Northbrook Health and Rehab

In the surveyor’s words

From the most serious findings on record at Northbrook Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 27, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident was safely transferred for 1 of 4 residents (R3) reviewed for safety in the sample of 15. This failure resulted in R3 sustaining a laceration to the right lower leg needing an emergency room visit requiring 33 stitches to the laceration. The findings include: R3's electronic medical record accessed on 10/27/23 show R3 is a [AGE] year-old Russian speaking resident with diagnoses that include weakness, peripheral venous insufficiency, and diabetes. R3's facility assessment dated [DATE] show R3 has severe cognitive impairment. […]

• Actual harm, isolatedF689Jan 26, 2023

  Based on observation, interview and record review, the facility failed to protect a cognitively impaired resident from severe injury(s) by failing to effectively monitor the resident; and failed to implement interventions from resident's behavioral plan of care which resulted in R50 being emergently transferred to local hospital for treatment of multiple fractures to the wrist and forearm. This failure affected 1 (R50) of 34 residents in the sample reviewed for accident/hazards. Findings include: On 01/24/23 at 10:23 AM, reviewed list of department reportables for last 6 months that showed R50 obtained a fracture of unknown origin in November 2022. At 12:10 PM, R50 was observed asleep in her wheelchair in room on the first-floor unit. […]

• Actual harm, isolatedF689Jul 31, 2022

  Based on interview and record review, the facility failed to follow a resident's plan of care by not having two staff assist while providing care for a resident at risk for falls and documented to require two staff assistances with bed mobility and ADL's (activities of daily living). This failure applied to one (R1) of one resident reviewed for accidents and supervision and resulted in R1 rolling out of bed during care and then having to be emergently transferred to the local hospital's medical intensive care unit for treatment of laceration to the back of her head, which required sutures. […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2023

  Based on observation, interview, and record review, the facility failed to properly label and store multiple refrigerated food items; failed to identify and discard expired dairy products within acceptable timeframe; and failed to follow their facility standards and guidelines for food labeling and storage. Findings include: On [DATE] at 10:48 AM, during initial tour of kitchen with V7 (Dietary Manager), surveyor entered walk in fridge #1 and observed a crate filled with vitamin A&D milk cartons dated [DATE], one carton was undated. Also observed in this same fridge, a ,d+[DATE] stack of yellow cheese wrapped in clear cling wrap that was not labeled or dated. […]

• No harm, potential for more than minimal, patternF656Aug 28, 2022

  Based on observation, interview and record review, the facility failed to develop and implement care plans for 4 (R1, R3, R4, R5) of 4 residents considered at-risk for elopement in the sample of 5 reviewed for care plans for elopement risk residents. Findings include: 1. R1 is a [AGE] year old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's elopement risk assessment dated [DATE] shows R1 with an elopement score (wandering) of 12 which equals high risk for elopement. On 8/26/22 at 10:45 AM, V2 (Director of Nursing) stated, An assessment score of 5 or above is considered at-risk for elopement and should not be allowed outside the facility without direct supervision. On 7/31/22 an initial incident report filed by the facility reads in part: Elopement. […]