Grove of Northbrook,The

In the surveyor’s words

From the most serious findings on record at Grove of Northbrook,The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 7, 2024

  Based on observation, interviews, and record review, the facility failed to follow its Code Yellow (elopement) Policy regarding monitoring residents identified as at risk for elopement. This failure resulted in R1 eloping from the facility and being off grounds for an unknown amount of time before a search was started, and a Code Yellow was called. All 15 residents being monitored for risk of elopement can be affected by this failure. The Immediate Jeopardy began on 10/23/2024 when R1 eloped from the facility, and the door alarm was canceled by the staff without initiating the code yellow protocol. V1 (Administrator) and V2 (Director of Operations) were notified on 12/02/2024 at 3:45 PM of the Immediate Jeopardy. […]

• Actual harm, isolatedF684Apr 2, 2026

  Based on interview and record review the facility failed to provide a safe environment and adequate supervision to a resident (R1) who was at risk of self-harming or foreign-body (batteries) ingestion; failed to develop and update an individualized care plan addressing the behavioral problem; failed to ensure to provide continues/ongoing psychotherapy program; and failed to report the two (2) incidents of R1 ingesting batteries in the facility to IDPH (Illinois Department of Public Health). These failures resulted in R1 having repeated access to batteries from TV remote controls, resulting in two (2) separate episodes of battery ingestion within one week that required transfer to hospital for emergency battery removal. […]

• Actual harm, isolatedF689Mar 2, 2024

  Based on interview and record review, the facility failed to have effective interventions in place for the monitoring and supervision of residents assessed to be at risk for falls and requiring staff assistance with dressing and ambulation; and failed to follow the resident plan of care by not providing needed assistance with dressing and ambulation. This failure applied to two of two (R3, R4) residents reviewed for falls, and resulted in R3 sustaining a fall resulting in a left hip fracture requiring surgical intervention, and R4 sustaining a left wrist fracture after a fall while not being assisted during ambulation. Findings include: 1. […]

• Actual harm, isolatedF689Dec 14, 2023

  Based on interviews and record reviews, the facility failed to use the proper equipment when providing incontinence care. This affected one of three residents (R11) reviewed for safety during care. This failure resulted in the use of a sit to stand device while providing incontinence care, contributing to R1 falling and sustaining a right shoulder fracture. Findings include: R11's MDS (Minimum Data Set), dated 7/7/23, notes R11's BIMS (Brief Interview for Mental Status) score is 15 out of 15. R11 is totally dependent on two persons physical assistance with transfers. R11 requires extensive assistance of two persons physical assistance with toileting. […]

• No harm, potential for more than minimal, widespreadF559Aug 27, 2026

  Based on interview and record review, the facility failed to ensure residents received written notification of room changes; failed to ensure resident's family/resident representative or state guardian were notified of any room changes; and failed to have a policy in place address how residents and/or representative will receive written explanation of room changes. These failures applied to 15 (R1, R6, R7, R9, R10, R11, R12, R14, R15, R18 - R23) of 15 residents reviewed for room change and has the potential to affect all 134 residents currently residing in the facility. Findings include:Facility provided a current census upon entrance which showed 134 residents currently residing in the facility.1. […]