Northbrooke Post Acute

In the surveyor’s words

From the most serious findings on record at Northbrooke Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 5, 2023

  Based on policy review, facility investigation review, weather website review, surveillance camera video footage review, medical record review, and interview, the facility failed to provide adequate supervision and ensure a safe and secure environment to prevent an incident of elopement for 1 of 4 (Resident #1) sampled residents reviewed for elopement. The facility's failure to ensure a safe environment to prevent an elopement resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility without staff knowledge or supervision from the Staffing Coordinator's unlocked office door, that did not have a working alarm system in place on 12/17/2022. […]

• Immediate jeopardy, isolatedF689Jan 15, 2022

  Based on policy review, video camera footage review, weather website review, medical record review, observation, and interview, the facility failed to provide a safe, secure environment, and adequate supervision for a vulnerable confused resident with exit seeking behaviors for 1 of 3 sampled residents (Resident #1) reviewed for elopement/wandering and exit seeking behaviors. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy when Resident #1, a vulnerable confused resident wandered out of the COVID Unit, wandered throughout the facility, pulled the fire alarm, and exited the facility unsupervised. Resident #1 was found by staff in an unlocked staff member's car. […]

• No harm, potential for more than minimal, patternF686Apr 16, 2025

  Based on policy review, medical record review, observation, and interview, it was determined the facility failed to follow physician orders, failed to provide pressure ulcer/injury treatments, and failed to ensure a pressure reducing mattress was properly implemented for 3 of 3 (Resident #20, #47 and #63) sampled residents determined to have pressure ulcers/injuries. The findings include: 1. Review of the facility's policy titled, Pressure Injuries Overview dated March 2020, revealed Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue .A pressure injury will present as intact skin and may be painful .A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful .Pressure ulcers/injuries… […]

• No harm, potential for more than minimal, patternF761Apr 16, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 3 of 6 staff member (Registered Nurse (RN)I, Licensed Practical Nurse (LPN) J ) left medication unattended, and out of sight, and opened oral medications were stored in a medication cup, when a medication was stored at bedside in 1 of 79 occupied rooms, when 1 of 6 medication carts (300 hall) was left unlocked, unattended, and out of sight of staff, when 3 of 6 ( 300 hall, 200 hall, and the short stay) medication carts had holes/cracks in the drawers. The findings include: 1. […]

• No harm, potential for more than minimal, patternF812Apr 16, 2025

  Based on policy review, observation, refrigerator and freezer temperature logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions. Food items stored unlabeled and undated, stored beyond use by date, and stored on freezer floor. Staff personal items sitting on workstation on top of equipment. Plastic storage containers and lids were dirty with sticky residue, metal table with rust on surface, ice machine had fuzzy debris hanging out of filter, and food trays stored with standing water on them. Drinks sitting out uncovered. Hand hygiene not performed when plating food and loading meal cart. The facility failed to maintain temperature logs for two nourishment refrigerator/freezers. […]