Inspection Reports for
Meadowbrook Bolingbrook

The facility was found to have multiple deficiencies including failure to provide adequate assistance with activities of daily living, medication errors, improper infection control practices, failure to provide dental care, improper food handling, and failure to offer and administer vaccines according to policy and CDC guidelines.

The facility failed to implement safety interventions and provide supervision to prevent two residents from injury, resulting in one resident sustaining a nasal bone fracture and laceration, and another sustaining a head laceration requiring staples and hospitalization.

The facility failed to protect residents from neglect by not ensuring medications were obtained and hospice orders followed for two residents during respite stays, resulting in one resident experiencing seizures and hospitalization. Additionally, the facility failed to prevent unnecessary medications for one resident and failed to administer required anticonvulsant medication and insulin for another hospice resident.

The facility failed to ensure residents received showers as scheduled and did not provide assistance with shaving and fingernail care for four residents reviewed. Documentation was lacking to confirm showers or bed baths were given as scheduled, and some residents had long fingernails and beard growth contrary to care plans.

The facility failed to protect residents R1 and R2 from sexual abuse by a housekeeper and failed to thoroughly investigate the allegations initially, not substantiating the abuse until new information was obtained. The facility now sustains the allegation that R2 was touched inappropriately by the former employee.

The facility failed to provide adequate assistance with activities of daily living and was short staffed, affecting multiple residents' care needs.

The facility failed to change a resident's rectal tube collection bag according to manufacturer guidelines, affecting one resident. The manufacturer guidelines specify the device is single use and should not be reused.

The facility failed to provide ordered pressure ulcer treatments for two residents (R1 and R5) as documented by missing treatment administrations on multiple dates. The facility's wound care nurses and medical director confirmed expectations for nursing staff to follow wound care orders.

The facility was found to have multiple deficiencies including failure to investigate grievances, protect residents from physical abuse, conduct thorough abuse investigations, provide timely incontinence care, and assess and intervene for elopement risk.

The facility was found to have multiple deficiencies including failure to notify residents of Medicare Part A service termination, privacy breaches, inadequate assistance with activities of daily living, improper wound care, medication storage and labeling issues, incorrect food portioning, inadequate dishwashing sanitization, failure to hold required QAPI meetings, lapses in infection control practices, and failure to offer and document COVID-19 vaccinations to residents and staff.

The facility failed to timely address pharmacist recommendations for two residents regarding psychotropic medication management, including failure to discontinue or reduce dosages as recommended.

The facility failed to implement care plan interventions for transfers to prevent falls for one resident. The staff member responsible was terminated for not following the plan of care.

Complaint investigation regarding failure to provide adequate incontinence care, fall prevention, supervision of smoking residents, and safe transfer practices.

The facility failed to provide timely incontinence care to one resident, did not adequately supervise residents at high risk for falls including one smoking unsupervised, and failed to maintain safe equipment and transfer practices. Multiple residents were affected by these deficiencies.

Complaint investigation of alleged verbal abuse involving resident R2; no prior investigation was conducted despite reports to staff and administration.

The facility failed to investigate an alleged verbal abuse incident involving resident R2. The Administrator acknowledged the failure and committed to initiating an abuse investigation.

The facility was found to have multiple deficiencies including failure to inform residents about the State Ombudsman program, inadequate assistance with activities of daily living, improper catheter care, medication errors, failure to serve diets as ordered, improper dishwashing temperatures, and lapses in infection control practices.