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Complaint Investigation

Northbrook Healthcare And Rehabilitation Center

August 14, 2025 · Cedar Rapids, IA · 6420 Council Street Ne
Citations 13
CMS Rating 1/5
Beds 130
Provider ID 165587
Healthcare Facility
Northbrook Healthcare And Rehabilitation Center
Cedar Rapids, IA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA — inspection on August 14, 2025.

Found 13 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0550
Resident Rights Deficiencies

Review of Progress Notes, titled Nurses Note Narrative, dated 8/5/25 at 5:58 AM and 8/5/25 at 4:05 PM, Resident #58 had falls in relation to trying to use the bathroom in his room. A Nurses Note Narrative, dated 8/9/25, included documentation the resident was found sitting on the floor in front of the toilet in his room. Resident #58 was noted to be continent and reported he lost his footing while entering the bathroom.

The Progress Notes lacked documentation facility staff discussed changes to the care plan with either the resident or resident's representative to include the interventions of signs.

On 8/13/2025 at 11:13 AM, Staff N, Certified Nurses Aide (CNA), reported Resident #58 did not like to wait when he needed to use the bathroom.

When asked by the surveyor if Resident #58 had complained about the signs in his room, Staff N reported Resident #58 did say something the other day after falling about the signs.

Staff N reported Resident #58 said that if he had to go, he was going to get up and go no matter what the signs told him.

Facility staff failed to consider the dignity and response of the resident when posting signs in the resident room.

165587 08/14/2025

Northbrook Healthcare and Rehabilitation Center 6420 Council Street NE Cedar Rapids, IA 52402

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0640 during a standard health inspection conducted on 2025-08-14.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-14.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2025-08-14.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide activities to meet all resident's needs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

During an interview on 8/13/2025 at 12:54 PM, the Director of Nursing (DON) explained the resident went out and came back in less than 24 hours so didn't require a full admission assessment on 8/13/25.

The DON was unable to locate vital signs or an assessment. At 1:00 PM, the DON reported she would have to ask the Assistant Director of Nursing (ADON) as she was able to locate information in the electronic health record better than I can. On 8/14/25 at 9:57 AM the DON and ADON were unable to provide and additional documentation of vital signs or physical assessments.

The undated facility policy titled Change in Condition Protocol directs staff to evaluate the resident's condition when a change from baseline is observed, complete a full assessment and document in Point Click Care (PCC), and every shift is required to perform and document vitals and a focused assessment.

The policy further directs staff that there are no exceptions to this requirement.

165587 08/14/2025

Northbrook Healthcare and Rehabilitation Center 6420 Council Street NE Cedar Rapids, IA 52402

During an interview with the ADON on 8/14/2025 at 9:54 AM she reported when she thought about the walker, she recalled one of the sides didn't have something right about it and it was discussed in a morning meeting.

She stated the restorative aide would have been responsible for checking the walker and it should have been repaired or out of service if not safe.

She said she would need to continue to work with the new restorative aide to monitor things like that.

On 8/14/2025 at 10:21 AM the Administrator stated she thought the documentation had been over-exaggerated.

She recalled the walker was disposed of and discussed that morning in a quality assurance meeting.

The restorative aide participated and staff were told to double and triple check equipment for safety after the incident.

She also asked maintenance and therapy to look into it.

165587 08/14/2025

Northbrook Healthcare and Rehabilitation Center 6420 Council Street NE Cedar Rapids, IA 52402

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-08-14.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-08-14.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Review of Progress Notes, titled Nurses Note Narrative, dated 8/5/25 at 5:58 AM and 8/5/25 at 4:05 PM, Resident #58 had falls in relation to trying to use the bathroom in his room. A Nurses Note Narrative, dated 8/9/25, included documentation the resident was found sitting on the floor in front of the toilet in his room. Resident #58 was noted to be continent and reported he lost his footing while entering the bathroom.

On 8/13/25 at 11:05 AM, Staff B, CNA, explained the morning time was the busiest time at the nursing home.

Staff B reported she had one other CNA working the hall she was on.

Staff B reported there were a few times residents had to wait longer than 30 minutes for their call light to be answered.

On 8/13/2025 at 11:13 AM, Staff N, CNA, reported Resident #58 did not like to wait when he needed to use the bathroom.

Staff N reported the residents usually did not have to wait longer than minutes.

Staff N reported the morning time was busiest with trying to get resident's up for the day.

165587 08/14/2025

Northbrook Healthcare and Rehabilitation Center 6420 Council Street NE Cedar Rapids, IA 52402

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-14.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0847 during a standard health inspection conducted on 2025-08-14.

Category: Administration Deficiencies

The facility was found deficient in the following area: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, IA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-14.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 13 deficiencies cited during this inspection of Northbrook Healthcare and Rehabilitation Center.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Review of the undated facility policy, titled Housekeeping Daily Tasks, revealed directions to housekeeping staff to clean residents toilets daily.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Cedar Rapids, IA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Northbrook Healthcare and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.