Northbrook Healthcare: Assessment Failures After Sepsis - IA
The resident, identified in inspection records only as Resident 96, was readmitted on June 3, 2025, following a hospitalization for cholecystitis, sepsis, and septic shock. Septic shock is a life-threatening condition characterized by dangerously low blood pressure and breakdown of cellular and metabolic function. She came back to the facility that afternoon. No physical assessment was completed that day. No vital signs were recorded. The same was true on June 4.
On June 5, a pre-dialysis assessment captured her vitals: blood pressure 96/56, oxygen saturation 88 percent, temperature 97.2 degrees. Those numbers, taken together, describe someone in a precarious state. No physical assessment accompanied them. By June 6, the record was blank again, no vitals, no assessment.
On June 7, the dialysis assessments were completed without any vital signs at all. A single temperature reading of 97.7 degrees appeared somewhere in the record. No physical assessment. On June 8 and June 9, no vital signs were documented.
June 8 brought a specific crisis. A progress note written at 1:30 that afternoon recorded that the resident had picked a scab and staff could not stop the bleeding. A nurse dressed the wounds on her legs, which had started bleeding and running down her leg. She was sent to the emergency department. When she came back, the clinical record contained no documentation of her return, no vitals, no assessment.
The next morning, June 9 at 11:36 a.m., a progress note described the resident with copious drainage from wounds on both legs, poor circulation to all extremities, and fingers and toes that were purple and cold. Staff were having difficulty getting an oxygen saturation reading at all. That afternoon, her cardiologist ordered her admitted to the hospital. No vital signs were documented that day either.
Shortly after midnight on June 10, a progress note recorded that she had been admitted to the hospital with a diagnosis that included sepsis.
When inspectors interviewed the Director of Nursing on August 13, she offered an explanation for the missing assessment on the initial June 3 return: the resident had gone out and come back in less than 24 hours, so a full admission assessment wasn't required. She was unable to locate vital signs or any assessment in the record. At 1:00 that afternoon, she told inspectors she would need to ask the Assistant Director of Nursing, who was better at navigating the electronic health record than she was.
The next morning, August 14, both the Director of Nursing and the Assistant Director of Nursing were unable to produce any additional documentation of vital signs or physical assessments.
The facility's own undated policy on change-in-condition monitoring states that staff are required to perform and document vitals and a focused assessment every shift when a change from baseline is observed, and that there are no exceptions to this requirement.
A resident who had just survived septic shock, whose blood pressure on June 5 was 96/56 and whose oxygen saturation was 88 percent, went days at a time without anyone documenting her temperature, her pulse, her blood pressure, or her breathing. When her legs bled through a dressing and she was rushed to the emergency department, she came back to a record that didn't note she had returned. Four days later, she was hospitalized again with sepsis.
Federal inspectors rated the violation at a level of minimal harm or potential for actual harm. The facility reported a census of 85 residents at the time of the August inspection.
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.
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 22, 2026 · Our methodology
Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA was cited for violations during a health inspection on August 14, 2025.
Septic shock is a life-threatening condition characterized by dangerously low blood pressure and breakdown of cellular and metabolic function.
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.