Northbrook Healthcare: Call Light Failures Caused Falls - IA
Then it happened again.
The resident, identified in federal inspection records only as Resident 58, fell twice in the span of a week at Northbrook Healthcare and Rehabilitation Center, on Council Street NE in Cedar Rapids. Both falls were tied to the same problem: he needed help getting to the bathroom, he used his call light, and nobody arrived in time.
Nursing notes show he fell on August 5 — once at 5:58 in the morning, once at 4:05 in the afternoon — both times while trying to reach the bathroom in his room. On August 9, staff found him sitting on the floor in front of his toilet. He told them he had lost his footing entering the bathroom.
He reported all of this himself during an interview on August 12. He said the morning wait happened a couple of times a week. He said going to the bathroom was the main issue. He said he had used his call light before each of the falls and that staff had not responded for about an hour. He got tired of waiting, got up, and fell.
His medical record makes the stakes plain. He had heart failure. He had a documented history of repeated falls and difficulty walking. A cognitive assessment gave him a score of 5, indicating severe cognitive impairment. His care plan, revised the day before the interview, required staff assistance with a walker for toileting, ambulation, and transfers. He could not safely get himself to the bathroom. The plan said so. The falls said so too.
A certified nursing assistant on his hall, identified in the report as Staff B, said the morning shift was the busiest time at the facility. She said there was one other CNA working the hall with her. She acknowledged there were times residents had to wait longer than 30 minutes for a call light to be answered.
Another CNA, Staff N, said the mornings were the hardest, with staff trying to get residents up for the day. She said residents usually didn't have to wait longer than minutes. The inspection record does not explain how both accounts can be true at the same facility, on the same hall, for the same resident.
The Director of Nursing told inspectors on August 13 that she expected staff to answer call lights within 10 minutes, or at least enter the room to tell the resident they would be back. She acknowledged that some residents required two staff members to assist them, which could slow response. The Administrator said staff should answer call lights in a timely manner and said the facility had added more staff.
The inspection was a complaint investigation, conducted August 14, 2025. Federal records classify the level of harm as minimal harm or potential for actual harm.
Resident 58 was not the only one waiting. The inspection narrative references at least one other resident who needed bathroom help, waited an hour, and ultimately went alone rather than continue to wait. That resident's situation was documented separately in the same report.
A man with a history of falls, severe cognitive impairment, and a care plan that said he needed help to walk to the toilet used his call light twice in one week. Both times, he waited an hour. Both times, he got up alone. Both times, he fell. The nursing home told inspectors it had added staff.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA was cited for violations during a health inspection on August 14, 2025.
Both falls were tied to the same problem: he needed help getting to the bathroom, he used his call light, and nobody arrived in time.
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.