F 0609
Level of Harm - Minimal harm
or potential for actual harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on observation, interview, and record review, the facility failed to report allegations of resident abuse
for 1 of 6 residents (R1) in the sample of 6 residents reviewed for abuse.
Residents Affected - Few
The findings include:
On 9/18/24 AT 10:00 AM, R1 was noted to have yellow/green bruising around her left eye orbit and a small
purple mark under her left eye near her cheek bone. When asked what happened to her eye, R1 imitated a
fist punching her in the left eye while saying the muchacho. R1 then became tearful and used a tissue to
dab at her eyes.
On 9/18/24 at 10:09 AM, V5, Licensed Practical Nurse (LPN), said if a resident had a new bruise, he would
ask them what happened. He would ask the CNAs (certified nursing assistants) if they knew about any
injuries to the resident. V5 said he would report it to the supervisor and the administrator. V5 said they
would need to investigate it. V5 said the investigation would include interviewing staff from the present shift
back 24-48 hours prior to find out if anything happened during care of the resident. They could review video
to see if it would provide any clues too. V5 said he believes the injury gets reported to IDPH, as well.
On 9/18/24 at 11:26 AM, V4, LPN, said when he came in the morning, he noticed a little bump and some
slight bruising around R1's eye. V4 said he made an incident report and reported it to the nurse practitioner,
but he did not report it to the supervisor or the administrator.
On 9/18/24 at 10:30 AM, V8, R1's son, said he was in the facility on 9/15/24 and R1 had a bruise around
her eye. V8 said when he asked what happened, R1 told him a man hit her. V9, R1's daughter-in-law, said
she went to see R1 later that week and again asked R1 what happened to her eye and R1 told her a man
punched her. V9 said R1's story did not change from what she had told V8 previously.
On 9/18/24 at 11:43 AM, V2, Director of Nursing (DON), said injuries of unknown origin would be reported
to V1, Administrator, as that is abuse and they would help with the investigation. V2 said nothing was
reported to her about potential abuse or an injury of unknown origin regarding R1.
On 9/18/24 AT 12:00 PM, V3, Assistant DON, said he saw R1 had a bruise and he spoke to V4, V6, CNA,
and V7, CNA, and was told R1 did not have any falls or incidents. V3 said if there is an injury of unknown
origin, they report the incident to V1. V3 said R1's bruise was not related to abuse because the staff would
report it if they think it is abuse. V3 agreed that a bruise has the potential to be caused by abuse and should
be investigated further. V3 said if they think an injury is abuse, they contact V1 right away. V3 said he didn't
feel he needed to tell V1 about R1's bruising.
(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:
145874
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
145874
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Manor - Naperville
720 Raymond Drive
Naperville, IL 60563
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 9/18/24 at 9:50 AM, V1 said he has not had any abuse allegations/investigations since July of 2024 or
any injuries of unknown origin. On 9/18/24 at 11:03, V1 said a resident with an injury of unknown origin has
to be considered abuse. He would investigate the injury, file a report with public health, and notify the
police. On 9/18/24 at 1:36 PM, V1 said R1's facial bruise was not reported to him because V3 said the
nurses did not think it was abuse, so it was not reported to him. V1 said if he had known, he would have
initiated an abuse investigation.
R1's Progress Notes dated 9/10/24 at 2:30 PM, show, Resident noted with bruising of unknown origin
around the L [left] eye. R1's Skin Condition sheet dated 9/10/24 at 1:40 PM, shows R1 has a bruise to her
face. R1's current care plan provided by the facility shows R1 has potential risk for abuse/neglect and any
issues pertaining to potential abuse/neglect situations are to be reported per policy.
The facility's Investigating Injuries Policy (undated) shows injuries of unknown source are to be reported to
the abuse coordinator.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145874
If continuation sheet
Page 2 of 2
