Inspection Reports for
Meadowbrook Bolingbrook

The survey identified multiple deficiencies including failures in providing adequate assistance with activities of daily living, medication administration errors, infection control breaches, improper food handling, and failure to offer required immunizations. The facility failed to provide dental care for a resident with painful and decaying teeth and did not follow policies for bed rail assessments and fall prevention.

The facility failed to implement safety interventions and provide supervision to prevent two residents from injury, resulting in one resident sustaining a laceration and nasal bone fractures 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 administered as ordered for hospice respite residents. Additionally, the facility failed to prevent unnecessary medications for one resident and failed to prevent significant medication errors for another resident, resulting in actual harm.

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 provided as required.

The facility failed to protect residents R1 and R2 from sexual abuse by a housekeeper on January 25, 2025, resulting in Immediate Jeopardy. The facility also failed to thoroughly investigate the allegations, initially not substantiating the abuse despite consistent resident statements and evidence. The Immediate Jeopardy was removed on February 18, 2025 after the facility presented a removal plan.

The facility failed to provide adequate assistance with activities of daily living for residents requiring staff help, and was also found to be short staffed, impacting resident care. Four of six residents reviewed experienced delays or lack of assistance with toileting, bathing, grooming, and transfers.

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, on multiple dates as documented in the medical records and confirmed by staff interviews.

The facility failed to fully investigate and resolve grievances related to incontinence care, failed to protect residents from physical abuse, did not conduct thorough abuse investigations, failed to provide timely incontinence care to a dependent resident, and did not assess or implement interventions for elopement risk for a resident. The facility also failed to provide adequate supervision to prevent accidents related to 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 labeling and storage issues, improper food portioning, inadequate dishwashing sanitization, failure to hold quarterly QAPI meetings, infection control lapses, and failure to offer and document COVID-19 vaccinations.

The facility failed to timely address pharmacist recommendations for two residents regarding psychotropic medication management, including failure to respond to gradual dose reduction recommendations and proper monitoring of PRN orders.

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.

The facility failed to provide adequate incontinence care to one resident and failed to implement proper fall precautions and supervision for five residents at high risk for falls. Additional issues included unsafe transfer practices and inadequate maintenance of equipment.

Complaint regarding alleged verbal abuse of resident R2: failure to investigate the allegation.

The survey found the facility failed to investigate an alleged verbal abuse incident involving resident R2. The facility's administrator acknowledged the failure and committed to initiating an abuse investigation.

The facility was found to have multiple deficiencies related to resident care, medication administration, dietary services, infection control, and sanitation. The facility failed to provide adequate assistance with activities of daily living, failed to maintain proper infection control practices, and failed to serve diets as ordered by physicians.