Northbrook Healthcare: Restorative Care Gaps - IA
The resident, identified in inspection records only as Resident 2, had been waiting since December.
A federal complaint inspection at Northbrook Healthcare and Rehabilitation Center, completed April 29, 2026, found that the facility failed to follow through on a restorative care recommendation made more than four months earlier, and failed to document whether the resident had been doing any exercise on her own in the meantime.
The resident had a history with physical therapy at the facility. She had previously completed a home exercise program and received education about it. She kept a portable pedal machine in her room. In December 2025, she received a new order for a physical therapy evaluation. The evaluation found she was not a candidate for further formal PT and that she remained at her baseline level of function. She admitted she had not been using the pedal machine. On December 19, 2025, the physical therapist made a restorative nursing recommendation for lower extremity exercises.
Four days later, on December 23, 2025, a licensed practical nurse documented in a progress note that the facility had received the referral for the restorative program.
Nobody acted on it.
Staff B, a certified nursing assistant and restorative aide, told inspectors on April 27 that he had no referral from physical therapy connecting Resident 2 to the restorative program. He said he had never received a copy of the recommendation. By the time the gap was discovered that afternoon, the resident had already received therapy and been discharged from the facility. She had used the pedal machine from home when she agreed to get out of bed, but whether she had done so consistently, and whether anyone had tracked it, was not documented.
Staff A, the LPN, told inspectors on April 29 that she did oversee the resident's therapy. She said she had reviewed the restorative recommendation on April 28, 2026, along with a progress note from December 4, 2025. But she reviewed it a day after the resident was already gone.
Inspectors noted a specific problem that went beyond the missed enrollment: no one had documented whether the resident was actually exercising independently. If the facility's position was that she could manage the pedal machine on her own, that assumption needed to be recorded somewhere. It was not.
The facility's own restorative nursing policy, dated 2025, describes the program's purpose as promoting a resident's ability to adapt and live as independently and safely as possible, with a focus on maintaining optimal physical functioning. It calls for the interdisciplinary team to conduct ongoing review and evaluation of the services needed to maintain or improve each resident's abilities, in line with that resident's goals and preferences.
The interdisciplinary team did not do that for Resident 2.
Inspectors rated the violation at the level of minimal harm or potential for actual harm, affecting a small number of residents. The citation falls under the federal requirement that nursing homes provide necessary services to maintain the highest practicable physical well-being of each resident.
What the record shows is a four-month window during which a physical therapist's recommendation sat unacted upon, an aide had no paperwork to work from, a nurse reviewed the file a day too late, and a resident with a history of not using her exercise equipment left the building without anyone having confirmed, in writing, whether she had been using it.
The pedal machine went home with her. Whether her legs are stronger or weaker than they were in December is not recorded anywhere.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northbrook Healthcare and Rehabilitation Center from 2026-04-29 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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA was cited for violations during a health inspection on April 29, 2026.
The resident, identified in inspection records only as Resident 2, had been waiting since December.
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.