Inspection Reports for Northbrooke Post Acute
121 Physicians Dr, Jackson, TN, 38305
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
180% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
79 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow interventions to prevent falls for Resident #328 and to ensure compliance with staffing requirements.
Complaint Details
The complaint investigation found that Resident #328 was not transferred according to care plan instructions, resulting in a fall incident without injury. The facility also failed to maintain required RN staffing levels on two days. Interviews with CNAs, Therapy Director, and Director of Nursing confirmed these issues.
Findings
The facility failed to follow fall prevention interventions for Resident #328, who slid out of a stand-up lift during transfer, and failed to ensure a Registered Nurse was on duty for at least 8 consecutive hours on two days reviewed. Interviews confirmed staff did not follow care plans for transfers and staffing schedules showed insufficient RN coverage.
Deficiencies (2)
Failure to follow interventions to prevent falls for Resident #328, including improper use of mechanical lifts and lack of staff education.
Failure to ensure a Registered Nurse was on duty for at least 8 consecutive hours on 3/16/2025 and 4/6/2025.
Report Facts
Days without 8 consecutive RN hours: 2
RN hours on 3/16/2025: 6.5
RN hours on 4/6/2025: 6.12
Dates of Occupational Therapy service: 2/4/2025 to 3/12/2025
Dates of Physical Therapy service: 2/4/2025 to 3/12/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Q | Certified Nursing Assistant (CNA) | Interviewed regarding fall incident and transfer procedures for Resident #328 |
| R | Certified Nursing Assistant (CNA) | Interviewed regarding transfer procedures and reporting for Resident #328 |
| Therapy Director | Interviewed about Resident #328's transfer methods and care plan | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about staff responsibilities for following care plans during transfers |
| Named RN D | Registered Nurse | Identified as having left early on 3/16/2025 contributing to insufficient RN coverage |
| MDS Coordinator | Registered Nurse | Identified as having left early on 4/6/2025 contributing to insufficient RN coverage |
| Staffing Coordinator | Interviewed about RN staffing requirements and schedules |
Inspection Report
Routine
Census: 79
Deficiencies: 15
Date: Apr 16, 2025
Visit Reason
Routine inspection of Northbrooke Post Acute nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to hold quarterly care plan meetings with resident participation, failure to provide residents access to personal funds, delayed refund of resident account balances after death, failure to provide information on advance directives, medication administration errors, inadequate pressure ulcer care, failure to follow fall prevention interventions, improper labeling and storage of feeding tube supplies, lack of physician orders and inaccurate care plans for oxygen therapy, failure to maintain required RN staffing hours, failure to post nurse staffing information, improper medication storage and security, unsanitary food storage and handling practices, and failure to implement proper infection prevention and control practices.
Deficiencies (15)
Failed to ensure Care Plan conference meetings were held at least quarterly with resident participation for 3 of 25 sampled residents.
Failed to assure residents authorized to manage personal funds had ready and reasonable access to those funds for 2 of 19 sampled residents.
Failed to refund 3 resident account balances within 30 days of death.
Failed to provide information regarding advance directives to 13 of 25 residents reviewed.
Failed to obtain physician's orders for foley catheter care and failed to follow physician orders for medication administration for 2 residents.
Failed to provide appropriate pressure ulcer care and failed to ensure pressure reducing mattress was properly implemented for 3 residents with pressure ulcers.
Failed to follow fall prevention interventions for 1 resident who fell while being transferred with a stand-up lift.
Failed to ensure enteral feeding, feeding syringe, and flush solution were properly labeled for 2 residents with PEG tube feedings.
Failed to obtain physician orders, failed to ensure orders were followed, and failed to accurately care plan for oxygen therapy for 3 residents.
Failed to ensure a Registered Nurse was on duty for at least 8 consecutive hours on 2 of 28 days reviewed.
Failed to post total number of staff and actual hours worked by licensed staff on Daily Staff Posting form for 31 of 31 days reviewed.
Failed to ensure medications were properly stored and secured; medication carts left unlocked and unattended; medication drawers cracked; medications left unattended and out of sight; opened oral medications stored improperly.
Failed to ensure food was stored, handled, prepared, and served under sanitary conditions including unlabeled and undated food, expired food, food stored on freezer floor, dirty containers, rust on equipment, and failure to perform hand hygiene during food preparation.
Failed to maintain accurate medical records related to Cardiopulmonary Resuscitation (CPR) for 1 resident; resident was full code in record but hospice admission changed code to DNR and this was not updated in medical record.
Failed to ensure proper infection control practices including failure to wear PPE for Enhanced Barrier and Contact Precautions, failure to disinfect reusable medical equipment, failure to properly store soiled linens, failure to perform hand hygiene, and presence of blood-tinged gauze on floor.
Report Facts
Residents reviewed for care plan meetings: 25
Residents with care plan meeting deficiencies: 3
Residents reviewed for personal funds: 19
Residents with personal funds access deficiencies: 2
Residents with delayed refund: 3
Residents reviewed for advance directives: 25
Residents with advance directive deficiencies: 13
Residents reviewed for medication administration: 25
Residents with medication administration deficiencies: 2
Residents reviewed for pressure ulcer care: 3
Residents with pressure ulcer care deficiencies: 3
Residents reviewed for falls: 4
Residents with fall prevention deficiencies: 1
Residents reviewed for feeding tube care: 3
Residents with feeding tube labeling deficiencies: 2
Residents reviewed for respiratory therapy: 4
Residents with respiratory therapy deficiencies: 3
Days with less than 8 hours RN coverage: 2
Days with missing nurse staffing postings: 31
Medication carts with holes/cracks: 3
Medication carts left unlocked and unattended: 1
Food items stored beyond use by date: 3
Unlabeled food items: 4
Missed wound treatments: 15
Missed medication administrations: 50
Missed wound care treatments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #4 | Named in care plan meeting deficiency | |
| Resident #17 | Named in care plan meeting deficiency | |
| Resident #28 | Named in care plan meeting deficiency | |
| Resident #35 | Named in personal funds access deficiency | |
| Resident #51 | Named in personal funds access deficiency | |
| Resident #329 | Named in delayed refund deficiency | |
| Resident #330 | Named in delayed refund deficiency | |
| Resident #331 | Named in delayed refund deficiency | |
| Resident #11 | Named in advance directive deficiency and feeding tube labeling deficiency | |
| Resident #30 | Named in advance directive deficiency | |
| Resident #34 | Named in advance directive deficiency | |
| Resident #37 | Named in advance directive deficiency | |
| Resident #49 | Named in advance directive deficiency | |
| Resident #61 | Named in advance directive deficiency and feeding tube labeling deficiency | |
| Resident #62 | Named in advance directive deficiency | |
| Resident #278 | Named in advance directive deficiency and infection control deficiency | |
| Resident #279 | Named in advance directive deficiency and infection control deficiency | |
| Resident #6 | Named in medication administration and catheter order deficiency | |
| Resident #63 | Named in medication administration, pressure ulcer care, and wound care deficiencies | |
| Resident #20 | Named in pressure ulcer care deficiency | |
| Resident #47 | Named in pressure ulcer care deficiency | |
| Resident #328 | Named in fall prevention deficiency | |
| Resident #21 | Named in medication storage deficiency | |
| Resident #46 | Named in medication storage deficiency | |
| Resident #50 | Named in infection control deficiency | |
| Resident #44 | Named in infection control deficiency | |
| Resident #229 | Named in infection control deficiency |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 29, 2024
Visit Reason
The inspection was conducted to assess compliance with pressure ulcer care standards and wound management for residents, including review of policies, medical records, treatment administration, and interviews with staff.
Findings
The facility failed to provide ordered wound care and failed to ensure that pressure reducing mattresses were properly implemented for residents with pressure ulcers. Documentation of wound care treatments was incomplete, and a pressure reducing mattress was not attached as ordered.
Deficiencies (3)
Failed to provide necessary treatment and services to promote healing of pressure ulcers for 2 of 4 sampled residents.
Failed to provide ordered wound care treatments as documented by missing signatures on Treatment Administration Records.
Failed to ensure pressure reducing mattress was properly implemented and attached to resident's bed.
Report Facts
Deficiencies cited: 3
Negative Pressure Wound Therapy frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Described resident's wound condition and confirmed mattress was not attached |
| LPN K | Licensed Practical Nurse | Assigned nurse for Resident #189 on 5/24/2024; admitted not performing scheduled wound care due to time constraints |
| Interim Director of Nursing | Interim DON | Provided information on wound care documentation and responsibility for mattress implementation |
| Administrator | Confirmed expectations for wound care performance and mattress use | |
| Regional Nurse Consultant | Confirmed treatments were not signed as administered on specific dates |
Inspection Report
Routine
Census: 88
Deficiencies: 9
Date: May 29, 2024
Visit Reason
Routine inspection of Northbrooke Post Acute nursing home to assess compliance with regulatory standards including resident dignity, housekeeping, ADL assistance, wound care, feeding tube management, medication administration, medication storage, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate housekeeping, failure to provide scheduled ADL assistance, incomplete wound care and improper use of pressure reducing mattresses, improper feeding tube management, nurse competency issues, unsecured medication storage, food safety violations, and lapses in infection prevention and control practices.
Deficiencies (9)
Staff failed to knock and announce themselves before entering resident rooms, violating residents' dignity and respect.
Facility failed to maintain a sanitary environment in 10 of 59 resident rooms with urine odors, dirty gloves, towels on floor, and stained privacy curtains.
Failed to provide scheduled bathing and showering assistance for 3 of 20 residents reviewed for ADL care.
Failed to provide ordered wound care and ensure pressure reducing mattress was properly implemented for 2 of 4 residents with pressure ulcers.
Failed to follow physician orders for PEG tube feeding and failed to date and label feeding bags for 2 of 2 residents reviewed.
Licensed nurses demonstrated lack of competency during medication administration including improper glucometer cleaning and difficulty administering PEG tube medication.
Medication cart left unlocked and unattended and medications left at resident bedside unsecured.
Food stored, prepared, and served under unsanitary conditions including carbon build-up on stove, undated and expired food items, and expired milk served to residents.
Failed to ensure proper hand hygiene and infection control practices by staff during meal service and resident care, including failure to wear PPE and improper handling of soiled linens.
Report Facts
Residents affected: 2
Residents affected: 10
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Census: 88
Residents receiving tray: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN L | Licensed Practical Nurse | Observed during medication administration with coaching on glucometer cleaning |
| LPN O | Licensed Practical Nurse | Observed during medication administration with difficulty administering PEG tube medication |
| Interim Director of Nursing | Interim DON | Interviewed regarding policies, wound care, feeding tube management, infection control, and medication storage |
| Regional Nurse Consultant | Regional Nurse Consultant | Confirmed wound care treatments were not signed as administered |
| Administrator | Facility Administrator | Interviewed regarding expectations for wound care and pressure reducing mattress use |
| Staff N | Observed adding formula to feeding bag and labeling it | |
| LPN K | Licensed Practical Nurse | Admitted not performing scheduled wound care due to time constraints |
| LPN H | Licensed Practical Nurse | Observed leaving medication cart unlocked and unattended |
| Certified Dietary Manager | CDM | Interviewed regarding food safety and kitchen conditions |
| Dietary Aide F | Interviewed regarding milk handling and expiration date checks | |
| CNA A | Certified Nurse Aide | Observed failing to perform hand hygiene and PPE use during meal service and resident care |
| CNA B | Certified Nurse Aide | Observed failing to knock before entering resident rooms |
| Housekeeper D | Housekeeper | Observed failing to wear PPE and assisting with resident repositioning |
| LPN E | Licensed Practical Nurse | Observed failing to wear PPE and perform hand hygiene |
| LPN C | Licensed Practical Nurse | Observed failing to perform hand hygiene during meal service |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 8
Date: Apr 8, 2022
Visit Reason
The inspection was conducted based on complaints and concerns related to resident care, safety, and infection control practices at Northbrooke Post Acute.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to notify responsible parties of incidents, inadequate care planning and implementation, unsafe environment, improper medication storage, failure to monitor resident health parameters, and inadequate infection control practices including COVID-19 screening failures.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of incidents, incomplete care plans and discharge summaries, unsafe environment and accident hazards, failure to follow physician orders for oxygen therapy, improper medication storage, failure to monitor resident weights, and inadequate infection control screening of staff for COVID-19.
Deficiencies (8)
Failed to notify the Responsible Party for 1 of 5 sampled residents (Resident #28) regarding an incident where the resident drank peri wash.
Failed to ensure the care plan was implemented and followed for fall interventions for 1 of 1 sampled resident (Resident #184).
Failed to complete discharge summaries and provide discharge instructions and medication reconciliation for 3 of 3 sampled residents (Resident #84, #85, and #285).
Failed to ensure a safe and secure environment and complete fall risk assessments for 6 of 6 sampled residents reviewed for accident hazards and falls.
Failed to follow physician orders to monitor oxygen flow rate for 1 of 4 residents (Resident #23).
Failed to ensure medications were securely locked and stored; 2 of 9 medication storage areas were found unlocked and unattended.
Failed to follow facility policy for monitoring weights for 1 of 5 sampled residents (Resident #67).
Failed to follow CDC infection control guidelines to ensure staff screening for COVID-19 prior to work for 27 of 106 staff members over 16 of 17 days reviewed.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 6
Residents affected: 1
Medication storage areas: 2
Residents affected: 1
Staff members: 27
Days: 16
Facility census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Interim Director of Nursing | Confirmed failure to notify responsible party, improper oxygen flow rate, call light placement, and medication cart security |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed call light should be within resident reach |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Commented on broken trapeze pole hazard |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed medication cart should not be left unlocked; keys to treatment cart should not be left unattended |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Confirmed medication cart should not be left unlocked |
| Administrator | Administrator | Confirmed incomplete discharge summaries and failure to screen staff for COVID-19 |
| Risk Manager | Risk Manager | Confirmed mattress was too short for bed frame |
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