F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to implement policies and procedures to prohibit
and prevent Abuse. This deficiency affects all five (R1, R3, R4, R5 and R6) residents reviewed for Abuse
Prevention Program.Findings include: R1On 9/9/25 at 9:51AM, Observed R1 lying in bed with low air loss
mattress. She has oxygen via nasal cannula. She is lethargic but arousable and weak. She needs total care
with ADLs (Activity of Daily Living) and transfers. Both V6 RN (Registered Nurse) and V7RN said R1 has
declined in mental status and ADLs. She is re-admitted yesterday from hospital with pneumonia. R1 is
initially admitted on [DATE] and re-admitted on [DATE] with diagnosis listed I part but not limited to
Atherosclerotic heart disease, Hypertension, Stage 3 Kidney disease, Stage 4 sacral pressure ulcer,
Dysphagia, Cognitive and communication deficit, Gait and mobility abnormalities, Severe protein calorie
malnutrition, Chronic embolism, and thrombosis of femoral vein. Comprehensive care plan indicated: She
has history of Stage 4 sacral pressure ulcer and at risk for developing. She has ADLs and mobility deficit.
She is at risk for falls related injury. She has history of depression with insomnia managed with medication.
Trauma screening assessment was not upon initial admission. Trauma screening was only completed when
R1 was re-admitted on [DATE]. R1 has reported mental abuse allegation on 6/3/25. No trauma assessment
was done after the abuse allegation. No Abuse prevention care plan was developed.R3On 9/9/25 at
10:05AM, Observed R3 up on high back wheelchair in front of her room. V7 RN said, R3 has bilateral shin
protector due for skin tear prevention. R3 need total assist with ADLs and uses mechanical lift for transfer.
She is awake but confused. R3 is admitted on [DATE] with diagnosis listed in part but not limited to Cerebral
infarction due to embolism, Hemiplegia affecting left non dominant side, Dysphagia, Type 2 Diabetes
Mellitus, Atrial fibrillation, Hypertension, Gait and mobility abnormalities, Lack of coordination, Metabolic
encephalopathy. Comprehensive care plan indicated: She is at risk for falls related injury. She has ADLs
and mobility deficit. She has cognitive and communication impairment due to CVA. She is at risk for
inadequate oral/fluid intake. She is on hospice care 8/13/25. She is on psychotropic medications for
antipsychotic and anti-anxiety. R3 refused admission Trauma screening/assessment as indicated in
assessment dated [DATE]. R3 is a vulnerable resident with cognitive impairment and behavioral issues. No
Abuse prevention care plan was initiated upon admission. R3 has reported sexual abuse allegation on
8/25/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care plan was
developed.R4On 9/9/25 at 10:58AM, Observed R4 up in wheelchair in the activity/dining room. She has
hard of hearing. She is alert and confused, responsive to simple questions. She needs assistance with
ADLs and transfers. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Age-related
osteoporosis, Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, Depression, Lack of coordination,
Gait and mobility abnormalities, Repeated falls. R4 refused trauma assessment upon admission as
indicated in assessment. Comprehensive care plan indicated: She is at risk for falls related injury. She has
depression
Residents Affected - Some
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145527
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145527
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brandel Health and Rehab
2155 Pfingsten Road
Northbrook, IL 60062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
managed by medication. She has ADLs and mobility deficit. She is at risk for inadequate oral/fluid intake.
She has cognitive deficits due to Alzheimer's and Dementia. She refused Trauma assessment as indicated
in assessment. She has physical abuse allegation report on 9/1/25. No trauma assessment was done after
the abuse allegation. No Abuse prevention care plan was developed.R5On 9/10/25 at 10:17AM, Observed
R5 up in recliner chair. She is alert and responsive with period of confusion. She needs maximum
assistance with ADLs and transfers. R5 is admitted on [DATE] with diagnosis listed in part but not limited to
Cerebral infarction, hemiplegia affecting right dominant side, Dementia with mood disturbance, Anxiety
disorder, Depression, Gait and mobility abnormalities, Dysphagia. Comprehensive care plan indicated she
is prone to skin tear or bruising related to fragile skin. She has history of depression and anxiety managed
by medications. She has ADLs and mobility deficit. She has presented with rapid significant health declined.
Family wishes comfort measures only. She is on hospice care on 2/11/25. No Trauma assessment done
upon admission. R5 is a vulnerable resident with cognitive impairment and behavioral issues. No abuse
prevention care plan was initiated upon admission. R5 has physical abuse allegation (employee to resident)
report on 3/26/25. No trauma assessment was done after the abuse allegation. No Abuse prevention care
plan was developed.R6 was admitted on [DATE] with diagnosis listed in part but not limited to Urinary Tract
Infection, Congestive heart failure, Atrial fibrillation, Parkinson's disease with dyskinesia, Type 2 Diabetes
mellitus, gait and mobility abnormalities, lack of coordination, Dementia, Cognitive deficit. Comprehensive
care plan indicated he is at risk for falls related injury. ADLs (Activity of daily living) and mobility deficits. He
has short term memory deficit and moderately impaired decision making. He has shortness of breath on
exertion and when lying in bed. He is at risk for inadequate oral/fluid intakes. No care plan for abuse
prevention. No trauma screening assessment was done upon admission. R6 was sent out to the hospital on
5/23/25 for shortness of breathing and was admitted with diagnosis of hypoxia and ribs fracture. Facility
completed and reported injury of unknown origin on 5/24/25. On 9/9/25 at 10:40Am, V3 SSD (Social
Service Director) said that she completes trauma screening assessment of resident upon admission. They
used trauma screening instead of abuse screening/assessment. She was told trauma assessment was only
done upon admission. She said, she did not do trauma assessment after resident has reported abuse
allegation. She did not develop abuse prevention care plan for vulnerable resident with cognitive impairment
and behavioral issues nor develop abuse prevention care plan for resident who reported abuse
allegation.On 9/9/25 at 11:47AM, V1 Administrator said that she is the abuse coordinator. She initiates
reported abuse allegation investigation. They screen employees and residents as part of the abuse
prevention program. The admission coordinator screens the resident prior to admission by checking
criminal background checks. Upon admission, the social service does the trauma screening instead of
abuse screening. V1 is not aware how often the trauma screening/assessment is done in the facility. She
said that resident should be assessed after allegation of abuse has been reported. Trauma assessment
should be completed. Reviewed Facility's policy on abuse prevention program revised 7/12/23 with V1
Administrator. Informed V1 that their policy did not have resident screening to prohibit and prevent both
abuse and neglect. She said it should indicate screening for both resident and employees to prohibit and
prevent abuse. She said that she will inform their corporate and consultant. On 9/9/25 at 12:19PM,
Reviewed R1, R3, R4, R5 and R6 medical records with V2 DON and V3 SSD. Informed V2 DON and V3
SSD of concerns identified from the following residents: R1 is initially admitted on [DATE]. Trauma
screening was not done upon admission. It was done completed when R1 was re-admitted on [DATE]. R1
has abuse allegation report on 6/3/25. No trauma screening was done. No abuse prevention care plan was
developed. V3 said that she was on vacation when the abuse allegation
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145527
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145527
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brandel Health and Rehab
2155 Pfingsten Road
Northbrook, IL 60062
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
incident occurred. V14 Memory Care coordinator was in charged in her absence. R3 is admitted on [DATE].
R3 refused trauma screening as indicated in R3's assessment. R3 is a vulnerable resident with cognitive
impairment and behavioral issues. No Abuse prevention care plan was initiated upon admission. R3 has
abuse allegation report on 8/25/25. No Trauma screening was done. No Abuse prevention care plan was
developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14 Memory
Care coordinator was in charged in her absence. R4 is admitted on [DATE]. Trauma screening was not
done. R4 has abuse allegation report on 9/1/25. No Trauma screening was done. No Abuse prevention care
plan was developed. V3 said that she was on vacation when the abuse allegation incident occurred. V14
Memory Care coordinator was in charged in her absence. R5 is admitted on [DATE]. Trauma screening was
not done upon admission. R5 is a vulnerable resident with cognitive impairment and behavioral issues. No
abuse prevention care plan was initiated upon admission. R5 has abuse allegation report on 3/26/25. No
trauma screening was done. No abuse prevention care plan was developed. R6 was admitted on [DATE].
No care plan for abuse prevention. No trauma screening assessment was done upon admission. R6 was
sent out to the hospital on 5/23/25 for shortness of breathing and was admitted with diagnosis of hypoxia
and ribs fracture. Facility completed and reported injury of unknown origin on 5/24/25. On 9/9/25 at
12:30PM, Both V2 DON and V3 SSD said that Trauma screening assessment should be done upon
admission. Trauma assessment should be done to the resident after allegation of resident abuse. Abuse
prevention care plan should be formulated after abuse allegation made. Abuse prevention care plan should
also be developed for those vulnerable residents who has cognitively impaired with behavioral issues. On
9/10/25 at 10:37AM V15MDS Coordinator/Care Plan Coordinator said that Trauma screening assessment
should be done upon admission. If resident has reported allegation of abuse, the social service should
complete resident trauma assessment and develop abuse prevention care plan. Vulnerable resident who
are cognitively impaired, with behavioral issues should be care planned for abuse prevention because
resident can react negatively to other resident and the other way around. On 9/10/25 at 12:33PM, V14
Memory Care Coordinator said that she covers for V3 SSD in her absence. She said that upon admission,
they completed resident's trauma screening /assessment. They use trauma assessment instead of abuse
screening. She was told only do the trauma assessment once upon admission. She does not update
resident's trauma assessment after allegation of abuse.On 9/10/25 at 2:30PM, Informed V1 Administrator
and V2 DON of above concerns regarding implementation of abuse prevention program. Facility's policy on
Abuse Prevention Program revised 7/12/23 did not indicated screening of residents as indicated in State
Operating Manual. Facility's policy on Trauma-informed and culturally competent care revised August 2022
indicated: Purpose: To guide staff in providing care that is culturally competent and trauma-informed in
accordance with professional standards of practice. To address the needs of trauma survivors by minimizing
triggers and or re-traumatization. Resident screening: 1. Performed universal screening of residents, which
includes a brief, non-specialized identification of possible exposure to traumatic events.Resident Care
Planning:1. Develop individualized care plans that address past trauma in collaboration with the resident
and family.
Event ID:
Facility ID:
145527
If continuation sheet
Page 3 of 3