Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Oak Hill Health & Rehabilitation during CMS and state inspections, most recent first.
Two residents did not consistently receive physician‑ordered medications, and nursing documentation was incomplete or missing when doses were not given. One resident with a UTI and chronic kidney disease had multiple scheduled doses of Bactrim DS left blank or coded as "other" on the MAR over several ordered courses, with progress notes often stating the drug was "awaiting delivery" and some MAR entries lacking any explanatory note, despite the drug being available in an automated dispensing system. Another resident with neuropathy and other comorbidities had ordered daily IM cyanocobalamin injections, but several MAR entries were marked as "not applicable" or "other" without corresponding progress notes; the resident reported feeling unusually fatigued and believed not all B‑12 injections were received, and the DON later stated that not all doses had arrived from the pharmacy and that nurses should have followed up and notified the physician.
Two residents experienced missed doses of ordered medications without proper documentation or physician notification. One resident with a history of UTIs and chronic kidney disease had multiple scheduled doses of Bactrim DS marked with codes on the MAR indicating issues such as "other/see nurse notes," with some notes stating the drug was awaiting delivery and other entries lacking any explanation, and no record that the provider was notified of the missed doses. Another resident with osteoarthritis, cerebellar ataxia, pneumonia, and generalized weakness had ordered daily IM cyanocobalamin injections for neuropathy, but several doses were coded as not applicable or other on the MAR without corresponding Progress Notes or evidence that the physician was informed when the medication was not available or not given, contrary to facility medication monitoring and administration policies.
Surveyors found that PASRR documentation was not accurately completed for several residents with mental health diagnoses, including those prescribed multiple psychotropic medications and with documented histories of depression, anxiety, psychosis, and other psychiatric conditions. Despite clear evidence in clinical records and physician orders, PASRR forms often failed to reflect these diagnoses, a fact confirmed by interviews with the DON and Administrator.
The facility did not ensure IV dressing changes were performed as ordered for two residents with PICC lines, with dressings left unchanged beyond the required interval. Additionally, a resident received Carvedilol for hypertension outside of the physician-ordered blood pressure parameters, with staff interviews revealing confusion about the order's instructions. These deficiencies were confirmed through observation, record review, and staff interviews, in violation of facility policy and physician orders.
Surveyors found that medications and IV infusions were not properly labeled or securely stored. IV bags and tubing for two residents were missing required date and time labels, and topical medications were left unsecured on bedside tables. Staff interviews confirmed that these practices did not follow facility policy or professional standards.
Multiple residents reported that their food was cold or lukewarm, and a test tray investigation confirmed that hot foods and drinks were not served at required temperatures. The Certified Dietary Manager verified that the measured temperatures did not meet facility policy or professional standards for safe food service.
Surveyors found that food items in the kitchen and nourishment areas were not stored according to professional standards, including unlabeled and undated tater tots, uncovered slices of pie, and an ice scooper left in direct contact with ice. Staff interviews confirmed these practices did not comply with facility policy for food safety.
The facility did not maintain complete and accurate medical records for a resident with a PICC line and two residents receiving insulin therapy. Observed deficiencies included incorrect or missing documentation of dressing changes, incomplete entries in the MAR for insulin administration, and lack of documented provider notification for high blood glucose readings, despite facility policy requiring thorough and timely documentation.
An LPN administered medication, enteral feeding, and performed an IV flush for a resident with physician-ordered Enhanced Barrier Precautions (EBP) without wearing the required PPE, including gown, gloves, and mask. There was no EBP signage on the resident's door, and the LPN was unaware of the EBP requirements due to the lack of signage. The DON confirmed staff should follow orders and use appropriate PPE.
The facility failed to secure medications, as observed in two residents' rooms where Systane eyedrops and other items were found accessible. Interviews revealed that the residents used these items without physician orders for self-administration. Staff confirmed that medications should not be left at the bedside without proper authorization, which was not obtained for these residents.
Failure to Administer and Document Ordered Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered medications as prescribed for residents with active treatment needs. One resident with a history of urinary tract infections and chronic kidney disease was ordered Bactrim DS 800-160 mg twice daily for a UTI over multiple 14‑day courses beginning in mid‑December. The MAR showed the initial dose was given, but subsequent scheduled doses on multiple mornings were either left blank or coded as “9 – Other/See Nurse Notes,” with progress notes repeatedly stating “awaiting delivery” of Bactrim. Despite this, new Bactrim orders with new start dates were entered several times, and there were repeated gaps where doses were not administered as ordered. On several dates, there was no corresponding nursing documentation explaining the non‑administration of the medication, even when the MAR indicated a code requiring a nurse note. A second resident, admitted with diagnoses including primary generalized osteoarthritis, cerebellar ataxia, pneumonia, and generalized muscle weakness, had a physician’s order for Cyanocobalamin (Vitamin B‑12) 1000 mcg IM daily for seven days for neuropathy. The MAR documented codes of “12 – Not Applicable” for two scheduled administration dates and a “9 – Other/See Nurse Note” on another date. However, the resident’s progress notes contained no documentation explaining the use of these codes or why the injections were not administered as ordered. The resident later reported feeling more fatigued than usual and believed she had not received all of her B‑12 injections, and stated that the facility was having problems obtaining the shots. Interviews and policy review further clarified the nature of the deficiency. The DON stated that when medications are unavailable, nurses are expected to document this on the MAR, notify the provider, and follow up with the pharmacy, and also noted that Bactrim was available in the facility’s automated medication dispensing system. For the B‑12 injections, the DON reported that the pharmacy had sent the medication in a kit and not all doses had arrived, and again stated that nurses should have contacted the physician and checked with the pharmacy when the medication was not available. Facility policies on Medication Monitoring and Medication Administration required that refusals, frequent holding of medications, adverse consequences, and discrepancies be reported and documented, but the records for both residents showed missing doses and incomplete or absent documentation related to those missed medications.
Failure to Document Unavailable Medications and Notify Physicians of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to properly document unavailable medications and to notify physicians when ordered medications were not administered as prescribed. For one resident with a history of urinary tract infections and chronic kidney disease, physician orders directed Bactrim DS to be given twice daily for multiple 14‑day courses beginning in mid‑December. The MAR showed an initial dose given, followed by blank or coded entries (such as “9 – Other/See Nurse Notes”) for multiple scheduled doses. Progress Notes for some of these dates documented that Bactrim was “awaiting delivery,” but there were also instances where a “9” code appeared on the MAR without any corresponding explanatory note in the record. Across several consecutive order periods for this same resident, the facility repeatedly entered new Bactrim DS orders with new start dates while multiple morning doses were not administered and marked with code 9 on the MAR. For some of these missed doses, the Progress Notes indicated the medication was still awaiting delivery from the pharmacy, and a later note documented that the pharmacy was contacted and that Bactrim was to be sent stat with use of an automated dispensing system supply until delivery. However, review of the medical record from mid‑December through the end of the month did not show documentation that the physician was notified when Bactrim DS was not administered as ordered during these periods. For another resident admitted with diagnoses including primary generalized osteoarthritis, cerebellar ataxia, pneumonia, and generalized muscle weakness, physician orders directed daily intramuscular cyanocobalamin (vitamin B‑12) injections for neuropathy over seven days. The MAR documented codes of “12 = Not Applicable” on two days and “9 = Other/See Nurse Note” on another day for the B‑12 injections, but the Progress Notes contained no documentation explaining these codes or the reasons the injections were not given. This resident reported feeling more fatigued than usual and believed she had not received all of her B‑12 injections, and the DON stated that not all doses had arrived from the pharmacy. Review of this resident’s record for the relevant period showed no documentation that the physician was notified when the B‑12 injections were not administered as ordered, despite facility policies requiring reporting and documentation of medication issues.
Failure to Accurately Complete PASRR Documentation for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Reviews (PASRR) were accurately completed for all residents reviewed for mood and behavior disorders. Specifically, for seven residents, the PASRR documentation did not reflect the presence of serious mental illness or intellectual disability, despite clinical records and physician orders indicating diagnoses such as anxiety disorder, major depressive disorder, psychosis, bipolar disorder, schizoaffective disorder, PTSD, and other psychiatric conditions. In several cases, residents were prescribed multiple psychotropic medications for these conditions, yet their PASRR forms did not acknowledge any mental illness. For example, one resident was readmitted with diagnoses including anxiety disorder, major depressive disorder, and psychosis, and was prescribed medications such as Xanax and Zoloft, but the PASRR did not document any serious mental illness. Another resident had a history of bipolar disorder and major depressive disorder, with physician orders for Depakote, aripiprazole, escitalopram, Remeron, and buspirone, and a psychiatry note referencing schizoaffective disorder, yet the PASRR failed to indicate any mental illness. Similar discrepancies were found for other residents, where clinical documentation and medication orders clearly indicated mental health diagnoses, but the PASRR forms either omitted these diagnoses or only partially documented them. Interviews with facility leadership, including the DON and Administrator, confirmed that the PASRRs were not completed accurately and did not include all applicable diagnoses. The Administrator acknowledged the inaccuracies and stated an expectation that PASRRs should be correct. The findings were based on both record review and staff interviews, highlighting a pattern of incomplete or inaccurate PASRR documentation for residents with significant mental health needs.
Failure to Follow Physician Orders for IV Dressing Changes and Medication Parameters
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders for intravenous (IV) dressing changes and medication management for multiple residents. For two residents with peripherally inserted central catheters (PICCs), observations revealed that the dressings covering the insertion sites were not changed within the required timeframe specified by physician orders and facility policy. One resident's PICC dressing was dated twelve days prior, despite an order to change it weekly, and staff interviews confirmed the dressing should have been changed earlier. Another resident's PICC dressing was also not changed within the seven-day interval required by both physician order and facility policy, as confirmed by staff and the DON during interviews. Additionally, the facility failed to ensure medication was administered according to physician-ordered parameters for a resident prescribed Carvedilol for hypertension. The medication was administered multiple times when the resident's systolic blood pressure was below the ordered threshold, contrary to the physician's instructions to hold the medication if the systolic blood pressure was less than 135. Staff interviews indicated confusion regarding the interpretation of the order's parameters, and the DON acknowledged that medications were given outside of the specified parameters. The facility's policy requires medications to be administered as ordered by the physician and in accordance with professional standards of practice.
Failure to Label and Secure Medications and IV Infusions
Penalty
Summary
Surveyors observed multiple instances where medications and biologicals were not properly labeled or securely stored. In one case, a resident had an IV pole at bedside with a Zosyn infusion bag and tubing that were not labeled with the date or time. Similar deficiencies were noted with another resident, where both the IV medication bag and tubing lacked required labeling. Additionally, topical medications such as CeraVe eczema relief cream and Germa Ubre Plus analgesic ointment were found unsecured on bedside tables, accessible to residents without proper authorization or assessment for self-administration. Interviews with staff confirmed that IV medications should be labeled with the date and time, and that residents require a self-administration assessment and physician approval to keep medications at bedside. Facility policies reviewed by surveyors also required labeling of IV tubing and medications in accordance with professional standards and federal regulations. The observed failures to label and secure medications were not in compliance with these policies and accepted standards of practice.
Failure to Serve Food and Drinks at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that foods and drinks were served at safe and appetizing temperatures, as evidenced by multiple resident complaints and direct observation. Several residents reported that their food was consistently cold or lukewarm. During a test tray investigation, it was observed that the last tray was plated and placed on an enclosed meal delivery cart, then delivered to the hallway. Upon removal from the cart, the temperatures of the scrambled eggs, sausage, and orange juice were measured and found to be 101°F, 120°F, and 48°F, respectively. These temperatures did not meet the facility's policy or professional standards, which require hot foods to be above 140°F and cold foods/drinks to be below 41°F. The Certified Dietary Manager confirmed during an interview that the measured temperatures were not within the acceptable range for safe food service. Review of facility policy and the Room Test Tray Evaluation Form further supported that food and beverages must be distributed in a manner that maintains proper temperatures and prevents them from being held in the danger zone (40°F-140°F) for more than four hours. The failure to maintain appropriate food and drink temperatures was substantiated by both resident interviews and direct temperature measurements during meal service.
Failure to Store and Handle Food According to Professional Standards
Penalty
Summary
Surveyors observed multiple failures in food storage practices within the facility's kitchen and nourishment areas. In the kitchen walk-in freezer, a clear plastic bag of tater tots was found on a shelf without a label or date. Additionally, two trays of uncovered slices of pie were observed on a rolling cart in the walk-in cooler. Staff interviews confirmed that the tater tots should have been labeled and dated, and the pie should have been covered, in accordance with facility policy and professional food safety standards. Further observation in the nourishment refrigerator/freezer on the second floor revealed an ice bucket with an ice scooper laying directly on the ice. Staff acknowledged that the scooper should not have been in contact with the ice, and the Dietary Manager was unaware of the scooper's origin. Review of the facility's food safety policy confirmed requirements for labeling, dating, and covering food, as well as proper storage and handling procedures, which were not followed in these instances.
Incomplete and Inaccurate Medical Record Documentation for Central Catheter and Insulin Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by multiple documentation lapses. For one resident with a peripherally inserted central catheter (PICC) line, the dressing was observed to be dated incorrectly, and the Treatment Administration Record (TAR) did not align with the physician's order for weekly dressing changes. Staff could not recall the reason for the discrepancy or explain the incorrect dating of the dressing. Additionally, two residents with orders for insulin therapy had incomplete or missing documentation in their Medication Administration Records (MAR). One resident's MAR had a blank entry for a scheduled insulin dose, and staff interviews revealed that while communication with the provider may have occurred, it was not documented in the medical record. Another resident with sliding scale insulin orders had multiple blood glucose readings above 400 mg/dl, but there was no documentation of physician notification or follow-up as required by the orders. The facility's policy requires accurate and timely documentation of all resident care and provider communications, which was not met in these cases.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
Staff B, LPN, prepared and administered medication and enteral feeding to Resident #444 without wearing the required personal protective equipment (PPE), including gown, gloves, and mask, despite physician orders for Enhanced Barrier Precautions (EBP) dated 6/20/2025. The LPN also performed an intravenous flush of the resident's PICC access device without appropriate PPE. Observation of the resident's room revealed there was no signage indicating the need for EBP. During interviews, the LPN stated that they rely on door signage to determine isolation requirements and were unaware of the need for EBP or the appropriate PPE to use, as there was no signage present. The Director of Nursing confirmed that staff are expected to follow orders and wear the appropriate PPE.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure that medications were kept secured, as observed in the rooms of two residents. During an observation, Systane eyedrops were found on the bedside tables of both residents, and additional items such as Equate Baby Powder and Equate Arthricream Rub were found in one resident's room. Interviews with the residents revealed that they used these items regularly, but there were no physician orders permitting self-administration of these medications. Staff interviews confirmed that medications should not be left at the bedside unless a physician has approved self-administration and a self-administration form has been completed. The Assistant Director of Nursing and the Director of Nursing both verified that the residents in question did not have orders or evaluations for self-administration, and therefore, the medications should not have been accessible to them. The facility's policy clearly states that residents may not retain medications in their rooms without written orders from their attending physician.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brooksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Spring Hill | 1.6 mi | ★★★★★ | 0 | 0 |
| Evergreen Woods | 1.8 mi | ★★★★★ | 0 | 0 |
| Brooksville Healthcare Center | 7.1 mi | ★★★★★ | 10 | 0 |
| Northbrook Center For Rehabilitation And Healing | 7.6 mi | ★★★★★ | 1 | 0 |
| Aviata At Brooksville | 8.7 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.