Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to supervise residents to prevent them from drinking alcohol,
becoming drunk and falling.
This applies to 3 of 3 residents (R3, R4 and R5) reviewed for supervision in the sample of 7.
The findings include:
R3's MDS (Minimum Data Set Assessment), dated 12/26/23, shows she has no cognitive impairment.
R3's Care Plan, last reviewed on 1/16/24, states, Alcohol addiction/dependency have negatively impacted
my health and cognitive functioning. I acknowledge mixing a concoction of alcoholic beverages in my room
while at (facility). Due to my addiction history and husband's reports of her begging to go to the bar while
out on pass and general expectation that I will pursue alcohol, I am not appropriate for independent out on
pass. The interventions include: Implement increasingly restrictive interventions in a effort to help the
resident break the addictive cycle. Interventions may include: supervision while in the community, restricted
independent pass privileges, implementation of money guidance and budget controls to reduce/prevent
access to substances.
R3's Fall report, dated 12/1723, states, At 11:30 PM (V11, Certified Nursing Assistant/CNA) calling NOD
(Nurse on Duty) to check resident on the dining room floor. NOD checked resident immediately resident
seen sitting down on the dining floor and claiming she lost her balance and slid to the floor. Assessed
resident both upper and lower extremities able to move without any pain. Both legs are equal. No bones
protruding on both sides. Able to stand up with assist. Resident assisted back to bed. Vital signs taken.
Neuro check initiated. Denies hitting the head. MD informed and with order to send to the hospital for X-ray.
R3's Hospital Documents, dated 12/18/23, state, Brief Synopsis: (R3) is a [AGE] year old female with a
PMHx (Past Medical History) of alcoholic liver cirrhosis complicated by Hepatic Encephalopathy,
Non-insulin Dependent diabetes Mellitus, essential hypertension, seizure disorder, major depression with
psychosis who presented from the skilled nursing facility with unwitnessed fall. Patient reported consuming
3-4 drinks of vodka the night prior and she had a fall and was unable to get up. Her alcohol level was .233.
She had mild abdominal pain and lipase was notable elevated to 565. CT (Computed Tomography) showed
mild pancreatic ductal dilation, no inflammation or lesions seen.
R3's Progress Notes, dated 12/18/23, states, At 1:55 AM resident was being sent to Hospital due to fall and
per Hospital resident found out that she intoxicated with alcohol. Per Hospital x-ray of
(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:
145809
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
145809
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grove of Northbrook,the
263 Skokie Boulevard
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
pelvis and chest x-ray done with negative of fractures. Resident still in ER on IV fluids due to intoxication
then they will run labs again. If result will be normal resident will come back to facility. Endorsed to A.M.
nurse.
R3's Progress Notes, dated 12/19/23, state, At 1:45 PM, resident returned from (local) Hospital ambulating
with unsteady gait. Paramedic was walking with resident, stand by assist. Instructed and encourage
resident to use walker during ambulation. Resident was evaluated post unwitnessed fall on 12/17/2023 with
no fractures and negative CT scan per result records, and resident was treated for alcohol intoxication and
mild acute alcoholic pancreatitis and lactic acidosis.
R3's Progress Notes, dated 12/20/23, and written by V6 (Nurse Practitioner) state, Patient seen via video
call regarding her recent ER encounter status post unwitnessed fall. Alcohol level was .233, she admits
drinking vodka the night before the fall. She also complained of abdominal pain with lipase level of 565, CT
abdomen with mild pancreatic ductal dilation. Patient was hydrated at the hospital with improvement
symptoms wise and was sent back to (Facility). Currently patient reports having unsteady gait. She usually
ambulates with walker independently. She denies pain or discomfort and is not in any acute distress.
Promises not to drink alcohol ever again .
On 1/19/24 at 9:30 AM R3 stated, The floors had just been waxed a few days before and I had my slippers
on. I just slipped and fell. Me and (R5) had a little Christmas party in the dining room. We weren't supposed
to but we had our own party. We had a bottle of Vodka-(R4) brought it in and (R5) paid for it. After I fell, I got
up and I went to bed. Then they came in and and got me out of bed and put me in the ambulance. They
were more concerned about my heart and my EKG than my fall. I know the rules are no alcohol. I went to
the cafeteria to get a snack before bed and I slipped. I kind of caught myself with my hands. I wasn't hurt
and I got myself up. I have a walker because therapy thinks I fell because my legs are weak, but I can walk
without it. I didn't fall because I didn't have a walker. I fell because the floors were waxed and I had been
drinking.
On 1/19/24 at 1:30 PM, V11 (CNA) stated, I saw her on the floor as I was walking to my unit. She was
saying help me, help me. I asked her what happened, and she told me the floor was slippery and she just
wanted me to help her get up. I told her I had to get the nurse first, so I called for the nurse. (R3's) speech
was slurred and she was walking funny. I kind of thought, did you drink? I just kept asking her if she was
okay because she was walking sideways. She kept saying she was fine. We walked her to her room and got
her in bed. She was very heavily perfumed, and that is all I could smell. She usually doesn't wear that much
perfume. I went back to the dining room but I didn't see any alcohol. That is the only time I have heard of
her doing that. The residents are not allowed to have alcohol in the facility.
On 1/19/24 at 12:45 PM, V9 (Registered Nurse/RN) stated, It was right at the change of shift, and I was
moving from one unit to the other. The CNA called to me and told me that (R3) fell. (R3) kept denying that
she actually fell. We helped her up and she was very wobbly. She had been with a couple other residents
(R4, R5) in the dining room for a while. She was just so wobbly. I called the doctor and I called my
supervisor. (R3) smelled like alcohol and the doctor said to send her out. I had not ever seen her like this
before. She seemed impaired. No one else was in the dining room with her when she fell, but (R4) and (R5)
had been in there with her. They were having fun in there. We found out from the hospital that (R3's) blood
alcohol level was really high. Residents are not allowed to have alcohol in the facility.
On 1/19/24 at 9:50AM, R4 stated, I did not witness (R3) fall, I didn't see anything. She told me
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145809
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
145809
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grove of Northbrook,the
263 Skokie Boulevard
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
she was in bed and they came and got her out and took her by ambulance to the hospital. There was a
bottle of alcohol brought in- ok, I brought it in. It was me, (R5) and (R3). It was a 750ml bottle and there
wasn't any left when we were done, so I guess we drank it all. I had a pass to go out and (after that) they
restricted it for like 3 weeks. I have it back now.
When I was with (R3), she seemed fine. She was not stumbling or slurring her words or anything. No one
wants to be treated like they are 12. They say this is not a jail, but there is really no freedom. It was never
my intention to have anything happen to her. She seemed fine, and then she went to the hospital, and of
course they drew blood and found the alcohol. I had gone back to my room and went to bed.
R4's MDS, dated [DATE], shows she has no cognitive impairment.
On 1/19/24 at 12:20 PM, R5 stated, The alcohol came from (Local Grocery Store). R5 did not want to say
who brought it in, but when Surveyor asked if it was (R4) who got the alcohol, R5 agreed that it was.
R5 continued, We sat in the dining room for a couple of hours. R5 was asked if R3 seemed impaired when
they were done, and R5 smiled and stated, We all were. I went back to my room and went to bed. I did not
see (R3) fall. I was diagnosed with Dementia a while back, and they took my pass away. I can't go out
without someone going with me. I have never brought alcohol in before. We just wanted to have a little
party.
R5's MDS, dated [DATE], shows he has not cognitive impairment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145809
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the January 19, 2024 survey of GROVE OF NORTHBROOK,THE?
This was a inspection survey of GROVE OF NORTHBROOK,THE on January 19, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GROVE OF NORTHBROOK,THE on January 19, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.