Northbrook Healthcare And Rehabilitation Center
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
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northbrook Healthcare and Rehabilitation Center
6420 Council Street NE Cedar Rapids, IA 52402
SUMMARY STATEMENT OF DEFICIENCIES
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.
Based on clincal record review, staff interview and policy review the facility failed to complete an assessment for 1 of 4 residents (Resident #96) reviewed for hospitalizations.
The facility reported a census of 85 residents.
Findings include: Progress Notes written on 6/3/25 at 4:28 PM document Resident #96 readmitted to the facility following cholecystitis (inflammation of the gallbladder), sepsis (sepsis happens when an infection you already have triggers a chain reaction throughout the body. It is a life threatening, medical emergency per the Center for Disease Control (CDC)), and septic shock (a severe form of sepsis characterized by dangerously low blood pressure and abnormalities in cellular and metabolic function).
The clinical record lacked a physical assessment or vital signs on 6/3 and 6/4.
The pre-dialysis assessment completed on 6/5 included vitals of Temperature 97.2 Fahrenheit (F), Pulse 88, Respirations 16, Blood Pressure (BP) 96/56 and oxygen saturation (O2 Sat) of 88%.
The post-dialysis assessment completed on 6/5 included vitals of Temperature 98.7 F, Pulse 80, Respirations 18, BP 124/80 and O2 Sat of 98%.
The clinical record lacked a physical assessment on 6/5.
The clinical record lacked a physical assessment or vital signs on 6/6.
The pre and post dialysis assessments on 6/7 lacked vital signs.
The clinical record did include a temperature of 97.7 F.
The clinical record lacked vital signs on 6/8 and 6/9.
The clinical record lacked a physical assessment on 6/7 and 6/8.
Progress Note written on 6/8/25 at 1:30 PM documented the resident had picked a scab and staff were unable to stop the bleeding.
The nurse completed the dressing change to the resident's legs that started bleeding and running down her leg.
The resident was sent to the Emergency Department (ED).
The clinical record lacked documentation of the resident returning from the ED, vitals or physical assessment upon return.
Progress Note written on 6/9/25 at 11:36 AM documented the resident had copious amounts of drainage from bilateral leg wounds.
She had poor circulation to all extremities, fingers and toes purple and cold and difficulty in getting an O2 sat reading.
Progress Note written on 6/9/25 at 3:39 PM documented the resident was to be admitted to the hospital per her cardiologist.
There were no vital signs documented on 6/9.
Progress Note written on 6/10/25 at 12:20 AM documented the resident was admitted to the hospital with diagnosis including sepsis.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northbrook Healthcare and Rehabilitation Center
6420 Council Street NE Cedar Rapids, IA 52402
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northbrook Healthcare and Rehabilitation Center
6420 Council Street NE Cedar Rapids, IA 52402
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Northbrook Healthcare and Rehabilitation Center
6420 Council Street NE Cedar Rapids, IA 52402
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: