Northbrook Healthcare: Sepsis Patient Assessment Gaps - IA
Resident #96 was readmitted to the facility on June 3 following treatment for cholecystitis, sepsis, and septic shock. Sepsis is a life-threatening medical emergency that occurs when an infection triggers a chain reaction throughout the body, according to the Centers for Disease Control. Septic shock represents a severe form characterized by dangerously low blood pressure and cellular dysfunction.
The clinical record contained no physical assessment or vital signs documentation on June 3 or June 4.
Staff finally recorded vital signs during dialysis on June 5. Before treatment, the resident's blood pressure measured 96/56 and oxygen saturation registered just 88 percent. After dialysis, her temperature had risen to 98.7 degrees and oxygen levels improved to 98 percent. But nursing staff completed no physical assessment that day.
June 6 passed with no vital signs or physical assessment documented.
On June 7, dialysis staff again failed to record vital signs during pre- and post-treatment checks. The clinical record showed only a single temperature reading of 97.7 degrees. No physical assessment appeared in the record.
The bleeding started June 8.
A progress note written at 1:30 PM documented that the resident had picked a scab and staff were unable to stop the bleeding. The nurse completed a dressing change to the resident's legs, but blood continued running down her leg. Staff sent her to the emergency department.
The clinical record contained no documentation of her return from the emergency room. No vital signs. No physical assessment.
By June 9, the resident's condition had deteriorated dramatically. A progress note written at 11:36 AM documented copious drainage from bilateral leg wounds. She had poor circulation to all extremities, with fingers and toes that appeared purple and cold. Staff had difficulty obtaining an oxygen saturation reading.
At 3:39 PM that same day, another note documented that the resident would be admitted to the hospital per her cardiologist's orders. No vital signs were recorded on June 9.
A progress note written at 12:20 AM on June 10 documented that the resident had been admitted to the hospital with a diagnosis that included sepsis.
During an interview on August 13, the Director of Nursing explained that the resident "went out and came back in less than 24 hours so didn't require a full admission assessment." When asked about vital signs or assessments, the DON was unable to locate any documentation.
At 1:00 PM, the DON said she would need to ask the Assistant Director of Nursing, explaining that the ADON "was able to locate information in the electronic health record better than I can."
The next day, neither the DON nor the ADON could provide additional documentation of vital signs or physical assessments.
The facility's own Change in Condition Protocol requires staff to evaluate a resident's condition when any change from baseline is observed. The policy mandates completion of a full assessment with documentation in the electronic system. Every shift must perform and document vital signs and a focused assessment.
The policy states there are no exceptions to this requirement.
Federal inspectors found that Northbrook Healthcare failed to complete proper assessments for Resident #96, one of four residents reviewed for hospitalizations. The facility reported a census of 85 residents at the time of the August inspection.
The violation carried a determination of minimal harm or potential for actual harm. But for Resident #96, the consequences were immediate: a return trip to the hospital with sepsis while nursing staff failed to document the basic vital signs that might have detected her deteriorating condition sooner.
The gaps in monitoring occurred during a critical period when the resident's body was fighting a life-threatening infection that had already progressed to septic shock. Her oxygen levels, blood pressure, and temperature fluctuations went largely unrecorded during days when such measurements could have provided early warning of complications.
Staff documented the resident's purple, cold extremities and difficulty obtaining oxygen readings only after her condition had become severe enough to require immediate hospitalization.
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 #96 was readmitted to the facility on June 3 following treatment for cholecystitis, sepsis, and septic shock.
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.