Health inspection·January 8, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide assistance to residents who required staff assistance for ADL (Activities of Daily Living) care. This applies to 4 of 6 residents (R2, R11, R12 and R13) reviewed for ADL care in a sample of 13. Residents Affected - Some The findings include: 1. Face sheet, dated 1/7/25, shows R11's diagnoses included ideopathic progressive neuropathy, weakness, low back pain, reduced mobility, lack of coordination, open wounds of the toes, and chronic kidney disease. MDS (Minimum Data Set), dated 10/4/24, shows R11 was cognitively intact, R11 was always incontinent of bowel/bladder, and R11 was dependent on staff for toileting hygiene, bathing/showering, dressing, hygiene, tub/shower transfers, and chair/bed transfers. Care plan, dated 2/27/23, shows R11 had decreased balance, mobility, and strength, and R11 was dependent on two staff for using a full body mechanical lift machine for transfers. On 1/7/25 at 10:19 AM, R11 was lying in his bed and expressed frustration that the staff were not assisting him to get him out of bed. R11 stated he requested to be gotten out of bed at approximately 9:00 AM earlier that morning. R11stated when he puts his call light on, staff respond, turn off the light and tell him they will return, but do not. R11 stated he lived at the facility for 2 years and prefers to get up out of bed after breakfast. On 1/7/25, R11 remained in bed until 10:50 AM. 2. Face sheet, dated 1/7/25, shows R12's diagnoses included fracture of left pubis and anterior wall of left acetabulum, head contusion, depression and anxiety, colostomy, and history of falls. MDS, dated [DATE], shows R12's cognition was intact and R12 required substantial/maximal assistance from staff for toileting hygiene. Care plan, dated 10/28/24, shows R12 had a colostomy and staff were to check and change R12 approximately every two hours. On 1/7/25 at 10:25 AM, R12's call light was on above the door of her room. R12 stated, I can't get a CNA (Certified Nurses Assistant) to change my colostomy and it's full! The colostomy bag was inflated and bulging from beneath her night gown. R12 stated My daughter is coming and I don't want her to see me like this! It's full! R12 stated she had already waited an hour since her initial request to staff to care for the colostomy. At 10:28 AM, V12 (CNA) came into R12's room and stated she was coming and that she needed to care for one more resident prior to assisting R12 with her colostomy bag. R12 stated, I will be back! Just under an hour later at 11:20 AM, R12's colostomy bag was changed. (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 4 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 01/08/2025 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)