Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northbrook Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
A resident expressed a desire to resume walking but was not receiving restorative services despite having an active physician's order for a walking program. The order, dated December 2024, specified ambulation with a two-wheeled walker and close contact assistance. The Director of Nursing confirmed the resident was not picked up for restorative services, and the Occupational Therapist noted the need to follow therapy goals. The facility lacked a policy to ensure residents with orders were included in restorative programs.
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in nutritional and medication management. One resident's MDS inaccurately reflected their caloric intake from tube feeding, while another resident's active diagnosis of pneumonia was not documented in the MDS. Staff interviews confirmed these discrepancies, highlighting a lack of adherence to the facility's policy on MDS accuracy and completeness.
A resident did not receive their medication as ordered by the physician. An LPN applied 1 gram of Diclofenac Sodium gel to each knee instead of the prescribed 2 grams per knee. The LPN was unsure of the correct dosage, and the DON later confirmed the order was entered incorrectly. The facility's policy requires medications to be administered as prescribed, which was not adhered to in this case.
A resident with a PICC line did not receive dressing changes according to professional standards. The dressing was not dated, and records showed discrepancies in the frequency of changes. The facility's policy required more frequent changes than what was documented, and the DON confirmed the lapses in protocol.
The facility failed to provide dietary services as ordered for three residents. A resident did not receive fortified foods as per their physician's order, and another resident's tube feeding rate was not increased despite a recommendation due to weight loss. Additionally, another resident did not receive fortified foods as ordered. The facility's policy on nutritional interventions was not followed, resulting in these deficiencies.
A facility failed to document arrival times and vital signs for a resident receiving dialysis on multiple occasions, as required by their policy. Staff interviews confirmed the lack of documentation and the expectation to complete communication forms for dialysis residents. The facility's policy outlines necessary steps for pre- and post-dialysis care, which were not followed.
The facility did not update the nurse staffing information daily as required. The posted information at the front desk was outdated, showing a date from several days prior. The Administrator and Staffing Coordinator confirmed that the staffing information should be updated daily, with the coordinator responsible during the week and the weekend supervisor on weekends. Although the staffing numbers were correct, the date was not updated.
The facility failed to properly store and manage medications, as observed with a resident's Ventolin inhaler left unattended and another resident with pills on their table without self-administration authorization. The facility's policy requires medications to be stored in locked compartments accessible only to authorized personnel.
The facility failed to maintain complete and accurate medical records for residents, leading to deficiencies in medication management and documentation. A resident's insulin administration was not documented, another's enteral feeding order was incorrectly recorded, and behavior monitoring for a third resident was inaccurately documented. These issues were acknowledged by the DON and staff involved.
The facility failed to ensure proper infection control practices during medication administration and care for residents under isolation precautions. An LPN and an RN were observed handling medications without proper hand hygiene or gloves. Additionally, a Wound Care Nurse and a CNA did not adhere to PPE requirements for residents under Enhanced Barrier Precautions and contact isolation, respectively. These actions were contrary to the facility's policies.
Failure to Provide Restorative Services for Resident Mobility
Penalty
Summary
The facility failed to provide restorative services to maintain mobility for a resident, identified as Resident #16, who was reviewed for such services. The resident expressed a desire to start walking again and was not participating in any physical therapy or walking program at the time of the interview. A physician's order dated December 16, 2024, indicated an active restorative program for the resident, which included ambulation using a two-wheeled walker, gait belt, and close wheelchair follow, with close contact assistance up to 100 feet, three times weekly. However, the Director of Nursing confirmed that the resident was not picked up for restorative services in December 2024, despite having an order for it. The Occupational Therapist stated that the goals in the referral should have been followed to continue the therapy goals. The Director of Nursing acknowledged the expectation for the restorative team to pick up residents with an order but noted the absence of a directly related policy.
Inaccurate Resident Assessments in Nutrition and Medication Management
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in nutritional and medication management. For one resident, the facility's records inaccurately reflected the resident's nutritional intake. Observations showed the resident receiving Jevity 1.5 via tube feeding at a consistent rate, yet the Minimum Data Set (MDS) inaccurately documented the resident's caloric intake as 25% or less from tube feeding. Interviews with the Registered Dietician and Certified Dietary Manager confirmed that the resident received all caloric intake through the gastric tube, contradicting the MDS entry. The MDS Registered Nurse acknowledged the error after consulting with dietary staff. In another case, the facility failed to document an active diagnosis of pneumonia for a resident in the MDS. The resident was admitted with a diagnosis of pneumonia and had a physician's order for Levaquin to treat the condition. However, the MDS did not reflect this active diagnosis under Section I. The MDS Registered Nurse admitted that the section was incorrect and should have included pneumonia. The facility's policy on MDS compliance emphasizes the need for accuracy and completeness, which was not adhered to in these instances.
Medication Administration Error for Resident
Penalty
Summary
The facility failed to ensure that a resident received their medication as ordered by the physician. During an observation, an LPN applied 2 grams of Diclofenac Sodium topical gel to a medication ruler and then applied 1 gram to each knee of a resident. However, the physician's order specified that 2 grams should be applied to each knee. The LPN was unsure of the correct dosage and stated the need to call the APRN for clarification. The Director of Nursing later confirmed that the order was entered incorrectly into the system, indicating that 2 grams should be applied to each knee. The facility's policy on administering medications states that medications should be administered in accordance with prescriber orders, which was not followed in this instance.
Failure to Adhere to PICC Line Dressing Change Protocols
Penalty
Summary
The facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for a resident receiving intravenous therapy. During an observation, the resident was found with a single lumen PICC line on her right arm, covered with a transparent dressing and gauze underneath, which was not dated. The resident mentioned that the dressing was last changed on a Thursday, but the Medication Administration Record indicated the last change was on a previous Saturday. The physician's order required the dressing to be changed every Saturday evening shift, but this was not adhered to. Additionally, the facility's policy stated that gauze dressings should be changed every 2 days and transparent dressings every 5-7 days, which was not followed. The Director of Nursing confirmed that the dressing should be labeled with the date of change and that the dressing changes were not performed as required.
Failure to Provide Dietary Services as Ordered
Penalty
Summary
The facility failed to provide dietary services as ordered by the physician for three residents. Resident #352 was observed receiving meals that did not include fortified foods as per the physician's order for a Low Concentrated Sweets diet with fortified foods. The Registered Dietitian and Certified Dietary Manager confirmed that fortified foods were not included in the meal tickets, which should have been oatmeal for breakfast and mashed potatoes for lunch and dinner. Resident #31 was observed receiving Jevity 1.5 via feeding tube at a rate of 80 milliliters per hour, despite a recommendation to increase the rate to 85 milliliters per hour due to weight loss. The recommendation was not followed, and the physician was not notified of the need to increase the tube feeding rate. Resident #405 also did not receive fortified foods as ordered, with meals lacking the required oatmeal and mashed potatoes. The facility's policy on nutritional interventions was not adhered to, leading to these deficiencies.
Failure to Document Dialysis Care for a Resident
Penalty
Summary
The facility failed to ensure proper assessment and documentation for a resident receiving dialysis services. Specifically, the facility did not document arrival times and vital signs on the Dialysis Center-Facility Communication Forms for multiple dates, including 2/28/2025, 3/3/2025, and 3/5/2025. Additionally, there was no communication form available for the dialysis visit on 3/10/2025. The facility's policy requires that a nurse complete the top section of the form before dialysis and the bottom section after dialysis, including signing and dating the form. However, these procedures were not followed, as confirmed by interviews with staff members who acknowledged the missing documentation and the expectation to complete these forms. The deficiency was further highlighted during interviews with staff members, including two LPNs and the Director of Nursing (DON), who confirmed the lack of documentation and the expectation for staff to complete the communication forms for dialysis residents. The facility's policy on the care of residents receiving dialysis, last reviewed on 2/19/2025, outlines the necessary steps for pre- and post-dialysis care, which were not adhered to in this case. This lack of compliance with the facility's policy and procedure resulted in the failure to properly assess and document the resident's condition before and after dialysis treatments.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily as required. Upon entry to the facility, it was observed that the nurse staffing information displayed at the front desk was outdated, showing a date of 3/19/2025. During an interview, the Administrator acknowledged that the federal requirement mandates daily updates to the staffing information. The Administrator explained that the staffing coordinator is responsible for updating the information during weekdays, while the weekend supervisor handles it on weekends. The staffing coordinator confirmed their responsibility for updating the information during the week and noted that although the staffing numbers were correct, the date had not been updated.
Improper Storage and Administration of Medications
Penalty
Summary
The facility failed to ensure proper storage and administration of drugs and biologicals in accordance with accepted professional principles. During an observation, a Ventolin HFA inhaler was found on the nightstand of a resident who claimed to self-administer the medication. However, the Director of Nursing confirmed that no residents were authorized to self-administer medications, and there was no order for the inhaler in the resident's records. This indicates a lapse in medication management and oversight, as medications should not be left unattended and must be administered by authorized personnel. In another instance, a resident was observed with a cup containing multiple pills on their overbed table, stating they would take them later. A review of the resident's medical records showed no evaluation for self-administration of medications. The facility's policy requires all medications, except those in emergency drug kits, to be stored in locked compartments accessible only to authorized personnel. These findings highlight the facility's failure to adhere to its medication storage policy, potentially compromising resident safety.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate medical records for several residents, leading to deficiencies in medication management and documentation. For one resident, the Medication Administration Record (MAR) lacked entries for the administration of Insulin Glargine on two specific dates, despite the resident stating that all medications were given. A Licensed Practical Nurse (LPN) admitted to being distracted and failing to document the administration, which was acknowledged by the Director of Nursing (DON) who noted the missing entries. Another resident's physician order for enteral feeding was incorrectly documented, stating to hold bolus feeding if the resident ate less than 50% of their meal, when it should have been the opposite. This error was identified by the DON and confirmed by the Certified Dietary Manager. Additionally, behavior monitoring documentation for a third resident was inaccurately recorded, with staff using 'NA' instead of 'Y' or 'N' to indicate the presence or absence of behaviors. This was recognized as a user error by the DON and confirmed by two LPNs, who stated that 'NA' should not be used in behavior monitoring documentation.
Inadequate Infection Control Practices During Medication Administration and Isolation Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during medication administration and care for residents under isolation precautions. During an observation, a Licensed Practical Nurse (LPN) was seen scratching her head and then continuing to prepare medication without performing hand hygiene. The LPN also handled medication capsules with bare hands, contrary to the facility's policy that requires gloves to be worn during such tasks. The Director of Nursing (DON) confirmed that the staff should have performed hand hygiene after touching their face and should not have handled medication with bare hands. In another instance, a Registered Nurse (RN) was observed opening medication capsules with bare hands, stating that gloves were not necessary as she was only touching the outside of the capsules. This was against the facility's policy, which mandates glove use during medication preparation. Additionally, the Wound Care Nurse failed to wear a gown while providing care to a resident under Enhanced Barrier Precautions, despite signage indicating the need for such precautions. The DON confirmed that gown and glove use is required during high-contact care activities for residents under these precautions. Furthermore, a Certified Nursing Assistant (CNA) entered a resident's room, who was under contact isolation for C. difficile, without wearing a gown. The CNA admitted to being in a hurry and not noticing the precaution signage. The DON reiterated that appropriate PPE should be worn before entering rooms of residents on contact isolation. The facility's policies on hand hygiene, medication administration, and isolation precautions were not adhered to, leading to these deficiencies.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Nursing homes near Brooksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brooksville Healthcare Center | 0.6 mi | ★★★★★ | 10 | 0 |
| Aviata At Brooksville | 2 mi | ★★★★★ | 0 | 0 |
| Oak Hill Health & Rehabilitation | 7.6 mi | ★★★★★ | 2 | 0 |
| Evergreen Woods | 7.8 mi | ★★★★★ | 0 | 0 |
| Aviata At Spring Hill | 7.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.