Northbrook Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF690Jul 10, 2026

  Based on clinical record review, staff interviews, urologist interview, hospital record review, death certificate and policy/procedure review, the facility failed to provide accurate measurements of urinary output, and failed to implement fluid intake and assessments/interventions for 4 out of 4 resident with a an indwelling catheter (Resident #9, #4, #7 and #12) and 3 out of 4 resident that were diagnosed with a urinary tract infection (Resident #9, #7 and #12) which resulted in Resident #9 who showed no urinary output for 32 hours and had a fluid intake of 150 cc over a 48 hour period from 1/9/26-1/12/26. Resident #9 displayed symptoms of confusion, abdominal distention, and discomfort during cares on 1/12/26. […]

• Immediate jeopardy, isolatedF760Jul 21, 2024

  Based on clinical record review, hospital record review, resident and staff interviews the facility failed to prevent a significant medication error from occurring. Resident #2 received Glimepiride 2 mg for 77 days without a diagnosis of diabetes or a physician's order. The nurse on duty at the time the order was received entered another resident's order in this resident's electronic health record (EHR). Over the 77 day timeframe, 11 nurses/Certified Medication Aides (CMA) who administered the medication, the Director of Nursing (DON), the provider (at least 3 visits including a med review visit), and the pharmacy consultant (at least 3 Drug Regimen Reviews) failed to identify the error. These circumstances posed Immediate Jeopardy to resident health and safety. […]

• Actual harm, isolatedF689Aug 22, 2024

  Based on observation, record review, resident interviews, staff interviews, and policy review the facility failed to follow a resident's Care Plan for transfers and to assess a resident immediately after a fall for 1 of 3 residents reviewed (Resident #6). The resident required a mechanical lift with the assistance of 2 staff for transfers. The facility failed to provide assistance of 2 while the resident was transferred in the shower room which resulted in the resident sliding out of the mechanical lift sling. The facility further failed to conduct an assessment of the resident prior to getting her up from the shower room floor. […]

• Actual harm, isolatedF689Apr 10, 2024

  Based on observation, clinical record review, facility investigation report, and staff interviews, the facility failed to supervise 1 of 6 residents reviewed in order to prevent a fall with injury (Resident #4). The facility reported a census of 78 residents. Findings include: The MDS (Minimum Data Set) dated 12/14/2023 revealed Resident #4 had severely impaired cognitive abilities, required extensive assistance to transfer from one surface to another, and had a fall that resulted in a major injury. The resident had diagnoses including weakness, depression, and dementia. […]

• Actual harm, isolatedF686Apr 21, 2022

  Based on observation, record review and staff interviews the facility failed to prevent the development of a facility acquired unstageable (obscured full thickness skin and tissue loss) pressure ulcer and failed to implement a treatment order for the wound for one of two residents reviewed for pressure ulcers (Resident #22). The facility reported a census of 44 residents. Findings Include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was rarely to never understood. The resident required the extensive assistance of two persons physical assist for bed mobility and transfer. Per the assessment, the resident identified at risk for pressure ulcer development, and had no unhealed pressure ulcers/injuries. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]