Northbrook Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF604Mar 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was free from physical abuse when two Certified Nursing Assistants (CNAs) intentionally held down Resident 1 against his will while performing perineal care (the cleaning and maintenance of the genital and anal areas). This failure resulted in Resident 1 feeling belittled and upset. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with a diagnosis of pleural effusion (abnormal buildup of fluid between the lungs and the chest wall). A review of a care plan, initiated on 2/19/25, indicated Resident 1 had an activities of daily living self care performance deficit related to generalized weakness. […]

• No harm, potential for more than minimal, widespreadF804Jan 30, 2026

  Based on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition and palatability when three residents (Resident 20, Resident 26, Resident 30) out of 38 residents received meals that were flavorless, difficult to chew and overcooked.This failure decreased the facility's potential to serve food to residents with nutritive content and decreased the residents' potential to maintain or increase their meal intake with food served by the kitchen.Findings:During a concurrent interview and observation in Resident 26's room on 1/28/26at 8:30 a.m., Resident 26 complained about the potatoes he was served for breakfast. The cubed potatoes noted on his plate were pale in color. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2026

  Based on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when:Clean plastic cups were stored in soiled, heavily scratched plastic racks and food crumbs were observed under a layer of dirty plastic netting which clean eating utensils were stored on top of in a utensil tray; and,The front of the facility stove was stained with old grease drippings while the stovetop was encrusted with hardened black residue; and,Cook 1 failed to maintain proper hand hygiene during meal prep and trayline when he repeatedly contaminated his gloves by touching his personal clothing and other kitchen items before handling food products; and,Refrigerated items found with no use by… […]

• No harm, potential for more than minimal, widespreadF925Jan 30, 2026

  Based on observation and interview, the facility failed to maintain an environment free of pests for 38 residents for a census of 38 when two flies were observed in the kitchen during food preparation.This failure decreased the facility's potential to prevent foodborne illnesses among residents.Findings:During a concurrent observation and interview in the kitchen on 1/28/26 at 10:55 a.m., two flies were observed flying around the area where lunch was being prepared. The Certified Dietary Manager (CDM) confirmed the presence of flies in the kitchen. The CDM stated the flies may have come in with someone when they entered the building from the outside. […]

• No harm, potential for more than minimal, widespreadF761Mar 27, 2023

  Based on observation, interview, and record review, the facility failed to ensure discontinued medications were removed from stock according to facility policy and procedure (P&P), medications were appropriately labeled with a pharmacy label identifying which resident they were for, and expired medications were not available for resident use. The deficient practices had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency from being used past their discard date. […]