Inspection·January 29, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to immediately notify a resident's representative when a resident had a change in condition requiring transfer to the local hospital. This applies to 1 of 3 residents (R1) reviewed for change in condition notification in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on January 2, 2025, and returned to the facility on January 9, 2025. R1 has multiple diagnoses including, acute encephalopathy due to sepsis, acute respiratory failure with hypoxia, diabetes, multiple sclerosis, paraplegia, major depressive disorder, PVD (Peripheral Vascular Disease), heart disease, idiopathic neuropathy, cognitive communication deficit, dysphagia, severe sepsis with septic shock, pneumonitis due to inhalation of food and vomit, hydronephrosis, Stage 4 pressure ulcer of the sacral region, weakness, dementia, hearing loss, history of falling, and acquired absence of right leg above the knee. R1's MDS (Minimum Data Set) dated November 4, 2024 shows R1 is cognitively intact, is dependent on facility staff for transfers between surfaces, and requires substantial/maximal assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. On January 2, 2025 at 8:37 PM, V3 (LPN-Licensed Practical Nurse) documented R1 had three episodes of vomiting and was clammy, with an elevated heart rate. V3 documented, she notified R1's doctor and family and he was sent to the local hospital at 8:30 PM. On January 27, 2025 at 12:05 PM, R1 was lying in bed in his room. V5 (Spouse of R1) was sitting at R1's bedside. V5 said, R1 was sent to the local hospital on January 2, 2025. V5 said, No one called me to tell me my husband (R1) was sent to the hospital. I had no idea. The next morning the hospital calls me and tells me [R1] was being rushed to surgery. I didn't even know he was at the hospital, and I didn't get to see him before he went to surgery. This was very upsetting to both of us. We have been married over 40 years, and I would have wanted to be there for him. He ended up with a kidney stone and other problems, and he ended up in intensive care. I was told by [V2] (DON-Director of Nursing) that the nurse called the wrong number when she tried to call me. She used the wrong area code. My number is in the chart. There is no reason for this. They also have his sister's phone number, and our daughter's phone number. Why didn't they try to call someone else if they weren't able to reach me? Instead, they left a message on a total stranger's telephone about my husband. (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 11 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 01/29/2025 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)