Northbrook Healthcare: Falls From Unanswered Calls - IA
Resident #58 at Northbrook Healthcare and Rehabilitation Center told inspectors he got tired of waiting and tried to get up on his own. Both times, he fell.
The resident has heart failure, a history of repeated falls, and difficulty walking. His medical assessment showed a cognitive score of 5, indicating severe impairment. He requires staff assistance with toileting, dressing, and moving around with his walker.
"I had to go to the bathroom and used my call light prior to each of the falls," the resident told inspectors on August 12. "Staff did not respond for about one hour, he got tired of waiting, got up and fell."
The falls happened within days of each other. Nursing notes from August 5 documented falls "in relation to trying to use the bathroom in his room" at 5:58 AM and 4:05 PM. Four days later, staff found him sitting on the floor in front of the toilet in his room.
The resident said waiting for help happened "frequently" — a couple times a week. "He had to wait to get up for up to hour in the mornings, because he was waiting on help from staff," according to the inspection report.
Staff acknowledged the delays. CNA Staff B told inspectors the morning shift was "the busiest time at the nursing home" and said there were times residents waited longer than 30 minutes for call lights to be answered. She worked with just one other aide on her hall.
Another aide, Staff N, said Resident #58 "did not like to wait when he needed to use the bathroom." She claimed residents "usually did not have to wait longer than minutes" but admitted mornings were the busiest time "with trying to get resident's up for the day."
The facility's own policy contradicted what staff described. The Director of Nursing told inspectors she expected staff to answer call lights within 10 minutes, or at least enter the room to check on the resident and explain they would return.
She acknowledged staffing challenges. "They had a lot of residents which required the assistance of two staff so it could take a minute," she said.
The Administrator said staff should answer call lights "in a timely manner" and claimed they had added more staff.
But the pattern continued. Another resident told inspectors about waiting an hour to use the bathroom and eventually giving up. "She just went by herself," the report noted.
Federal inspectors found the facility failed to provide adequate supervision and assistance to prevent accidents. The violation affected multiple residents and posed minimal harm or potential for actual harm.
Resident #58's care plan, last updated August 12, specified he needed staff assistance with his walker for toileting, walking, and transfers. The plan also required staff help with dressing and personal hygiene.
His medical assessment painted a picture of significant vulnerability. Beyond the severe cognitive impairment, heart failure, and fall history, he was completely dependent on staff for basic activities including toileting, lower body dressing, mobility, and transfers.
The falls followed a predictable pattern documented in nursing notes. Each time, the resident needed the bathroom, used his call light, waited approximately an hour without response, attempted to get up alone, and fell.
Staff explanations revealed systemic understaffing during the facility's busiest periods. With residents requiring two-person assistance and only minimal staffing on each hall, call lights went unanswered for extended periods.
The August inspection occurred after complaints about the facility's care. Inspectors documented the call light delays as part of broader concerns about supervision and accident prevention.
For Resident #58, the consequences were immediate and physical. Two falls in one week, both directly linked to unmet bathroom needs and hour-long waits for assistance that never came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northbrook Healthcare and Rehabilitation Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA was cited for violations during a health inspection on August 14, 2025.
Resident #58 at Northbrook Healthcare and Rehabilitation Center told inspectors he got tired of waiting and tried to get up on his own.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.