Meadowbrook Manor - Naperville

In the surveyor’s words

From the most serious findings on record at Meadowbrook Manor - Naperville, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jan 21, 2022

  Based on observation, interview, and record review, the facility failed to implement infection control policies and procedures per facility and CDC (Centers for Disease Control) guidelines regarding the isolation of Covid-19 positive residents, and for the use of Personal Protective Equipment (PPE) when interacting with residents who test positive for Covid-19. This failure has the potential to affect 35 residents (R4, R6, R17, R23, R28, R30-31, R33-34, R39, R47-49, R54-55, R63, R65, R68, R72, R75-76, R79, R86-88, R93, R97, R108, R127, R130, R140, R160, R165, R170 and R173) on R168's unit who were not already Covid-19 positive on 1/12/2022, or who had recovered from Covid-19 in the 90 days prior to 1/12/2022. This failure resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF600Jan 23, 2024

  Based 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. […]

• Actual harm, isolatedF687Jul 2, 2025

  Based 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. The findings include: R5's EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, diabetes, stenosis, and vascular disease. R5's EMR said she was dependent on staff assistance with her mobility and hygiene care, and at risk for developing ulcers. On 6/30/2025 at 9 AM, V24 (Wound Care Nurse/WCN) changed R5's left heel wound dressing. […]

• Actual harm, isolatedF689Jul 2, 2025

  Based 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. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including history of falls, traumatic subdural hemorrhage, hydrocephalus with presence of cerebrospinal fluid drainage device, hallucinations, vascular dementia with moderate agitation, abnormalities of gait and mobility, unsteadiness on feet, difficulty in walking, cognitive deficit, and hearing loss. […]

• Actual harm, isolatedF686Jan 29, 2025

  Based 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. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on January 2, 2025 and returned to the facility on [DATE]. […]