Meadowbrook Manor - Naperville

Inspectors wroteBased on observation, interview and record review the facility failed to perform laboratory testing for residents with new respiratory illness symptoms. The facility also failed to follow their water management plan. This applies to all 212 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dining experience in a manner that would promote dignity. This applies to 6 of 16 residents (R12, R42, R80, R138, R191, R199) reviewed for dining experience in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the narcotic medication that were removed from its container for resident administration to ensure accurate count of the controlled medication. This applies to 10 of 10 residents (R2, R18, R34, R55, R58, R109, R126, R141, R145, R74) reviewed for controlled medication count in the sample of 35.

Inspectors wroteBased on interview and record review the facility failed offer the 2025-2026 Covid-19 vaccination to residents. This applies to 5 of 5 residents (R48, R71, R142, R162, and R164) reviewed for immunizations in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to keep a resident free from chemical restraint. This applies to 1 of 5 residents (R11) reviewed for unnecessary medications in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance in cleaning and trimming nails to residents that needed extensive assistance for personal hygiene. The applies to 3 of 5 (R1, R97, R108) residents, reviewed for ADL (Activities of Daily Living) in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate staffing to meet the care needs of residents. Staffing was insufficient to provide residents with assistance with incontinence care, preventing the development of pressure wounds, assisting with care needs, answering the call light and screams for help. This applies to 4 residents R1, R2, R3 and R6 in a sample of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to provide personal care to a resident with a pressure ulcer. This applies to 1 of 4 (R1) residents reviewed for pressure wounds in a sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a diabetic resident's feet were monitored to prevent complications. This failure resulted in the resident acquiring a necrotic diabetic ulcer on her left heel. This applies to 1 out of 3 residents (R5) reviewed for foot care.

Inspectors wroteBased on interview and record review, the facility failed to supervise a resident with high risk for falls. This failure resulted in the resident falling and requiring hospitalization for acute traumatic brain injury, seizures, and altered mental status. This applies to 1 out of 3 residents (R1) reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report an allegation of financial abuse by a family member. This applies to 1 out of 3 residents (R4) reviewed for financial abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the pressure ulcer intervention of a pressure-relieving mattress was working for a resident with known multiple pressure wounds. This applies to 1 out of 3 residents (R4) reviewed for pressure wounds.

Inspectors wroteBased on interview and record review, the facility failed to assist a resident with his social services needs. This applies to 1 out of 3 residents (R4) reviewed for social service needs.

Inspectors wroteBased on interview and record review, the facility failed to follow insulin administration instructions for a diabetic resident. As a result of this failure, R4 had an acute episode of hypoglycemia, which required the administration of emergency reversal-medications by emergency paramedics. This applies to 1 out of 3 residents (R4) reviewed for diabetes management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use a two-person transfer with a gait belt, as shown in the EMR (Electronic Medical Record), for a resident with a history of multiple falls. This applies to 1 of 3 residents (R2) reviewed for accidents and supervision in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers were repositioned at regular intervals as ordered by the physician, received timely incontinence care, and received wound care treatments to ensure wounds are clean, as ordered by the physician. This failure resulted in delayed healing of R1's facility-acquired pressure ulcer. This failure applies to 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure residents received timely incontinence care, showers, oral care, and assistance with shaving. This failure applies to 5 of 6 residents (R1, R2, R3, R5, and R6) reviewed for assistance with ADLs (Activities of Daily Living) in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to immediately notify a resident's representative when a resident had a change in condition requiring transfer to the local hospital. This applies to 1 of 3 residents (R1) reviewed for change in condition notification in the sample of 6.

Inspectors wroteBased on observation, interview the facility failed to ensure that sanitary practices are maintained to prevent cross contamination during dishwashing procedure and storage of dish rags. This applies to 199 residents that receive foods prepared and served from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 7 of 7 residents (R29, R58, R129, R149, R152, R153 and R180) reviewed for ADL (activities of daily living) in the sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date medications after it was opened to determine expiration dates and failed to remove expired medications from the medication carts. In addition, the facility failed to ensure that a narcotic with a broken package/container is discarded. This applies to 10 of 10 residents (R16, R27, R88, R106, R115, R129, R132, R146, R148, and R180) reviewed for medication storage in the sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound treatment as ordered. This applies to 1 of 7 residents (R112) reviewed for pressure ulcer prevention and treatment in the sample of 35. This failure resulted in the worsening of an acquired pressure ulcer wound from a stage 2 to an unstageable wound.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply a resting hand splint for a resident to prevent contractures. This applies to 1 of 4 residents (R155) reviewed for range of motion in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe transfer for a resident who requires 2 staff assistance for transfer from one area to another. This applies to 1 of 3 residents (R99) reviewed for transfers in the sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the alternate meal with similar nutritive value as the main entrée for residents that had history of weight loss. This applies to 2 of 6 residents (R60, R152) reviewed for nutrition in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's order during medication administration. There were 32 medication opportunities with 5 errors resulting to 15.63% medication error rate. This applies to 2 of 4 residents (R25 and R164) reviewed for medication administration in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices related to hand hygiene, removal of gown after leaving resident's bedroom, and disposal of soiled linen and gown. This applies to 3 of 35 residents (R25, R129, and R146) reviewed for infection control in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of resident abuse for 1 of 6 residents (R1) in the sample of 6 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and obtain treatment orders for a resident with a known surgical wound. This applies to 1 of 3 residents (R1) reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility staff (V3, Registered Nurse) and (V16, CNA/Certified Nursing Assistant) failed to report an allegation of mistreatment and or potential sexual abuse to the administrator. This applies to one of nine residents (R1) reviewed for abuse in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse. R6 was found with R7 in his closed bedroom with a chair placed to block the door. R6 is severely cognitively impaired and she was sitting on R7's bed, exposed, with her pants and incontinence brief around her ankles. R7 was naked from the waist down. Staff also failed to identify R7's behaviors (getting into a female resident's bed and disrobing in the hallway) as potentially sexually inappropriate behaviors, and failed to report those behaviors. This applies to 2 of 4 residents (R6, R10) reviewed for abuse. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to isolate to control the spread of a potential communicable disease for residents identified with suspicious rashes. This applies to 3 of 3 residents (R1-R3) reviewed for infection control practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess residents for self-administration of medications and, failed to obtain physician orders to have medications stored in resident rooms. This applies to 4 of 4 residents (R27, R67, R84 and R105) reviewed for medications in the sample of 73.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignified care during medication administration and failed to promote dignity of a resident with indwelling catheter. This applies to 4 of 4 residents (R56, R138, R141 and R195) reviewed for dignity in a sample of 73.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have call lights accessible to dependent residents. This applies to 5 of 5 residents (R24, R26, R164, R175, and R184) reviewed for accommodation of needs in a sample of 73.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain hazard free environment to residents. This applies to 5 of 5 residents (R27, R37, R157, R163 and R191) reviewed for accidents and supervision in a sample of 73.

Inspectors wroteBased on observation, interview and record review, facility failed to follow contact isolation precautions, follow appropriate hand hygiene, contain soiled linen and provide appropriate personal hygiene. This applies to 4 of 4 residents (R5, R111, R46 and R114) reviewed for infection control in a sample size of 73.

Inspectors wroteBased on observations, interviews and s reviews, the facility failed to report and provide necessary care to 2 residents (R24, R46) who were reviewed for change in condition in a sample of 73. 1. On 10/31/23 R24, who has a history of coronary artery disease, hypertension, arrhythmia, atrial fibrillation, and a history of myocardial infarction, was observed in her bed reporting to have chest pain and her call light was not in reach. R24 said she had not called for help because she was unable to find her call light. The surveyor reported to R24's nurse V5, that R24 was complaining of chest pain. At 11:59am V5 came into R24's room and R24 told her she was having chest pain. V5 told her she would go get her some Tylenol for her pain and left R24's room. V5 did not assess R24's vital signs at that time. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement interventions to prevent a resident from developing a pressure ulcer. This applies to 1 of 4 resident R115 reviewed for facility acquired pressure ulcers in a sample of 73 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure anti-contracture devices were applied as ordered. This applies to 1 of 16 residents (R195) reviewed for anti-contracture devices in a sample size of 73.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide necessary catheter care in a timely manner to 1 of 3 residents (R46) reviewed for catheter care in a sample of 73. On 10/31/23 at 1:35pm V9 CNA (Certified Nurse's Assistant) was preparing R46 for a shower. V9 removed R46's brief and observed urine in his brief, R46 has an indwelling catheter. V9 told R46 that his catheter must be leaking, and she would tell his nurse. On 11/1/23 at 2:58pm a review of R46's electronic records did not show any documentation of a report that R46's catheter was leaking urine. On 11/2/23 at 9:38am V5 (Nurse) said that V9 never reported that R45's catheter was leaking. On 11/2/23 at 10:08am V5 checked R46's brief and observed urine in his brief. At 10:13am V5 said that she notified R46's Nurse Practitioner about the leaking catheter and was given orders to change the catheter. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitary storage of respiratory equipment when not in use. This applies to 3 out of 4 (R5, R27, and R97) residents reviewed for use of respiratory equipment in the sample size of 73. 1. Different observations on 10/31/2023 at 11:03 AM and 11/1/2023 showed R97's firm plastic suction tip was not contained and was left on top of the suction machine. R97 had a decannulated tracheostomy with stoma open to air. On 11/2/2023 at 9:31 AM, V2 (DON-Director of Nursing) said respiratory equipment should be cleaned and contained in a bag for infection control. R97's admission Records show R97 was admitted on 8/ 16/2023. R97's diagnoses included malignant neoplasm of lung and larynx. Facility's Departmental (Respiratory Therapy) - Prevention of Infection Policy revised on November 2011 sated the following: . Purpose: [...]