92's records revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, protein-calorie malnutrition, gastrostomy tube, hypertension, cardiovascular disease, anemia, hyperlipidemia, major depressive disorder, GERD (Gastroesophageal Reflux Disease). Review of the physician orders for Resident #29 reads, Order Summary: Enteral Feed Order every 4 hours Bolus with 8 oz (240 ml [milliliter]) Jevity 1.5 via g-tube q [every] 4 hours. Order Date: 12/01/2021. During an observation on 6/27/2022 at 2:00 PM, Staff A, Registered Nurse (RN), approached Resident #92 to administer his enteral feeding. Staff A pulled the privacy curtain halfway and left the door wide open. Staff A proceeded to expose the abdomen to visualize the G-tube. Staff A attached the feeding syringe to the distal end of the G-tube and poured 100 ml of water. Staff A proceeded to pour Jevity 1.5, 237 ml via gravity. Staff A exited the resident room at 2:10 PM. During an interview with Staff A, RN, on 6/27/2022 at 2:11 PM, when asked if he ensured privacy for Resident #92 during G-tube feeding, Staff A stated, I was about to pull the curtain around, but his roommate was leaving the room. 2. Review of Resident #410's records revealed the resident was admitted on [DATE] with the diagnoses to include gastrostomy tube and dysphagia. Review of the physician orders for Resident #410 reads, Order Summary: Jevity 1.5 Cal Liquid (Nutrition Supplements), Give 240 ml via G-tube every 4 hours related to Gastrostomy Status . Order Date: 06/29/2022. During an observation on 6/28/2022 at 1:25 PM, Staff B, Licensed Practical Nurse (LPN), entered Resident #410's room with Jevity solution and Amoxicillin 10 ml in a medicine cup. Staff B proceeded to expose Resident #410's abdomen to visualize the G-tube. Staff B did not pull the privacy curtain. Resident $401's roommate, Resident #409, was up on a chair approximately 3 feet within direct visual view to Resident #410. Resident # 409 was watching the G-tube feeding process. Staff B proceeded to connect the feeding syringe to the distal end of the G-tube. Staff B poured 30 ml of water to the tube, followed by the 10 ml of Amoxicillin, and then flushed the syringe with 30 ml of water. Staff B then poured the Jevity solution 237 ml to the G-tube, slowly infusing via gravity. During an interview with Staff B, LPN, on 6/28/2022 at 1:35 PM, she confirmed that she did not provide privacy to Resident #410. Staff B stated, I knew I am supposed to do those steps, but I was too nervous and shaky and not thinking right. During an interview with Resident #410 at 1:40 PM, when asked how he felt about his privacy during the tube feeding process, he stated, It happens all the time that I do not care anymore. Review of the facility policy and procedure titled Resident Rights with the review date of January 19, 2022 reads, (h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meeting with family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set assessment was accurate for 1 of 5 resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set assessment was accurate for 1 of 5 residents reviewed for unnecessary medications, Resident #48. Findings include: Review of Resident #48's quarterly Minimum Data Set, dated [DATE], revealed the resident received an anticoagulant medication for 7 days prior to the assessment. Review of Resident #48's medication administration record for the period from 4/1/2022 through 4/30/2022, did not show documentation that the resident had been administered an anticoagulant medication during April 2022. During an interview on 6/28/2022 at 12:53 PM, the Minimum Data Set Coordinator confirmed Resident #48 was not administered an anticoagulant medication during April 2022. She stated she must have clicked [anticoagulant] by accident.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to verify that the gastrost...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services to verify that the gastrostomy tube (G-tube) was functioning before beginning a feeding and before administering medications, which may include checking for gastric residual volume (GRV) according to professional standards of practice for 2 of 6 residents who received ostomy care, Resident #92 and #410. Findings include: 1. Review of Resident #92's records revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, protein-calorie malnutrition, gastrostomy tube, hypertension, cardiovascular disease, anemia, hyperlipidemia, major depressive disorder, GERD (Gastroesophageal Reflux Disease). Review of the physician orders for Resident #29 reads, Order Summary: Enteral Feed Order every 4 hours Bolus with 8 oz (240 ml [milliliter]) Jevity 1.5 via g-tube q [every] 4 hours. Order Date: 12/01/2021 . Enteral Feed Order every shift Enteral: Check residual prior to initiating a feeding. If greater than 100 CC's, hold feeding and recheck in 1 hour(s) . Order Date: 11/24/2021 . Enteral Feed Order every shift Enteral: Check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding, when there is an interruption of feeding, or at least every shift for continuous feeding. Order Date: 11/24/2021. During an observation on 6/27/2022 at 2:00 PM, Staff A, Registered Nurse (RN), approached Resident #92 to administer his enteral feeding. Staff A raised the head of the bed. The resident was in semi-Fowlers position. Staff A proceeded to expose the abdomen/ G-tube. Staff A attached the feeding syringe to the distal end of the G-tube and poured 100 ml of water. Staff A did not check for gastric residual and or check for G-tube placement. Staff A proceeded to pour Jevity 1.5, 237 ml via gravity. During an interview on 6/27/2022 at 2:11 PM, Staff A, RN, confirmed that he did not check G-tube placement, did not check for residual, and did not rinse the feeding syringes after using it. Staff A stated, I checked the residual early today and was 5 ml. I will remember to rinse syringes. Review of Resident #92's Minimum Data Set (MDS) with assessment reference date of 11/30/2021 showed the resident was coded for tube feeding under Section K. Review of Resident #92's care plan initiated on 12/4/2021 reads, Focus: [Resident #92's name] requires tube feeding r/t [related to] Depression, Dysphagia, Swallowing problem, and CVD . Interventions: Check for tube placement and gastric contents/ residual volume per facility protocol and record . Monitor/ document/ report PRN [as needed] any s/sx [signs/ symptoms] of: Aspiration- fever, SOB [Shortness of Breath], tube dislodged, infection at tube site. 2. Review of Resident #410's records revealed the resident was admitted on [DATE] with the diagnoses to include gastrostomy tube and dysphagia. Review of the physician orders for Resident #410 reads, Order Summary: Jevity 1.5 Cal Liquid (Nutrition Supplements), Give 240 ml via G-tube every 4 hours related to Gastrostomy Status . Order Date: 06/29/2022. Review of Resident #410's care plan initiated on 6/27/2022 reads, Focus: [Resident #410's name] requires tube feeding r/t [related to] Dysphagia . Interventions: Administer Jevity 1.5 240 ml [milliliter] via G-Tube Q4 [every 4] 4 hours . Check for tube placement and gastric contents/ residual volume per facility protocol and record . Flush GT (gastrostomy tube) with 50 ml of water Q4 hours for total of 300 ml/24 hours . Provide local care to G-Tube site as ordered and monitor for s/sx [signs and symptoms] of infection. During an observation on 6/28/2022 at 1:25 PM, Staff B, Licensed Practical Nurse (LPN), entered Resident #410's room with Jevity solution and Amoxicillin 10 ml in a medicine cup. Staff B donned personal protective equipment (PPE). The resident was seated upright on a wheelchair. Staff B proceeded to expose the resident's abdomen to visualize the G-tube. Staff B proceeded to connect the feeding syringe to the distal end of the G-tube. Staff B poured 30 ml of water to the tube, followed by the 10 ml of Amoxicillin, and then flushed the syringe with 30 ml of water. Staff B then poured the Jevity solution 237 ml to the G-tube, slowly infusing via gravity. Staff B did not check for gastric residual and did not check the G-tube placement. Staff B flushed the G-tube with 100 ml of water. Staff B immediately placed the feeding syringe with the plunger in a plastic container bag without rinsing them. Staff B doffed off the gloves and exited the room. During an interview on 6/28/2022 at 1:35 PM, Staff B, LPN, confirmed that she did not check for residual and G-tube placement, and did not rinse the feeding syringe after use. Staff B stated, I knew I am supposed to do those steps, but I was too nervous, shaky, and not thinking right. During an interview on 6/28/2022 at 1:06 PM, Unit B Manager stated, Nurse is to check for residual, and tube placement before giving the feeding. The nurse uses a stethoscope to auscultate the abdomen for placement. They give the feeding by gravity. Unit B Manager acknowledged that the feeding syringe must be rinsed after use and placed separating the syringe and the plunger in the plastic bag. Review of the policy and procedure titled Feeding Tubes reviewed on January 19, 2022 reads, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of tube feedings . Procedure: Feeding Administration. 1- Bolus Gravity Feedings: d. Verify tube placement using both of the following 2 methods: * Auscultation: Instill 10-20 cc [cubic centimeter] of air using 30 cc syringe into gastric tube and listen for sound of air rushing or gurgling by placing stethoscope over upper left quadrant of abdomen. * Aspiration: Using a 30 cc syringe, clear tube with 20 cc of air. Withdraw gastric contents and evaluate color of aspirate. e. Check for residual, as indicated . h. Allow feeding prescribed solution to drain in by gravity, refilling the syringe as necessary (note: To avoid instilling more air into the stomach, do not allow syringe to empty before adding more solution) . Miscellaneous: . 3. Proper placement of the tube must be assessed by auscultation and gastric aspiration before the instillation of any liquid into it.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0885 (Tag F0885)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to inform residents, their representatives, and families by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19...

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Based on record review and interview, the facility failed to inform residents, their representatives, and families by 5 PM the next calendar day following the occurrence of a single confirmed COVID-19 infection. Findings include: Review of the facility records revealed Residents #98, #14, and #93 were COVID-19 positive on 6/2/2022, and Resident #47 was COVID-19 positive on 6/20/2022. Further review of the records did not reveal any notifications sent to the residents, resident representatives, and families. During an interview on 6/29/2022 at 2:00 PM, the Infection Control Nurse stated that notifications were not sent out when those residents were COVID-19 positive. Review of the policy and procedure titled COVID-19 Dedicated Unit: Responding to COVID-19 in the facility reviewed on January 19, 2022 reads, Policy: The facility will adhere to current CDC [Centers for Disease Control and Prevention] guidance and the direction of the Florida Department of Health and/or the Agency for Health Care Administration for infection prevention and control of COVID-19 . Procedure for COVID Positive Unit: . Communication: * Develop a system of notification and communication: 1. Promptly (by 5 pm the next calendar day) notify staff, residents and families about identification of COVID-19 in the facility.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered, labeled, and discarded in the areas of the kitchen coolers and freezers,...

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Based on observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered, labeled, and discarded in the areas of the kitchen coolers and freezers, failed to ensure food was properly served on the tray line, and failed to ensure the equipment were cleaned as per the policy guidelines. Findings include: A walk-through tour of the kitchen on 6/27/2022 at 9:16 AM with the Certified Dietary Manager (CDM) showed an opened large container of macaroni salad with no open date in the walk-in cooler. The tour also revealed a food container labeled as Lasagna and a pan of chicken noodle soup placed on the steam table at 9:13 AM that was designated as lunch by the CDM. During an interview on 6/27/2022 at 10:28 AM, the Certified Dietary Manager (CDM) confirmed that the observed products did not have a label and identified them as macaroni salad, potato salad, and cottage cheese. The CDM stated, The products should be labeled according to the policy. All products should be closed or covered when stored. The CDM confirmed that Lasagna and soup were on the tray line at 9:30 AM and should be placed on the line 30 minutes or less before serving the meal. A follow-up tour of the kitchen on 6/28/2022 at 7:33 AM with the CDM showed a pink slimy buildup on the interior door of the ice machine, a 2-cup measuring cup left in a large bulk container of flour, five containers of what appeared to be cottage-cheese on a tray in the walk-in cooler without a label, numerous dirty pots and pans and utensils in the prep-sink, numerous dirty rags, which were not in a sanitation solution bucket, and numerous food particles inside the microwave oven on the sides, top and base. The CDM was observed taking temperatures of the pan of scrambled eggs on the tray line and the pan of prepared oatmeal without sanitizing the thermometer between the two foods. During an interview on 6/28/2022 at 8:28 AM, the CDM confirmed that no dipping or measuring devises should be stored in the bulk food containers, and the thermometer should be cleaned and sanitized with an alcohol pad after temping each food to prevent cross-contamination. The CDM verified the presence of a pink slimy substance on the interior door of the ice machine and confirmed that the microwave was dirty with numerous food particles on the top and base of the equipment. Review of the policy and procedure titled Sanitation/Infection Control reads, 5. All equipment is cleaned as needed. The following suggestions indicate the frequency of cleaning of major equipment, but the list is not all inclusive . c. Once weekly, storage shelves are cleaned thoroughly, as are tables, chairs, dish machines, knife guard, counter, janitor's closets, all drawers, refrigerators, freezers and flatware containers. Dishes & cups are soaked for stain removal. Graters, spice racks, work tales, baseboards, hoods & filter, range, all stainless steel equipment, ice machines, the storeroom (including the shelves), carts, oven, & racks are cleaned & sanitized. Review of the policy and procedure titled Food Serving Temperatures reads, Holding Temperatures . 3. The temperature will be taken and recorded for all hot and cold food items at each meal prior to starting tray service. Sanitize thermometer prior to taking temperature of each item . 7. Heating food in the steam table is prohibited. Heating food to the proper temperature is accomplished by direct heat (stove, oven, steamer, etc.) and food is then transferred to the steam table not more than 30 minutes before meal service. 8. Foods temperatures shall maintain minimum temperatures through tray line or no greater than 2 hours on tray line. Review of the policy and procedure titled Food Storage reads, Procedures . 6. Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are not to be stored in the food containers but are kept covered in a protected area near the containers . 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
Concerns
  • • 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
  • • $20,770 in fines. Higher than 94% of Florida facilities, suggesting repeated compliance issues.
  • • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Northbrook Center For Rehabilitation And Healing's CMS Rating?

CMS assigns NORTHBROOK CENTER FOR REHABILITATION AND HEALING an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Northbrook Center For Rehabilitation And Healing Staffed?

CMS rates NORTHBROOK CENTER FOR REHABILITATION AND HEALING's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 46%, compared to the Florida average of 46%.

What Have Inspectors Found at Northbrook Center For Rehabilitation And Healing?

State health inspectors documented 23 deficiencies at NORTHBROOK CENTER FOR REHABILITATION AND HEALING during 2022 to 2025. These included: 23 with potential for harm.

Who Owns and Operates Northbrook Center For Rehabilitation And Healing?

NORTHBROOK CENTER FOR REHABILITATION AND HEALING is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by INFINITE CARE, a chain that manages multiple nursing homes. With 120 certified beds and approximately 111 residents (about 92% occupancy), it is a mid-sized facility located in BROOKSVILLE, Florida.

How Does Northbrook Center For Rehabilitation And Healing Compare to Other Florida Nursing Homes?

Compared to the 100 nursing homes in Florida, NORTHBROOK CENTER FOR REHABILITATION AND HEALING's overall rating (2 stars) is below the state average of 3.2, staff turnover (46%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Northbrook Center For Rehabilitation And Healing?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Northbrook Center For Rehabilitation And Healing Safe?

Based on CMS inspection data, NORTHBROOK CENTER FOR REHABILITATION AND HEALING has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Florida. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Northbrook Center For Rehabilitation And Healing Stick Around?

NORTHBROOK CENTER FOR REHABILITATION AND HEALING has a staff turnover rate of 46%, which is about average for Florida nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Northbrook Center For Rehabilitation And Healing Ever Fined?

NORTHBROOK CENTER FOR REHABILITATION AND HEALING has been fined $20,770 across 1 penalty action. This is below the Florida average of $33,287. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Northbrook Center For Rehabilitation And Healing on Any Federal Watch List?

NORTHBROOK CENTER FOR REHABILITATION AND HEALING is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

NORTHBROOK CENTER FOR REHABILITATION AND HEALING

575 LAMAR AVE, BROOKSVILLE, FL 34601 | (352) 799-2226

D
Trust Grade (48/100)
2.0
CMS Rating
23
Deficiencies

Strengths

  • 4-star quality

Concerns

  • 2-star rating

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025