Northbrook Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of resident-to-resident abuse involving one of four sampled residents (Resident 2) was reported to the State Survey Agency and the Long-Term Care Ombudsman within the required timeframe. This finding had the potential to result in an inability for the appropriate authorities, such as the State Survey Agency and the Long-Term Care Ombudsman to promptly intervene and ensure the safety and well-being of residents. In addition, the delay in reporting could have prevented a timely investigation, protective measures, and corrective actions, increasing the risk of further harm or unaddressed abuse within the facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition and palatability when three residents (Resident 20, Resident 26, Resident 30) out of 38 residents received meals that were flavorless, difficult to chew and overcooked. This failure decreased the facility's potential to serve food to residents with nutritive content and decreased the residents' potential to maintain or increase their meal intake with food served by the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when:Clean plastic cups were stored in soiled, heavily scratched plastic racks and food crumbs were observed under a layer of dirty plastic netting which clean eating utensils were stored on top of in a utensil tray; and,The front of the facility stove was stained with old grease drippings while the stovetop was encrusted with hardened black residue; and,Cook 1 failed to maintain proper hand hygiene during meal prep and trayline when he repeatedly contaminated his gloves by touching his personal clothing and other kitchen items before handling food products; and,Refrigerated items found with no use by date. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment free of pests for 38 residents for a census of 38 when two flies were observed in the kitchen during food preparation. This failure decreased the facility's potential to prevent foodborne illnesses among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were honored for four residents (Resident 10, Resident 30, Resident 41, Resident 26) of 38 sampled residents when the residents were served meals which contained food they disliked. This failure decreased the facility's potential to serve food that met residents' nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement care plans for two residents (Resident 20, Resident 21) of four sampled residents when Licensed Nurses (LN) did not:Initiate a care plan for Resident 20's need for oxygen therapy; and,Implement interventions indicated in Resident 21's care plan regarding the risk of skin impairment. These failures decreased the facility's potential to communicate Resident 20's care needs regarding oxygen therapy among facility staff and resulted in Resident 21 sustaining a wound to her left lateral (a side of the body positioned away from midline) upper calf.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 3) of four sampled residents was properly groomed and had her call light within reach when Resident 3 was observed to have uncombed hair, dirty fingernails, and fecal matter (bowel movement) on her pillowcase, sheets and bedside table, and had no way to call for assistance. This deficiency decreased the facility' potential to ensure Resident 3 received personal care to maintain adequate hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 20) out of four sampled residents when in Resident 20's oxygen concentrator had visible dust and debris in the vents. This failure decreased the facility's potential to prevent bacteria and debris from directly entering Resident 20's lungs, placing her at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to provide medications as ordered by the prescriber, when two residents (Resident 1 and Resident 2) of three sampled residents received their medications late on two days. This failure decreased the facility's potential to prevent serious health consequences including worsening symptoms, disease progression, and increased risk of complications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 3 errors out of 43 opportunities, which resulted in a medication error rate of 6.98 % for 2 (Resident #2 and Resident #4) of 5 residents observed during medication administration.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure medication administration records accurately reflected the medications administered for 1 (Resident #27) of 5 residents reviewed for unnecessary medications. In addition, the facility failed to ensure medication orders were correctly transcribed into the electronic health record (EHR) for 1 (Resident #2) of 5 residents observed during medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was free from physical abuse when two Certified Nursing Assistants (CNAs) intentionally held down Resident 1 against his will while performing perineal care (the cleaning and maintenance of the genital and anal areas). This failure resulted in Resident 1 feeling belittled and upset.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued medications were removed from stock according to facility policy and procedure (P&P), medications were appropriately labeled with a pharmacy label identifying which resident they were for, and expired medications were not available for resident use. The deficient practices had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency from being used past their discard date.

Inspectors wroteBased on food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department and a qualified Dietary Supervisor or fulltime RD was overseeing the day-to-day operations of the kitchen, and evaulating dietary staff for competencies (cross reference F 812). These failures resulted in issues with safe and effective food storage, meal production (cross reference F 804) correct therapeutic diets being plated (cross reference F803) and infection control (cross reference F 812). Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness.

Inspectors wroteBased on dietary observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members were not: 1) following recipes for a.spinach and b. meatloaf 2) following therapeutic diets when a. portion sizes were not plated correctly, meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed properly, and b.mash potatoes were not fortified 3) qualified to oversee the day-to-day operations of the kitchen and 4) qualified to evaluate cooks for competences. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare a meal tray with 1) the individual therapeutic portion size for 30 out of 33 residents, when 30 residents' meatloaf portion size was not followed per the residents' lunch meal card, and 2) 13 out of 13 residents on a Fortified diet did not have their mash potatoes fortified with one oz of gravy per Spring 2023 Week 3 Fortified Lunch. These failures to ensure nutritional content could result in decreased dietary intake and resulted in less calories and protein, which may result in weight loss and further compromise resident medical status.

Inspectors wroteBased on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) frozen vegetables were not sealed, 2) dietary staff did not know quaternary (quat ammonium compounds designed to kill germs) wet time for sanitizer solutions, 3) cook did not sanitize countertop after preparing meat, and 4) the cook was not wearing appropriate aprons for cooking and washing cooking utensils and equipment per the facility's policy/procedure. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal distress, weight loss and in severe instances may result in death.

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified staff member to function in the role of Infection Preventionist (IP) (individual responsible for the facility's activities aimed at reducing the spread of disease by collecting and analyzing data on healthcare-associated infections, identifying outbreaks, and using appropriate prevention strategies to prevent and control further spread), per the facility's assessment plan. This failure created potential for inability to implement programs and activities to prevent and control infections in a population of vulnerable residents, which placed 33 of 33 Residents at risk for infections.

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light system was accessible to residents while lying on the floor in the restrooms for residents in 19 of 21 rooms. This failure created the potential for residents, who fell while using the restroom, from activating the call light system and summoning help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for two out of three residents (Resident 8 and Resident 26) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications.

Inspectors wroteBased on food production observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1) holding time for Penne pasta, green beans, and turkey and gravy was over 1 hour prior to the beginning of meal service, 2) frozen spinach was cooked on the stovetop for over two hours prior to placing on the steam table, 3) recipes were not followed, 4) two out of 12 Sampled Residents (Resident 2 and Resident 33) and three Unsampled Residents (Resident 1, Resident 4, and Resident 86) did not like the food and/or had issues with the temperature of the food, the texture of food items, quality of the food or taste of the food, and 5) test tray evaluation of noon meal tray on 3/22/23 at 1 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program addressed the full range of care and services provided by the facility when a dietary department representative participated in only three of the previous 12 QAPI meetings. This failure had the potential for the facility to neglect dietary quality deficits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a glucometer was not disinfected in accordance with facility policy and procedure (P&P) and manufacturer's specifications after resident use. This failure had the potential to result in the development of infection and transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C).

Inspectors wroteBased on interview and record review, the facility failed to ensure its policy and procedure on abuse prevention indicated required time frames for reporting allegations of abuse, neglect, misappropriation of resident property, or exploitation to the Department, as well as the need to submit the facility's investigative report of such allegations to the Department, and the required time frame to do so. These failures had the potential for untimely reporting of abuse, neglect, misappropriation of resident property, or exploitation to the Department and failure to submit the respective investigative reports to the Department, thereby hindering the Department's investigation of the allegations.

Inspectors wroteBased on interview and record review, the facility failed to hold quarterly care conferences for one of three residents (Resident 16). This failure prevented Resident 16's Responsible Party to be involved in Resident 16's care plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 12) who signed arbitration agreements understood the agreement when Resident 12 was cognitively impaired when he signed the agreement. This failure resulted in Resident 12 agreeing to something he did not understand.