Glenbrook Rehabilitation & Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Glenbrook Rehabilitation & Skilled Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 30, 2024

  Based on interview and record review, the facility failed to ensure services were effectively provided a resident admitted without pressure-related skin impairment and identified to be risk to develop pressure injuries to prevent the development of a pressure injury for 1 of 1 resident reviewed for pressure injuries. (Resident M) This deficient practice resulted in Resident M developing a facility-acquired stage two pressure injury on the left buttock that deteriorated to an unstageable pressure injury with infection that required debridement twice, and facility-acquired stage two pressure injuries on the coccyx and right buttock, and a facility-acquired stage one pressure injuries on the right hip. […]

• No harm, potential for more than minimal, widespreadF880Oct 5, 2021

  Based on observation, interview and record review, the facility failed to properly prevent transmission of COVID-19 for 1 of 1 observations made (Employee 3, Resident 18) and for 9 employee and 51 visitor screenings. This had the potential to affect all residents residing in the facility. Findings include: 1. A continuous observation was made on 10/5/21 at 10:13 AM. Employee 3 exited Resident 13's room with an isolation gown, gloves and laundry in a plastic bag. Employee 3 walked down the hall to the laundry room, and entered the laundry room. At 10:22 AM, Employee 3 exited the laundry room without the isolation gown, gloves or laundry. Employee 3 was interviewed on 10/5/21 at 10:22 AM. […]

• No harm, potential for more than minimal, isolatedF602Aug 4, 2026

  Based on interview and record review the facility failed to ensure 3 of 3 residents were free of misappropriation of medications (Resident B, Resident C, Resident D).Findings include:A report, dated 7/10/26, indicated Registered Nurse 4 (RN) was allegedly taking discontinued medications from Resident B, Resident C, Resident D.In an interview, on 8/4/26 at 9:10 AM, the Administrator indicated an Administrator from another facility notified her RN 4 had possession of Resident B, Resident C, and Resident D's medications in her home. The Administrator indicated a police report was made, the officer confirmed the medications were in the home, labelled for Resident B, Resident C and Resident D and did not belong to RN 4. […]

• No harm, potential for more than minimal, isolatedF684Nov 19, 2025

  Based on observation, interview, and record review the facility failed to ensure staff followed physician orders for 3 of 3 residents reviewed. (Resident B, Resident C, and Resident D)Findings include: 1. A record review for Resident B began on 11/18/25 at 11:45 AM. Diagnoses included type 2 diabetes, atherosclerosis of the left leg, and right-sided below the knee amputation.A review of Resident B's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 14. (cognitively intact). The MDS indicated the resident received insulin injections 7 days a week. A review of physician orders, dated 9/10/25, indicated 8 units of Humalog insulin was to be administered three times a day with meals. […]

• No harm, potential for more than minimal, isolatedF689Sep 19, 2025

  Based on observation, interview and record review, the facility failed to ensure protective smoking equipment was provided and a electronic cigarette vapor free indoor room environment was provided for 2 of 20 residents reviewed (Resident 40 and Resident 17).Findings included:1) During an observation, on 09/15/2025 at 9:39 AM, Resident 40 was in the smoking area outdoors smoking a cigarette and was not wearing a smoking apron. During an observation, on 09/16/2025 at 1:32 PM, the Assistant Culinary Manager (ACM) lit a cigarette for Resident 40 in the outdoor smoking area. Resident 40 was not wearing a smoking apron. The ACM, approached Resident 36, assisted him in putting on a smoking apron and lit Resident 36's cigarette. […]