Glen Brook Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Glen Brook Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 27, 2021

  Based on observations, review of clinical records, select facility policies, and information submitted by the facility and staff interviews, it was determined that the facility failed to provide staff supervision as planned to monitor the activities and whereabouts of a resident with known unsafe exit seeking behaviors to prevent additional attempts to leave the facility unsupervised, which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or harm for one of seven residents identified at risk for elopement. […]

• Immediate jeopardy, isolatedF689Apr 21, 2021

  Based on observations, a review of clinical records, resident incident/accident reports, information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision as planned to monitor a resident with known unsafe behavior to prevent an unsupervised exit from the facility and threat to the resident's safety while ambulating outside the facility for one resident (Resident 3) out of 7 reviewed. Findings included: A review of the clinical record revealed that Resident 3 was admitted to the facility on [DATE]. The resident's diagnoses included Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). […]

• Immediate jeopardy, isolatedF689Mar 26, 2021

  Based on a review of clinical records and select incident reports and staff interview it was determined that the facility failed to provide sufficient staff supervision to prevent a fall resulting in minor injury to one of 24 residents reviewed (Resident 80) Findings include: A review of clinical record revealed that Resident 80 was admitted to the facility on [DATE], with diagnoses which includes dementia with behavioral disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and a history of falling. […]

• Actual harm, isolatedF600Dec 8, 2023

  Based on a review of the facility's abuse policy, clinical records and select investigative reports and resident and staff interviews it was determined that the facility failed to ensure that one resident (Resident 26) out of 35 sampled was free from physical abuse perpetrated by another resident (Resident 24), which caused Resident 26 to fall and sustain a traumatic hematoma to the forehead and facial bruising. Findings included: A review of the current facility policy titled Abuse, Neglect and Exploitation, last reviewed by the facility April 15, 2023, revealed that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect,… […]

• Actual harm, isolatedF689Dec 8, 2023

  Based on a review of clinical records, select facility policy, and investigative reports, observations and resident and staff interviews, it was determined that the facility failed to provide necessary staff set-up and positioning assistance with eating as required by a resident to prevent an accident while eating resulting in a second degree burn for one (Resident 132) out of 35 residents sampled. Findings include: The American Burn Association ([NAME]) classifies burns by the depth of the wound: superficial skin injuries are classified as first-degree burns, partial-thickness skin injuries are classified as second-degree burns, and full-thickness skin injuries are classified as third-degree burns. […]