Northbrook Healthcare and Rehabilitation Center

Inspectors wroteBased on clinical record review, staff interviews, urologist interview, hospital record review, death certificate and policy/procedure review, the facility failed to provide accurate measurements of urinary output, and failed to implement fluid intake and assessments/interventions for 4 out of 4 resident with a an indwelling catheter (Resident #9, #4, #7 and #12) and 3 out of 4 resident that were diagnosed with a urinary tract infection (Resident #9, #7 and #12) which resulted in Resident #9 who showed no urinary output for 32 hours and had a fluid intake of 150 cc over a 48 hour period from 1/9/26-1/12/26. Resident #9 displayed symptoms of confusion, abdominal distention, and discomfort during cares on 1/12/26. [...]

Inspectors wroteBased on clinical record review, policy/procedure review, facility investigation review, resident and staff interviews the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 out of 6 residents reviewed. (Resident #6 and Resident #10). The facility identified a census of 67 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to provide professional standards of quality by not following physician orders for coumadin (a blood thinner) to be started and not give for 3 days for 1 resident (Resident #2) and failed to follow the physicians order for Occupational Therapy to be given 2 times a week for 1 resident (Resident #3) out of 4 residents reviewed. The facility reported a census of 67 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to provide complete incontinent cares for 1 of 3 resident (Resident #13) reviewed. The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy/procedure review at the time of the investigation, the facility failed to assess a resident with a change in condition for 1 of 6 residents reviewed. (Resident #8). The facility identified a census of 67 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interview the facility failed to administer the restorative program as recommended by the therapy department for one of three residents reviewed (Resident #2). The facility reported a census of 71 residents.

Inspectors wroteBased on record review and resident interviews the facility failed to consistently answer call lights in a timely manner for 3 of 3 residents reviewed, (Residents #4, #5 and #6). The facility reported a census of 77 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to administer medications as ordered for 2 of 3 residents reviewed (Resident #1 and Resident #4) when Resident #1 received Resident #2's insulin injection and was transferred to the emergency room (ER) for close observation, and Resident #4 received Resident #8's morning medications and required monitoring of his blood pressure (BP) every shift for the following 72 hours. The facility reported a census of 77 residents.

Inspectors wroteBased on observation, clinical record review, manufacturer's product manuals, resident and staff interviews, the facility failed to ensure staff utilized the correct full body mechanical lift sling size, resulting in 1 of 3 residents utilizing a mechanical lift to slide in the sling, and be lowered to the floor (Resident #3). The facility identified a census of 79 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility policy review, the facility failed to respond in a respectful manner to a resident (Resident #7) who requested help to find a bathroom for 1 of 3 residents reviewed for dignity. The facility also failed to protect residents' right to privacy when electronic health information was left visible and unattended on a computer in 2 of the 4 hallways observed. The facility reported a census of 87 residents.

Inspectors wroteBased on observation, resident interviews, staff interviews, and policy review the facility failed to answer call lights within 15 minutes to meet resident needs for 7 of 9 residents reviewed (Residents #13, #28, #53, #55, #58, #60, #81). The facility reported a census of 85 residents.

Inspectors wroteBased on observation, interviews, Food and Drug Administration (FDA) Food Code, and policy review dietary staff failed to properly wear hair restraints while preparing and serving food during 3 of 3 observations. The facility reported a census of 85 residents.

Inspectors wroteBased on observation, record review, interviews, and policy review the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents. The facility failed to adequately clean toilets and keep them in good repair, ensure beds were made in a timely manner, and to repair damaged or missing window screens. The facility reported a census of 85 residents.

Inspectors wroteBased on observation, clinical record review, resident interviews, staff interviews, and policy review the facility failed to treat residents with dignity and respect, and to provide care in a dignified manner for 3 of 4 residents reviewed for dignity (Residents #58, #85, #93). Facility staff failed to maintain a resident's wheelchair in a clean and sanitary manner, staff used an expletive when describing a resident's behavior in front of others, and the facility posted signs in a resident's room regarding toileting without consulting them. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, the Long Term Care Facility Resident Assessment Instrument 3.0 Version 1.18.11 last updated October 2023 (RAI), and staff interview the facility failed to submit the Minimum Data Set (MDS) within the required time frame for 1 of 1 resident's reviewed for timely submission. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident interview, and staff interview, the facility failed to ensure staff obtained and/or administered medications per physician order and professional standards of practice for 1 of 1 residents sampled (Resident #7) with a resident reported medication error by staff. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 1 of 1 residents reviewed for activities(Resident #81). The facility reported a census of 85 residents. The admission Minimum Data Set (MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #81 which included anxiety, depression, and weakness. The MDS stated it was very important for the resident to go outside when the weather was good. The MDS listed the Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. [...]

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to utilize foot pedals during wheelchair transport in order to ensure safety and failed to ensure good working order of a walker to prevent falls for 3 of 5 residents reviewed for accidents (Residents #12, #49, and #101). The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, review of facility policy/protocol, resident and staff interview, the facility failed to ensure that a resident with symptoms of a potential urinary tract infection (UTI) received prompt testing and ongoing assessment to prevent worsening of symptoms for 1 of 1 resident (Resident #17) with a complaint of a possible UTI. The facility reported a census of 85.

Inspectors wroteBased on clinical record review, observation, facility policy review and staff interview, the facility failed to ensure nursing staff followed facility policy and physician orders regarding checking for enteral feeding tube placement, checking for residual gastric volume, and flushing with the correct amount of fluid prior to administering an enteral feeding to 1 of 1 sampled residents (Resident #4) with an gastric feeding tube. The facility reported a census of 85.

Inspectors wroteBased on electronic health record (EHR) review, clinical record review, facility records, resident, physician and staff interviews, the facility failed to ensure a resident understood the Alternative Dispute Resolution before signing the agreement for 1 of 3 residents (Resident #104) reviewed. The facility reported a census of 89 residents.

Inspectors wroteBased on clinical record review, observation, facility policy review and staff interview, the facility failed to ensure staff followed infection prevention policies including enhanced barrier precautions for 3 of 3 sampled residents (Resident #4, #6, and #58) who required the use of enhanced barrier precautions and for the staffs' lack of knowledge in the handling of soiled linens. The facility reported a census of 85. 1. The Minimum Data Set (MDS) assessment, dated 7/14/25, identified Resident #4 had diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing). The MDS identified the resident received nutrition enterally (through a feeding tube) and had a severe cognitive impairment. [...]

Inspectors wroteBased on clincal record review, staff interview and policy review the facility failed to complete an assessment for 1 of 4 residents (Resident #96) reviewed for hospitalizations. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, policy review, and observations the facility failed to keep the facility in a clean, homelike manner. The facility reported a census of 73 residents.

Inspectors wroteBased on staff interview, resident record review, and facility policy review the facility failed to treat 1 out of 3 residents reviewed with respect and dignity (Resident #7). The facility reported a census of 73 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections during dining and during wound care for 2 of 2 residents reviewed for wound care (Resident #16 and #52). The facility reported a census of 72 residents.

Inspectors wroteBased on observation, family interview, staff interview, and clinical record review the facility failed to ensure resident dignity for 2 of 3 residents reviewed (Residents #16 & #52). The facility reported a census of 72 residents.

Inspectors wroteBased on resident interview, family interview, staff interview, clinical record and documents review the facility failed to include resident in decision making, denied resident right to be informed and choose options affecting care for 1 of 6 resident reviewed for choices (Resident #19). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to fully review and revise the comprehensive Care Plan for 1 of 5 residents who were sampled for Care Plan review (Resident #5). The facility reported a census of 72 residents.

Inspectors wroteBased on observation, staff interview, resident interview, and policy review the facility failed to follow the diet order for 1 of 3 residents reviewed on therapeutic diet (Resident #19). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview, and dialysis transfer agreement the facility failed to ensure pre and post dialysis assessments were completed for 1 of 1 resident reviewed for dialysis (Resident #19). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 3 residents who transferred to the hospital (Resident #5). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to notify the resident and the resident's representative of the facility policy for bed hold, including reserve bed payment, for 1 of 3 residents who were reviewed for hospitalization (Resident #5). The facility reported a census of 72 residents.

Inspectors wroteBased on observation, record review, resident interviews, staff interviews, and policy review the facility failed to follow a resident's Care Plan for transfers and to assess a resident immediately after a fall for 1 of 3 residents reviewed (Resident #6). The resident required a mechanical lift with the assistance of 2 staff for transfers. The facility failed to provide assistance of 2 while the resident was transferred in the shower room which resulted in the resident sliding out of the mechanical lift sling. The facility further failed to conduct an assessment of the resident prior to getting her up from the shower room floor. The facility reported a census of 74 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to complete a quarterly assessment in a timely manner for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 74 residents.

Inspectors wroteBased on clinical record review, hospital record review, resident and staff interviews the facility failed to prevent a significant medication error from occurring. Resident #2 received Glimepiride 2 mg for 77 days without a diagnosis of diabetes or a physician's order. The nurse on duty at the time the order was received entered another resident's order in this resident's electronic health record (EHR). Over the 77 day timeframe, 11 nurses/Certified Medication Aides (CMA) who administered the medication, the Director of Nursing (DON), the provider (at least 3 visits including a med review visit), and the pharmacy consultant (at least 3 Drug Regimen Reviews) failed to identify the error. These circumstances posed Immediate Jeopardy to resident health and safety. The facility was notified of the Immediate Jeopardy on 7/19/24 at 4:15 PM which began on 4/23/24. [...]

Inspectors wroteBased on observation; clinical record review; a written grievance; and staff, resident, and family interviews the facility failed to provide consistent restorative cares to prevent decline in mobility and/or range of motion for 3 of 4 residents reviewed (Residents #1, #2, #3). The facility reported a census of 77 residents.

Inspectors wroteBased on record review, policy review, and interviews the facility failed to ensure providers reviewed medications and associated diagnoses for 1 of 3 residents reviewed (Residents #2). During 3 visits in June 2024, including a medication review, the provider did not find the medication error The facility reported a census of 77.

Inspectors wroteBased on record review, policy review, and interviews the facility failed to ensure pharmacy consultants reviewed medications and associated diagnoses for 1 of 3 residents reviewed (Residents #2). During 3 separate monthly drug regimen reviews the pharmacy consultant failed to find the diabetic medication error for the resident. The facility reported a census of 77.

Inspectors wroteBased on observation, clinical record review, facility investigation report, and staff interviews, the facility failed to supervise 1 of 6 residents reviewed in order to prevent a fall with injury (Resident #4). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, policy review and staff interviews, the facility failed to provide 4 of 5 resident's reviewed with 2 baths weekly (Residents # 3, #4, #5, #6). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, policy review, and observations, the facility failed to provide appropriate assessments and interventions for 4 of 6 residents reviewed with impaired skin and a change of condition (Residents #1, #6, #8, #9). The facility reported a census of 78 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to follow the resident's Care Plan for 1 of 11 residents reviewed (Resident #6). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, policy review and observations, the facility failed to follow physician's orders for 3 of 3 residents reviewed (Resident #1, #6, #9). The facility reported a census of 78 residents.

Inspectors wrote3. Resident #46's MDS assessment dated [DATE] identified a BIMS score of 6, indicating severe cognitive impact. The MDS included diagnoses of medically complex conditions, renal insufficiency (inadequate kidney function), Alzheimer's disease and traumatic brain injury. The Care Plan Focus revised 9/20/23 indicated that Resident #46 had an activities of daily living (ADL) self-care performance deficit related to Alzheimer's, confusion, dementia, fatigue, shortness of breath, stroke, and traumatic brain injury. On 10/10/23 at 1:05 PM observed Resident #46 in the hallway outside of his room without pants or underwear on, sitting in his wheelchair. Resident #46's private area was visibly exposed. Resident #46 asked Staff E, Housekeeper, to get him assistance. Resident #46's roommate and two other residents noted in the hallway at the time. [...]

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to store and prepare food under sanitary conditions for 2 of 2 kitchen observations that included sanitizer buckets, expired food items, and a dishwasher in disrepair. Observations of staff clothing touching the pureed food containers during the puree and reheat processes which impacted 3 of 3 residents. The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to notify the physician and family when a resident required the Heimlich maneuver for 1 of 4 residents reviewed (Resident #39).

Inspectors wroteBased on observation and staff interviews the facility failed to provide a clean, safe and comfortable environment for the residents. The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record review, facility policy review, staff and resident interview, the facility failed to report a resident to resident altercation to the Iowa Department of Inspections and Appeals (DIA) for 1 of 1 residents sampled for a resident to resident altercation (Resident #41).

Inspectors wroteBased on clinical record review, facility policy review, staff and resident interview, the facility failed to complete a thorough investigation for 1 of 1 residents sampled for a resident to resident altercation (Resident #41).

Inspectors wroteBased on clinical record review, family and staff interviews, the facility failed to accurately complete a comprehensive Care Plan for 1 of 15 residents reviewed (Resident #39).

Inspectors wroteBased on observation, record review, policy review, and interviews the facility failed to weigh a resident weekly as ordered by the physician for 1 of 3 residents reviewed for nutrition (Resident #14).

Inspectors wrote4. Resident #37's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS included diagnoses of arthritis, traumatic brain injury, and anxiety. Resident #37 required extensive assistance from two persons for bed mobility, transfers, dressing, and toilet use, with an extensive assistance from one person for eating and personal hygiene. The Care Plan Focus revised 9/20/23 documented that Resident #37 required assistance meeting his emotional, intellectual, physical, and social needs related to cognitive deficits. The Intervention dated 11/21/22 indicated that Resident #37 needed assistance/escort to activity functions. [...]

Inspectors wroteBased on observation, record review, policy review, and interviews the facility failed to a comprehensive assessment of a resident's nutritional needs for 1 of 3 residents reviewed (Resident #14) for nutrition.

Inspectors wroteBased on observation, clinical record review, and staff interview the facility failed to secure a level 4 controlled drug, lorazepam concentrated liquid (anti-anxiety medication), that required refrigeration in a locked medication refrigerator for 2 of 2 mediation refrigerators in the facility. Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence. The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record review, observations, facility policy review, staff, and resident interviews, the facility failed to implement prevention practices to decrease the risk of infection for 2 of 8 the residents reviewed (Resident #39 and Resident #26). The facility failed to clean Resident #39's machine used to breathe at night. The nurse failed to wear gloves while giving Resident #26, his insulin. The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record view and staff interview, the facility failed to transmit 73 Minimum Data Set (MDS) assessments for facility within the required timeframe. The facility reported a census of 61 residents.