Meadowbrook Manor - Naperville
MEADOWBROOK MANOR - NAPERVILLE in NAPERVILLE, IL — inspection on September 3, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
dried feces.
Dried caked feces were between the gluteal fold. R1's labia and gluteal fold was reddened. R1 had a small open area on her coccyx.On 9/2/25 at 12:32 PM, V6 CNA stated her shift started a 6AM, but she had not provided incontinence care or turned R1 prior to 11:55 AM. V6 stated the wound nurse provided incontinence care and repositioned the resident during the dressing change.On 9/2/25 at 12:42 PM, R1 stated V6 had not provided any incontinence care during her shift and repositioned her at 11:55 with the physical therapist.On 9/2/25 at 3:10 PM, V8 Family Member stated R1 had called him a couple of times with request for him to call nursing station for assistance. V8 stated on one of the calls R1 had complained of being left in soiled brief for over two hours.On 9/2/25 at 3:18 PM, V9 RN (Registered Nurse) stated R1 was on antibiotics for a UTI and had a pressure wound on her coccyx. V9 did not see any documentation of a pressure wound or UTI prior to or on admission.On 9/2/25 at 4:50 PM, V3 Wound Nurse stated there was no documentation of a coccyx pressure wound on 8/27/25 when R1 was admitted to the facility. V3 stated there was no documentation of a coccyx pressure wound was in R1's hospital discharge records. V3 stated she discovered and documented R1's wounds on 8/29/25 during the skin assessment. V3 stated the coccyx wound measured 2.0 cm (centimeters)x 0.2 cm x 0.2cm. V3 stated R1 is obese and unable to reposition without the assistance of two staff members. R1 is incontinent of bowel and bladder moisture is a contributing factor to skin break down. V3 stated nursing staff is responsible for repositioning and providing incontinence care for R1.On 9/2/25 at 6:17 PM, V1 Administrator stated should not need to call their family members to obtain staff assistance.The facility policy Wound Care Prevention dated April 2025 states, all residents will receive appropriate care to decrease the risk of skin break down.
The nursing department will review all new admissions / readmissions to put a plan in place for the prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information.
Clean skin at time of soiling and at routine intervals.The facility policy Incontinence Care dated April 2025 states, incontinence care is provided to keep residents as dry comfortable and odor free as possible. It also helps in preventing skin breakdown.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Meadowbrook Manor - Naperville
720 Raymond Drive Naperville, IL 60563
SUMMARY STATEMENT OF DEFICIENCIES
has been told by staff they are working short of staff. R6 stated it can take ten minutes to three hours for the call light to be answered. R6 stated if staff are feeding other residents she must wait for incontinence care.
R6 stated she put her call light on at about 8:30 AM to get dressed and out of bed but was not gotten up until 11AM.On 9/2/25 at 12:07 PM, V7 CNA (Certified Nursing Assistant) stated she sometimes has 17 to 20 residents to care for. V7 stated sometimes she is unable to complete like resident showers.
Residents must sometimes wait a long time to have their call light answered.
What we don't get done we inform the scheduler, and the task is passed on to the next shift or the next day.
Some residents aren't happy when they're not showered when it's scheduled.On 9/2/25 at 3:50 PM, V11 CNA stated when there is a staffing shortage the residents may miss getting showered. If there is staffing shortage and no one picks up it's expected the CNAs working will make up the shortage.On 9/2/25 at 4:26 PM, V4 Scheduler stated if there is a staffing shortage the managers and restorative aids should fill in and assist but aren't taking a full team.
V4 stated she was a CNA able to fill in on the floor if needed.On 9/3/25 at 3:50 PM, V4 Scheduler stated staff are to initial on the schedule when they work. A check mark by nursing staff names mean they did not initial but they were working and accounted for. If there is no initial or check mark by the staff name that means they called off.
Names that are lined out means that staff member was reassigned to another unit.
V4 stated the staffing ratios for the 1st floor AM and PM shifts should have 3-4 nurses and 4-5 CNAs.
The 1st floor night shift should have 2 nurses and 3 CNAs.
The 2nd floor AM and PM shifts should have 3 nurses and 5-6 CNAs.
The Night shift 2nd floor should have 2 nurses and 4 CNAs.
The 3rd floor AM and PM shifts should have 2 nurses and 3 CNAs.
The 3rd floor night shift should have 1 nurse and 2 CNAs.
The memory care unit AM and PM should have 1 nurse and 2-3 CNAs.
The memory care unit night shift should have 1 nurse and 2 CNAs.The staffing schedule for August 2025 and September to date were reviewed.
The facility had 22 shifts that worked with less than the required number of nurses or CNAs as determined by the facility for August 2025.On 9/2/25 at 6:17 PM, V1 Administrator stated there was no facility policy for staffing.
Facility ID: