Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Based on observation, interview and record review, the facility failed to protect a cognitively impaired
resident from severe injury(s) by failing to effectively monitor the resident; and failed to implement
interventions from resident's behavioral plan of care which resulted in R50 being emergently transferred to
local hospital for treatment of multiple fractures to the wrist and forearm. This failure affected 1 (R50) of 34
residents in the sample reviewed for accident/hazards.
Findings include:
On 01/24/23 at 10:23 AM, reviewed list of department reportables for last 6 months that showed R50
obtained a fracture of unknown origin in November 2022. At 12:10 PM, R50 was observed asleep in her
wheelchair in room on the first-floor unit. There were no assistive devices or protective coverings observed
on or near R50 that could have prevented her from receiving any further injury(s).
Reviewed R50's electronic medical records with the following noted:
R50 is a cognitively impaired resident with past medical history including but not limited to: Insomnia,
Dysphagia, Aphasia, Cognitive Communication Deficit, Unsteadiness on Feet, Lack of Coordination,
Weakness, History of Falling, and Displaced Spiral Fracture of Shaft of Right Ulna.
MDS (minimum data set) dated 01/13/2023 showed R50 with a BIMS (Brief Interview of Mental status)
score of 99 denoting severe cognitive impairment and an inability to complete the interview due to this
severe cognitive decline. This same MDS showed a behavior being exhibited 4 to 6 times during the period
of assessment and required extensive assistance in all activities of daily living including (but not limited to)
transfers and toileting.
Care plan with last completion date of 01/17/2023 reads in part, The resident is/has potential to be
physically aggressive. Dementia, Poor impulse control during providing care, procedures or assistance.
Resident is combative, pounding on the table with her right hand due to confusion. Goal: The resident will
not harm self or others through the review date. Interventions showed: Monitor behavior episodes and
attempt to determine under-lying cause.
Monitor/document/report PRN and signs and symptoms of resident posing danger to self and others. When
the resident becomes agitated, intervene before agitation escalates. The resident has severely impaired
cognitive function or impaired thought processes related to Difficulty making decisions, Impaired decision
making. Resident is unable to complete her BIMS interview. The resident has a communication problem r/t
Expressive Aphasia, Language barrier, Slurring. Date initiated for all was 04/12/2022.
(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 4
Event ID:
145971
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
145971
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northbrook Health and Rehab
4101 Lake Cook 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 0689
Level of Harm - Actual harm
Residents Affected - Few
Current physician orders with start date of 4/18/22 showed to, monitor behaviors with codes used: Behavior
Code 0=No Behavior 1=Fear/Panic 2=Anger 3=Scream/Yell 4=Danger/Self/Others 5=Delusions
6=Hallucinations 7=Sad/Tearful 8=Emot. withdrawal/Withdrawal act. 9=Other(describe) Interventions1=Music, aromatherapy 2=Reminiscence, reality orientation 3=Exercise, activity 4=1:1 5=Reduce Stim
6=PRN given Outcome- I=Improved S=Same W=Worse Side Effects 0=None 1=EPS 2=Tardive Dys.
3=Hypotension 4=Inc. behavior 5=Sedation/drowsiness 6=Inc. falls/dizziness.
R50's eMar (electronic medication administration record) reviewed from November 2022 to present that
showed inconsistent behavioral monitoring was completed as ordered by physician, and no documented
behavioral notes found from 11/10/2022 through 11/28/2022 (date of incident).
R50's Health Status Note dated 11/28/2022 09:00 showed, Resident noted with blue/green in color
discoloration to right forearm. When site is touched pt c/o pain and is noted grimacing. Pt is A&0 x 1 and is
unable to verbalize what happened. Pt is very combative and is noted to swing arms at staff during care.
Tylenol administered. Pt does have dialysis today. Contacted MD by phone and updated. Received orders
for stat x ray of right forearm, ulna, radius, hand 2 view. All orders carried out.
R50's Radiology Note dated 11/28/2022 13:45 showed, Relayed x-ray result to NP of MD by phone.
Received orders to send pt. to Glenbrook hospital for treatment and evaluation (Dx fx to distal ulna and
ulnar styloid) All orders carried out. DON made aware.
R50's eMar (electronic medication administration record) Hour of Administration Note dated 11/28/2022
21:29 showed, The resident was not received at the taken over of the shift. It was reported that the resident
fell and had fracture at the distal ulna. Presently in the hospital.
Records from the hospital dated 11/28/2022 showed, 2 views of right radius and ulna show a spiral fracture
of the mid to distal diaphysis of the right ulna.
Nurse Practitioner Note dated 11/29/2022 10:30 showed, f/u closed displaced spiral fracture of shaft of the
right ulna. FALLS: Maintain fall and safety precautions. BEHAVIORAL CHANGES: Nursing staff reports
increased agitation and combativeness toward staff during nursing care. In-house psych consulted and
patient's Seroquel dose was adjusted to 50mg TID.
Records from the orthopedic visit dated 12/19/2022 showed, R ulnar shaft fx (fracture). Short arm cast,
NWB (non-weight bearing), finger/elbow ROM (range of motion), f/u (follow up) 4 weeks.
On 01/25/2023 at 2:06 PM, interview V9 (Advanced Practice Registered Nurse) who said this last week,
R50's behaviors are better which could be contributed to the increase in seroquel. She then said her
behavior has been regulated by psych because they were having issues with her agitation and she gets in
moods where she doesn't like to be bothered. When asked what staff should be doing to manage her
behaviors, V9 said R50 should be monitored, staff should keep day/night orientation, keep her busy and at
ease, and calm her with redirection and/or activities. When asked if any different interventions could be
implemented by staff to prevent this behavior, V9 said staff could pad her chair for example to prevent
injury, and she is not sure why this was not implemented prior. V9 added that facility staff reported R50 was
sent out due to pain to her arm from banging on the table then said that she has never witnessed any
resident pounding on a table which would cause a fracture.
On 01/25/2023 at 3:00 PM, V10 (Medical Doctor) said he knew R50 previously, she's had a cognitive
decline over the last few years, some of which is irreversible. He added that R50 is at risk for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145971
If continuation sheet
Page 2 of 4
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
145971
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northbrook Health and Rehab
4101 Lake Cook 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 0689
Level of Harm - Actual harm
Residents Affected - Few
having traumatic fractures. V10 then said R50's behavior issues are mainly managed by psych as well as
facility staff and he was not aware R50 had a behavior of banging her hand/arm on the table. V10 added
that R50's fracture could have been the result of direct impact or a fall.
On 01/25/2023 at 3:30 PM, V16 (Registered Nurse) said R50 is alert 1-2, transfers with 1 assist and has
the tendency to be combative. V16 said her personal actions such as, body language and tone, along with
explaining what she is doing to R50 helps calm her and lessen combative or resistive behaviors.
On 01/25/2023 at 3:00 PM, V17 (Restorative Aide) said R50 is combative at times but he talks nice to her,
holds her hand to calm her both of which lessen her combative and/or resistive behaviors.
A scientific research paper pertaining to spiral fractures from Encyclopedia of Forensic Sciences (Second
Edition), 2013 via ScienceDirect reads, Spiral fractures occur due to torsion or twisting force that produces
a fracture that circles or spirals around the shaft.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145971
If continuation sheet
Page 3 of 4
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
145971
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Northbrook Health and Rehab
4101 Lake Cook 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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to properly label and store multiple
refrigerated food items; failed to identify and discard expired dairy products within acceptable timeframe;
and failed to follow their facility standards and guidelines for food labeling and storage.
Findings include:
On 01/23/2023 at 10:48 AM, during initial tour of kitchen with V7 (Dietary Manager), surveyor entered walk
in fridge #1 and observed a crate filled with vitamin A&D milk cartons dated 01/17/2023, one carton was
undated. Also observed in this same fridge, a 1/4 stack of yellow cheese wrapped in clear cling wrap that
was not labeled or dated.
On 01/23/2023 at 10:50 AM, entered walk in freezer #1 and observed a large box of opened and exposed
waffle fries that were not properly stored and unlabeled. At 10:53 AM, V7 opened reach in refrigerator #1
and surveyor observed an opened and unlabeled jar of grape jelly, a package of turkey, a package of ham,
and a package of yellow cheese all individually wrapped in clear cling wrap, and all were unlabeled.
On 01/23/2023 at 10:56 AM, V7(Dietary Manager) said any food item that is expired or unlabeled should be
thrown away immediately, then said she's been having issues with some milk cartons being undated.
Reviewed facility standards and guidelines for food labeling and storage last revised 03/02/2021 that
showed, foods are labeled and dated for identification purposes and to ensure they are discarded within
acceptable time frames according to HACCP guidelines; opened and perishable items are discarded after
72 hours or dated with the use by date; items not considered perishable are dated when the original
container is opened.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145971
If continuation sheet
Page 4 of 4
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Back to topCitations
7 citations 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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F915 - Buildings must have an outside window or outside door in every
Have proper power supply for life support equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the January 26, 2023 survey of NORTHBROOK HEALTH AND REHAB?
This was a inspection survey of NORTHBROOK HEALTH AND REHAB on January 26, 2023. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NORTHBROOK HEALTH AND REHAB on January 26, 2023?
Yes, 7 deficiencies were 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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.