Inspection Reports for Meadowbrook Bolingbrook

The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements related to resident care, medication administration, infection control, dietary services, and other aspects of nursing home operations.

The facility was found deficient in multiple areas including failure to provide adequate assistance with activities of daily living such as incontinence and nail care, failure to ensure daily weights for a resident on dialysis, failure to educate a resident on consequences of refusal of wound care, failure to provide appropriate diet consistency and supervision, failure to assess risk of entrapment prior to bed rail installation, medication administration errors, improper medication storage and labeling, failure to provide dental care, failure to serve correct portion sizes, failure to follow infection control protocols including enhanced barrier precautions, and failure to properly offer and document influenza, pneumococcal, and COVID-19 vaccinations.

The inspection was conducted due to complaints regarding the facility's failure to implement safety interventions and provide adequate supervision to prevent resident injuries.

The facility failed to prevent two residents from injury due to inadequate safety measures and supervision. Resident R2 fell from bed causing a laceration and nasal fractures, and Resident R3 fell from a wheelchair sustaining a head laceration requiring hospital admission and staples.

The complaint investigation found that the facility failed to prevent injuries to two residents (R2 and R3) due to staff not following safety protocols such as leaving beds in high position without mats or rails, and pushing a wheelchair without ensuring feet were on footrests. These failures caused actual harm including fractures and lacerations requiring hospital care.

The inspection was conducted due to a complaint investigation regarding the facility's failure to protect residents from neglect, specifically related to medication administration and hospice order compliance for residents admitted for hospice respite stays.

The facility failed to ensure medications were obtained and hospice orders followed for two residents admitted for hospice respite stays. One resident experienced seizures due to missed anticonvulsant medication and insulin, resulting in hospitalization. Another resident received unnecessary medications not aligned with hospice orders. The facility lacked proper communication and documentation regarding medication orders and failed to clarify conflicting medication lists between hospice and hospital records.

The complaint investigation revealed neglect related to failure to provide medications and follow hospice orders for two residents admitted for hospice respite stays. One resident experienced seizures due to missed medications and required hospitalization. The investigation included interviews with staff, family members, hospice representatives, and review of medical records and policies.

The inspection was conducted to assess the facility's compliance with providing care and assistance for activities of daily living (ADLs), specifically focusing on showering, shaving, and fingernail care for residents who are unable to perform these tasks independently.

The facility failed to ensure that residents received showers as scheduled and did not provide adequate assistance with shaving and fingernail care for 4 residents reviewed. Documentation showed multiple missed showers or bed baths without refusals recorded, and inconsistencies in shower documentation practices were noted.

The inspection was conducted due to allegations of sexual abuse by a housekeeper (V4) against residents R1 and R2 on January 25, 2025.

The facility failed to protect residents R1 and R2 from sexual abuse by a housekeeper. The investigation initially did not substantiate the allegations, but further evidence including video footage and interviews confirmed inappropriate contact. The facility also failed to thoroughly investigate and communicate key information during the investigation process.

The complaint involved allegations that a housekeeper sexually assaulted residents R1 and R2 on January 25, 2025. R2 reported being fondled and touched inappropriately, including her breast and vaginal area, and that the housekeeper made inappropriate comments. R1 also reported being touched inappropriately. The local police and facility conducted investigations. The housekeeper admitted to physical contact but denied inappropriate touching. The investigation was ongoing at the time of the report.

The inspection was conducted due to complaints regarding failure to provide assistance to residents requiring help with activities of daily living (ADLs) and insufficient staffing to meet resident care needs.

The facility failed to provide timely assistance to residents requiring help with ADLs, including toileting, bathing, and transfers, affecting 4 of 6 residents reviewed. Staffing shortages were documented, with only three CNAs assigned to 45 residents on the unit, causing delays in care and unmet resident needs.

The investigation was complaint-driven, focusing on allegations that residents were not receiving timely assistance with ADLs and that staffing levels were insufficient. The complaint was substantiated based on observations, interviews, and record reviews.

The inspection was conducted due to a complaint regarding the facility's failure to change a resident's rectal tube collection bag according to manufacturer guidelines.

The facility failed to change the rectal tube collection bag for one resident as required, instead emptying and reusing the bag contrary to manufacturer instructions, which specify single use only. Staff interviews revealed inconsistent knowledge and practices regarding bag changes, and the facility lacked a policy on rectal tube care.

The complaint investigation found that the facility staff did not change the rectal tube collection bag daily as required, instead emptying and reusing the bag, which is against manufacturer guidelines and increases infection risk. The complaint was substantiated based on interviews and record review.

The inspection was conducted to evaluate the facility's compliance with physician-ordered pressure ulcer treatments and wound care for residents, specifically reviewing treatment administration for pressure ulcers in sampled residents.

The facility failed to provide wound treatments as ordered for two residents (R1 and R5) with pressure ulcers, with missing documentation for multiple treatment dates. Despite these omissions, the medical director stated the wounds did not decline due to the missed treatments.

The inspection was conducted due to complaints regarding inadequate incontinence care, failure to investigate grievances, resident-to-resident abuse, and concerns about elopement risk assessment and prevention.

The facility failed to fully investigate family grievances related to incontinence care, did not provide timely incontinence care to a resident dependent on staff, failed to protect residents from physical abuse and did not conduct thorough abuse investigations, and did not assess or implement interventions for elopement risk within 24 hours of admission for a resident.

The complaint investigation focused on grievances about incontinence care for resident R7, allegations of physical abuse between residents R4 and R5, and concerns about supervision and elopement risk for resident R1. The facility failed to resolve grievances, protect residents from abuse, conduct thorough abuse investigations, provide timely incontinence care, and assess and intervene for elopement risk.

The inspection was conducted to assess compliance with Medicare/Medicaid regulations including notification of Medicare Part A service termination, privacy and confidentiality of resident records, assistance with activities of daily living, wound care, medication storage and labeling, food service, infection control, quality assurance, and COVID-19 vaccination status.

The facility was found deficient in multiple areas including failure to notify residents in writing about Medicare Part A service termination, failure to maintain confidentiality of medical records, inadequate assistance with grooming and eating, improper wound care for a stage 4 pressure ulcer, medication storage and labeling issues, improper food portioning, inadequate dishwashing machine sanitization, failure to hold required QAPI meetings, lapses in infection control practices, and failure to offer COVID-19 vaccines to residents and staff.

The inspection was conducted to evaluate the facility's compliance with medication regimen review requirements, specifically focusing on timely responses to pharmacist recommendations regarding psychotropic medications for residents.

The facility failed to timely address pharmacist recommendations for two residents reviewed for monthly medication reviews, including failure to discontinue or appropriately manage psychotropic medications as recommended. The facility's policies require timely physician responses and follow-up, but these were not consistently met.

The inspection was conducted due to a complaint regarding the facility's failure to implement care plan interventions for transfers to prevent falls.

The facility failed to follow the care plan for resident R1, who required two-person assistance for transfers, resulting in an improper transfer by a Certified Nurse Aide (V8) who attempted a one-person transfer causing R1 to be lowered to the floor. No injuries were noted initially, but pain was reported two days later with negative X-rays. V8 was terminated for not following the plan of care.

The complaint investigation found that the facility failed to follow the care plan for resident R1, resulting in an improper transfer and fall incident. The deficiency was substantiated with termination of the responsible Certified Nurse Aide.

The inspection was conducted to assess compliance with care standards related to activities of daily living, fall prevention, supervision, and safety in the nursing home.

The facility failed to provide adequate incontinence care to a resident dependent on staff, failed to follow fall precaution interventions for high-risk residents, did not provide adequate supervision for residents who smoked, and had unsafe transfer practices and environmental hazards such as a leaking toilet and missing commode parts.

The inspection was conducted due to an alleged allegation of verbal abuse reported by a resident (R2) against a staff member, which the facility failed to investigate.

The facility failed to investigate an alleged verbal abuse incident involving resident R2. Multiple staff members confirmed the allegation was reported to the Director of Nursing (DON), who denied knowledge. The Administrator acknowledged the failure to investigate and stated an abuse investigation would be initiated. The facility's Abuse Prevention Program Policy requires immediate reporting and investigation of abuse allegations, which was not followed.

The complaint involved an allegation of verbal abuse by a staff member towards resident R2. The allegation was reported by R2 and confirmed by staff members V5 (LPN) and V4 (Social Services), who reported it to the DON (V2). The DON denied knowledge of the allegation. The Administrator (V1) was unaware due to being on vacation but acknowledged the failure to investigate and committed to initiating an abuse investigation. The facility's abuse investigations from April to November 2023 showed no investigation was conducted regarding this allegation. No grievances related to R2 were found in the Grievance Log.

The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident rights, care, infection control, medication administration, dietary services, and safety.

The facility was found deficient in multiple areas including failure to inform residents about the Ombudsman program, inadequate assistance with activities of daily living, failure to provide appropriate range of motion support, improper catheter and incontinence care, medication administration errors, failure to serve diets as ordered, improper dishwashing sanitization, and lapses in infection prevention and control practices.