Inspection·November 19, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide treatments to pressure ulcers as ordered by the physician for 2 (R1, R5) of 3 residents reviewed for pressure ulcer treatments in the sample of 21. Residents Affected - Few The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 was transferred to the local hospital on October 6, 2024 and diagnosed with Covid-19 and altered mental status. R1 returned to the facility on October 11, 2024. On October 21, 2024, R1 was transferred to the local hospital and diagnosed with encephalopathy. R1 was readmitted to the facility on [DATE]. On November 3, 2024, R1 experienced labored breathing at the facility and was transferred to the local hospital where he was diagnosed with acute hypoxic respiratory failure. R1 returned to the facility on November 15, 2024. R1 has multiple diagnoses including, traumatic subdural and subarachnoid hemorrhage, craniotomy, hepatic encephalopathy, gastrostomy tube, cirrhosis of the liver, acute respiratory failure with hypoxia, hypertension, metabolic encephalopathy, pleural effusion, unstageable pressure ulcer, dysphagia, cognitive communication deficit, mitral valve insufficiency, UTI (Urinary Tract Infection), altered mental status, alcohol use, diseases of the pancreas, and history of venous thrombosis. R1's MDS (Minimum Data Set) dated October 31, 2024 shows R1 has moderate cognitive impairment and is totally dependent on facility staff for all ADLs (Activities of Daily Living). R1 has an indwelling urinary and is frequently incontinent of stool. R1 has bilateral upper and lower extremity range of motion limitations. R1's MDS continues to show R1 receives greater than 51 percent of his total number of calories from tube feeding. On September 10, 2024, V5 (WCN/RN-Wound Care Nurse/Registered Nurse) documented R1 was admitted to the facility with an unstageable pressure ulcer. The pressure ulcer measurements were 1.0 cm. (centimeters) by 0.5 cm. by unknown cm. deep. The EMR shows the following order for R1 dated September 11, 2024: Medihoney external gel. Apply to coccyx topically every day shift for skin condition. Clean with NSS (Normal Saline Solution), pat dry. Apply medihoney gel on wound bed. Cover with dry dressing. Change daily. The facility does not have documentation to show the wound treatment was administered as ordered on September 14, 15, 20, 21, 23, 25, 30, 2024 and October 2, 3, 2024. 2. The EMR shows R5 was admitted to the facility on [DATE]. R5 has multiple diagnoses including, heart disease, adult failure to thrive, hypertension, anemia, asthma, chronic kidney disease, dementia, emphysema, feeding difficulties, and abnormal gait and mobility. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145710 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145710 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 431 West Remington Boulevard Bolingbrook, IL 60440 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)