Cycle 1
Health 2025-04-16 · Fire 2025-04-16
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Jackson, TN
Northbrooke Post Acute
1-star overall rating with 2-star inspections with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
121 Physicians Dr, Jackson, TN
(731) 664-5050
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Links Healthcare Group
Operator or chain grouping
Approved since
1997-08-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
31 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.30
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
2.78
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.87% · Performance 22.79% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.64% · Performance 10.40% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 79.03% · Performance 76.53% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.11 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 12.04% · Lower 95% interval 6.92% |
| Discharge to community | 40.25% |
50.57%
10.3 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 31% · Lower 95% interval 31.69% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.55% |
95.27%
3.3 pts better
|
Numerator 68 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 55.1% |
53.69%
1.4 pts better
|
Numerator 27 · Denominator 49 |
| Discharge mobility score | 51.02% |
50.94%
0.1 pts better
|
Numerator 25 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 8.7% |
2.29%
6.4 pts worse
|
Numerator 6 · Denominator 69 · Adjusted rate 7.65% |
| Healthcare-associated infections requiring hospitalization | 10.4% |
7.12%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 18.42% · Lower 95% interval 6.16% |
| Staff COVID-19 vaccination coverage | 3.19% |
8.2%
5 pts worse
|
Numerator 3 · Denominator 94 |
| Staff flu vaccination coverage | 87.23% |
42%
45.2 pts better
|
Numerator 123 · Denominator 141 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 21 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 4.88% |
25.2%
20.3 pts worse
|
Numerator 2 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.9%
9.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.5%
4.1 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.6%
0.9 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 4.9% · Q4 4.6% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.3% |
11.8%
4.5 pts worse
|
11.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 7.0% · Q4 57.9% · 4Q avg 16.3% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
6.2%
2 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 12.9% · Q3 10.2% · Q4 3.3% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 48.4% |
32.2%
16.2 pts worse
|
19.6%
28.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.3% · Q2 53.2% · Q3 48.3% · Q4 46.9% · 4Q avg 48.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.3% |
18.1%
3.2 pts worse
|
16.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 22.7% · Q3 23.9% · Q4 19.1% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.2% |
19.9%
4.3 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.5% |
15.3%
6.2 pts worse
|
14.9%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 32.7% · Q3 16.7% · Q4 19.3% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.8% · Q3 0.9% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
1.9%
1.7 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.9% |
20.2%
7.3 pts better
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 23.8% · Q3 14.7% · Q4 10.4% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.4%
1.2 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 12.2% · Q3 6.2% · Q4 2.7% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
79.6%
16.2 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 90.9% · Q3 94.7% · Q4 98.7% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
11.2%
3.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.6%
0.9 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.9% |
79.8%
0.9 pts worse
|
79.7%
0.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
22.2%
0.3 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 24.2% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-29 · Fire 2024-05-29
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-04-08 · Fire 2022-04-08
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-16
D · Potential for more than minimal harm
2024-05-29
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-29
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-29
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-04-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-04-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
E · Potential for more than minimal harm
2024-05-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-05-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-31
E · Potential for more than minimal harm
2024-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-29
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-05-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-07-31
E · Potential for more than minimal harm
2022-04-08
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-05-02
E · Potential for more than minimal harm
2022-04-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-02
E · Potential for more than minimal harm
2022-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-05-02
Penalties and ownership
What sits behind the stars
Ownership
Links Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Rodriguez, Curtis
5% Or Greater Indirect Ownership Interest · Individual
Tilford, Toby
5% Or Greater Indirect Ownership Interest · Individual
121 Physicians Dr Tn LLC
5% Or Greater Mortgage Interest · Organization
Hammond, Jere
Operational/Managerial Control · Individual
Links Healthcare Group LLC
Operational/Managerial Control · Organization
Munchow, George
Operational/Managerial Control · Individual
Rodriguez, Curtis
Operational/Managerial Control · Individual
Tilford, Toby
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Maplewood Health Care Center
Jackson, TN
1-star overall rating with 1-star inspections with abuse icon flag with $144,120 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
West Tennessee Post Acute
Jackson, TN
3-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
Cypress Grove Post Acute
Jackson, TN
3-star overall rating with 3-star inspections with $17,355 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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