Health inspection·February 21, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fondled her breast and placed his hand inside her disposable brief and touched her vaginal area. The same tall, black man told her (R2), It's been a long time since you had a penis. R2 stated that she asked the man to stop what he was doing. R2 added that after the sexual assault, the man told her, I will see you later. According to R2, the sexual assault happened after breakfast, and she believes that the tall black man who sexually assaulted her was a housekeeper because he had a mop or a broom with him. During the same interview, R2 stated that after her sexual assault, she heard her roommate (R1) saying, that hurts. R2 stated that she was unable to see what was going on with R1 because the curtain between them was drawn. R2 believes that the same tall black man was inside R1's room. R2 stated that she did not call for help and/or immediately reported the sexual assault because she was in shock of what had happened to her. According to R2, she only reported the incident to her (Family) and her (Family) called the nurse. R2 stated that after her (Family) informed the nurse of the incident, multiple facility staff and police had talked to her, then she reported her sexual assault and what she had heard from her roommate (R1). R2 stated that she was offered several times by the facility to go to the hospital after the sexual assault, but she refused. On February 11, 2025, at 10:52 AM, R2 was in bed, alert and oriented and once again R2 stated that on Saturday (January 25, 2025) she was sexually assaulted by a tall black man wearing a mask. R2 was unable to recall the specific time but believed it was after breakfast. R2 stated that she saw the tall black man enter her room and he started cleaning using either a mop or a broom. R2 stated that it is a daily occurrence for the housekeeper to clean her room, so she did not pay attention to what was going on. She closed her eyes to sleep, then she was awakened to find the same tall black man fondling her breast and sucking her nipple, while his other hand was inside her disposable brief, touching her vaginal area. According to R2 during the sexual assault, the man commented, It's been a long time since you had a penis. R2 stated that she told the man to stop and to go away and the man told her, I will see you later. R2 stated that after leaving her side of the room, she saw the tall black man went to her roommate's (R1) side of the room. R2 stated that the curtain between her and R1 was drawn, and she could not see what was going on in R1's room, but she heard R1 said, Ouch, it hurts then she saw the tall black man leave their room. R2 stated that she was in shock, and she just wanted the man to leave her alone. R2 stated, that she cried the next day because she cannot believe what happened. R2 added, even up to now, I would start crying when I remember it. According to R2 she was traumatized. During the same interview, R2 was asked about the added information that she shared with regards to her nipple being sucked during the sexual assault because this information was not mentioned when she was first interviewed by the surveyor on January 30, 2025 in the presence of V3. R2 responded, I thought that I told you guys about that. R2's late entry progress notes dated January 30, 2025 at 3:13 PM, created by V11 (Licensed Clinical Psychologists) showed in-part under summary and treatment, Resident was referred secondary to allegations of being sexually assaulted by a janitorial staff member. Resident open and willing to address her emotions. Reported an increase of racing thoughts at night, feels uneasy at times, also reported feelings of anger secondary to incident. R2's late entry progress notes dated February 4, 2025 at 1:22 PM, created by V11 (Licensed Clinical Psychologist) showed in-part, Resident continued to discuss and work through negative emotions secondary to incident that occurred a few weeks ago. She shared that the thoughts have affected her ability to sleep some nights. She also expressed feeling angry at times. The progress notes documented under statements that pertain to treatment goals showed, The other day I couldn't sleep because it kept going on in my mind. How do you expect me to feel? one day I'm ok and the next day I'm not. On February 19, 2025 at 11:39 AM, V11 stated that she first saw R2 on January 30, 2025 because the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 2 of 15 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 02/21/2025 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)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident was referred by the facility. Stated that during her talk to R2, the resident told her that that a male housekeeping staff had touched her breast and had his hand inside her brief. V11 stated that during this initial meeting with R2, the resident had verbalized increased of racing thoughts at night, feeling uneasy and angry due to being touched without her consent by the housekeeper. According to V11, she made a follow up visit to R2 on February 4, 2025. V11 stated that during this visit, R2 expressed having difficulty sleeping at some nights and feeling angry at times because of being inappropriately touched by the housekeeper. R1 had multiple diagnosis including, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, flaccid hemiplegia affecting left non-dominant side, vascular dementia without behavioral disturbance and severe morbid obesity due to excess calories, based on the face sheet. R1's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition (BIMS of 7) and required total assistance from the staff with most of her ADLs. R1's progress notes dated January 25, 2025 at 9:08 PM created by V5 (LPN) showed, [Physician] called back and was notified that alleged staff was touching resident inappropriately. [Physician] stated to let nursing supervisor know and follow protocol. R1's progress notes dated January 26, 2025 at 9:47 AM, created by V9 (Physician) as a late entry showed that the resident was seen because of an unusual incident at the facility where R1's roommate (R2) alleged that a housekeeper had inappropriately touched her (R2). The progress notes documented that V9 examined R1 in the presence of the nurse and no new findings were documented. R1's transfer form dated January 28, 2025 at 11:55 AM, showed that the resident was sent to the hospital for evaluation for inappropriate touch. R1's progress notes dated January 29, 2025 at 10:27 AM, showed that the resident returned to the facility at around 1:20 AM post medical examination of alleged incident. There was no new order, and no result reported at the time. R1's hospital records dated January 28, 2025 showed that the resident was at the emergency department for further evaluation of possible sexual abuse and an SA (sexual assault) kit was performed per son's request. R1's electronic records including, progress notes and care plans showed no documentation that the resident had behavior of falsely accusing staff and/or residents of any abuse or inappropriate behavior towards her or other residents. On January 30, 2025 at 1:57 PM, R1 was in bed, alert and was able to respond verbally to simple questions and at times responds using gestures. In the presence of V3 (Acting Director of Nursing), R1 was asked if anyone had inappropriately touched her at the facility. R1 stated, he put his finger and using her right hand pointed at her disposable brief. R1 was asked if the person placed his finger inside her disposable brief and R1 nodded. R1 was asked if the person touched her vaginal area, and the resident nodded. R1 stated, he needs to be put away. R1 was asked to describe who had inappropriately touched her vaginal area and the resident stated, African American. R1 was not able to give further description, and she was not able to give the date and time of the incident. On February 11, 2025 at 11:14 AM, R1 was in bed, alert and was able to respond verbally to simple questions and would also respond using gestures. R1 was again asked if anyone had inappropriately touched her at the facility, R1 nodded. Using her right hand, she pointed at her disposable brief and stated, here. R1 was asked what the person did, and she responded, finger while pointing at her disposable brief. R1 described the person as, African American man. R1 was asked if the person placed his finger inside her brief and touched her vaginal area, R1 responded yes while nodding. R1 was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 3 of 15 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 02/21/2025 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)

F 0600 able to give further description, and she does not remember when the incident happened. Level of Harm - Immediate jeopardy to resident health or safety On February 3, 2025 at 2:13 PM, V8 (Detective) stated that the local police department had received the allegation of sexual abuse on January 25, 2025 and a police officer had made the report. V8 stated that on January 27, 2025 he went to the facility to speak to R2. During his conversation with R2, the resident informed him that a black man, wearing a mask fondled her breast and placed his hand inside her brief and touched her vagina. R2 described the man as the worker that comes to clean her room. V8 stated that a photo lineup was established but R2 was not able to identify the person that touched her because of the mask. According to V8, during his interview with R2, the resident also told him that she heard her roommate (R1) saying, don't touch me but she cannot see what was going on in her roommate's area because the curtain was drawn. V8 stated that he talked to R1 (roommate) and the resident had informed him that her private area was touched by someone that worked there, but no other information was given by R1. V8 stated that the facility identified the male housekeeper working on January 25, 2025 at R1 and R2's unit, to be V4 (Housekeeper). V8 stated that he spoke to V4 on January 27, 2025. He was told by V4 that he was inside R2's room in the morning (he does not remember the exact time) of January 25, 2025 to clean the room. According to V4 while inside R2's room, cleaning, he (V4) noticed food spills on R2's gown by the chest area. He (V4) used a towel to clean the spill on R2's gown and during that time, R2 told V4 to stop and not to touch her. V8 stated that V4 was inside R2 and R1's room on January 25, 2025 and admitted that he had physical contact with R2. V8 added that V4 was a housekeeper and should have not touched R2. V8 was asked about R2's allegation of being touched on her vaginal area and he (V8) responded that he was still investigating and will be talking to V4 again. V8 was asked about R2's allegation regarding her roommate (R1). V8 cannot give any information about it and stated that his investigation for both R1 and R2's cases are still ongoing and no further information could be shared. According to V8, he had the video footage that the facility gave him but had not looked at the said video footage yet. V8 stated that his investigation of the case is still on going and that there is no final determination yet. According to V8, The good thing is that he (V4) acknowledged that he was inside their room. As a housekeeper he should not touch a patient. V8 added that there is no projected date when he can complete the investigation. Residents Affected - Few On February 11, 2025, at 1:42 PM, V8 (Detective) stated the State Police sexual assault kit was performed for R1 at the hospital and the result will not be available in about five to six months. V8 stated that when he talked to V4 (housekeeper), he acknowledged that he was inside R1 and R2's room on January 25, 2025 to clean. V4 also admitted that he used a towel to clean the spill on R2's gown by the chest area, on January 25, 2025. According to V8, V4 admitted to having physical contact with R2, which should not have occurred because V4 was a housekeeper and not a nursing staff. During the same interview, V8 was asked if R2 had mentioned to him on January 27, 2025 when he talked to the resident about her allegation that the housekeeper had sucked her nipple and that the housekeeper told her, It's been a long time since you had a penis. V8 stated that R2 had told him about it. V8 stated that when he started to ask V4 about R2's allegation of being touched in her vaginal area, V4 requested to have an attorney and V4 was not questioned further about R1 and R2's case. According to V8 he had not shared any information to the facility about R1 and R2's case because the investigation was still an ongoing/open case. Review of the initial report to the State Agency made on January 25, 2025 at 7:20 PM, facility reported that on January 25, 2025 at 4:56 PM, R2 made an allegation of abuse. R2 alleged that a staff member spoke to her and touched her inappropriately. The initial report showed that no injuries and no complaints of pain was made by R2. The staff member was immediately suspended pending investigation. The Police was notified, and the Physician was made aware with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 4 of 15 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 02/21/2025 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)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few order to send R2 to the hospital for further evaluation and treatment. R2's responsible party was also made aware. Review of the same initial report showed an addendum which read, Upon initial investigation it was alleged by resident that her roommate was also touched inappropriately. Roommate [R1] with head to toe assessment with no injuries or pain noted. Roommate did not indicate any concern. Resident with no concerns. [Physician] and responsible party aware. Review of the facility's final report to the State Agency made on January 30, 2025 at 5:52 PM, regarding R2's allegation of abuse on January 25, 2025 showed, Resident (R2) alleged to her family that a male staff member wearing a blue shirt touched her inappropriately. She also stated he spoke to her inappropriately. [R2] later stated, that her roommate [R1] had also been touched and spoken to inappropriately. [R2] would not have been able to determine this as the curtains between the beds were drawn. The residents were both assessed with no skin alterations, visible injuries, pain, and both remained at their baseline for cognition. Resident [R2] initially refused to go to the hospital and later went to appointment for medical treatment and currently being treated for UTI (urinary tract infection) with IV (intravenous) (antibiotic). [R1's] (Family) arrived and requested to have [R1] sent to ER (emergency room) for (evaluation). Resident [R1] (primary care physician) and hospital evaluation with no findings. The same final report showed, Interviews with staff and residents could not substantiate abuse. The facility presented the statement of V4 obtained by V1 (administrator) via phone made on January 25, 2025 (no time was documented), as part of the facility investigation. V4's statement showed that V4 worked at the facility on January 25, 2025, during the morning shift as a housekeeper. V4 acknowledged that he swept and mopped inside R1 and R2's room. The statement documented in-part, While in there I did speak with the ladies by saying good morning while they were eating breakfast. After cleaning the room, I took the garbage out. I never spoke to the residents inappropriately or touched them inappropriately. After my workday I clocked out and left the building. The housekeeping schedule for January 25, 2025, showed that V4 was assigned to multiple rooms at the second floor east hallway, including the rooms of R1 and R2. V4's January 2025 time sheet showed that he clocked in on January 25, 2025 at 6:38 AM and clocked out the same day at 3:06 PM. Further review of V4's January 2025 time sheet showed no other activity past January 25, 2025. The facility presented documentation from Human Resources that on January 30, 2025, V6 (Housekeeping Supervisor) received a text message from V4 that he was resigning and will not be returning at the facility. On January 30, 2025, at 4:03 PM, V5 (Licensed Practical Nurse) stated that she was R1 and R2's nurse on January 25, 2025 during the morning (6:00 AM - 2:00 PM) and afternoon shifts (2:00 PM - 10:00 PM). V5 stated that on January 25, 2025 at around 3:00 PM, she received a call from V10 (Family of R2) telling her to check on R2 because the resident was scared because a black guy was in her room. She told V10 that she was just inside R2's room, and the resident did not say anything to her. After hanging up the phone with V10 she went to talk to R2. While V10 was listening on R2's phone, the resident informed her that a tall black guy touched her breast and placed his hand inside her brief and told her that she hasn't had a penis for a long time. V5 stated that after hearing R2's allegation she immediately informed V12 (Nursing supervisor) and then called V1 (Administrator) on his cellular phone to report the allegation. According to V5, since she also worked during the morning shift, she was aware that there was only one black male staff in the unit, and it was the housekeeper (V4). According to V5, he had seen V4 cleaning resident rooms. V5 stated that R2 did not report to her any abuse allegation during the morning shift and that she only learned about the allegation after R2's family (V10) called her to check on the resident. V5 stated that when she received the report from R2, V4 was no longer in the building. V5 stated that after she reported to V1 she went back to R2 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 5 of 15 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 02/21/2025 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)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assess the resident. R2 informed her that she was touched on her breast and on her private area by a black guy holding a mop. R2 had no bruising, no bleeding and no visible injury and/or complaint of pain. According to R2, she was touched on her vaginal area and no object was inserted. According to V5, R2 did not say anything to her after the sexual assault because she was scared and that the tall black guy told her (R2) that he will be back. V5 stated that V12 notified R2's physician about the allegation and the physician ordered for R2 to be sent to the hospital for evaluation. V5 added that R2 refused and that V1 also offered to send R2 to the hospital, but R2 refused. V5 added that after she completed assessing R2, the resident told her to check on her roommate (R1). R2 told her, Just check on her (R1). V5 stated that she assessed R1 with V12 (Nursing Supervisor). According to V5, R1 was hard of hearing. She asked R1 in the presence of V12, if she saw a black guy in her room and R1 nodded indicating yes. She asked R1 if he was touched by the black guy that she saw in her room and R1 nodded indicating yes. She asked R1, where she was touched and R1 pointed to her private area below her waist. V5 stated that she is a regular second floor nurse and had been assigned to R1 and R2. V5 stated that R1 is oriented x 1 (to person) and R2 is cognitively intact, good historian and reliable. According to V5, R1 and R2 had never made any false allegations towards any staff or other residents in the past. On February 11, 2025, from 1:55 PM through 3:05 PM, the video footage for the second floor east hallway and dining room for January 25, 2025 was observed with V3 (acting Director of Nursing). V3 explained that he had reviewed the footage on February 4 and 5, 2025 and that the video footage time was indicating daylight saving time and that one hour should be deducted from the posted time on the video to determine the actual time. To be able to watch the video clearly and identify the staff, the video footage must be zoomed in. On January 25, 2025 at 12:10 PM (actual time), a tall black man wearing a blue shirt, parked the housekeeping cart outside of R1 and R2's room (east hallway) and went inside the said room carrying a mop. V3 identified the tall black man as V4 (housekeeper). After 26 seconds, V4 came out of the room with the trash can. At 12:11 PM, V7 (CNA/Certified Nursing Assistant) went inside R1 and R2's room. From 12:11 PM through 12:30 PM, both V4 and V7 were observed going in and out of R1 and R2's room. At 12:30:26 PM, V4 went out of R1 and R2's room without the mop that he brought in the room (at 12:10 PM), he then moved the housekeeping cart away from R1 and R2's room. At 12:30:49 PM, V7 came out of R1 and R2's room with a food tray. At 1:28 PM, V4 was cleaning tables inside the unit dining room. At 1:30:20 PM, V4 went out of the unit dining room towards the east hallway without taking his housekeeping cart. While walking along the east hallway, V4 pulled out something from his back pocket which V3 believed was a towel or rug and on the same back pocket a small rectangular item was left hanging which according to V3 looks like a mask. At 1:30:44 PM, V4 went inside R1 and R2's room. According to V3, he had reviewed the same video footage and confirmed that prior to V4 entering R1 and R2's room at 1:30:44 PM, no other staff had entered the said room. At 1:37:08 PM, V4 went out of R1 and R2's room and was observed walking back and forth in the east hallway. V3 stated that V4 was inside R1 and R2's room for approximately seven minutes without staff present and without his housekeeping cart outside of the room for easy access to the cleaning supplies. At 2:30:26 PM, the housekeeping cart was observed along the east hallway, V4 came out of another resident's room, placed a broom and a dustpan in the housekeeping cart, then went inside R1 and R2's room without any visible cleaning supplies. At 2:31:40 PM, V4 went out of R1 and R2's room without any visible items or cleaning supplies at hand. At 2:32 PM, V4 went inside R1 and R2's room and at 2:32:01 PM, went back out and proceeded to go inside another resident's room at the east hallway. At 2:33:37 PM, V4 again went inside R1 and R2's room and at 2:34:20 PM, V4 came out of the room with a garbage bag and talked to a staff identified by V3 as V13 (CNA). According (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 6 of 15 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 02/21/2025 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)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to V3, he asked V13 what they were talking about and V13 stated that according to V4, R2 wanted to be boosted up in bed. At 2:35:12 PM, V4 again went inside R1 and R2's room and came out at 2:37:09 PM carrying a mop (which he brought in the room at 12:10 PM and was only taken out). During the review of the video footage, V3 stated that he was wondering why V4 kept on going in and out of R1 and R2's room, after he was inside the same room from 12:10 PM through 12:30 PM cleaning while V7 (CNA) was inside the room. V3 added that he wanted to ask V4 what he was doing going in and out of R1 and R2's room after 12:30 PM and what he was doing inside the room for at least seven minutes (from 1:30:44 PM through 1:37:08 PM). V3 stated that he attempted to call V4 on February 7, 2025, but he did not answer. On February 11, 2025 at 4:24 PM, V3 (acting Director of Nursing) stated that he had been working at the facility for two years. V3 stated that there was no documentation, and he was not aware of any history of false allegations from R1 and R2 towards any staff or other residents. According to V3 he only started to review the video footage for the second floor east hallway for January 25, 2025 on February 4, 2025 until February 5, 2025 after being asked by the surveyor on February 3, 3025, if he had seen the footage. V3 stated that V1 (Administrator) had conducted the sexual abuse investigation of R2, including R1. V3 stated that he had assisted with the interviews with the nurses and the CNAs (Certified Nursing Assistants). According to V3, he had not spoken to R1 and R2 during the investigation and stated that it was his first time hearing the allegation from R1 and R2 when he was with the surveyor on January 30, 2025. V3 stated that after hearing R1 and R2's sexual assault allegation on January 30, 2025 (with the surveyor), he immediately informed their nursing consultant (V14) who was in the building. V3 stated that he and V14 then informed V1 (Administrator) of what R1 and R2 told the surveyor. V3 stated that over the phone, he informed V1 that R1 had pointed at her private area when R1 was asked, if anyone had touched her inappropriately. V3 also told V1 that R1 made a comment that the person needs to be punished or put away. V3 added that he also informed V1 that according to R2 a tall, black man wearing a mask which she (R2) identified as a housekeeper had touched her breast and had placed his hand inside her brief and touched her private area. V3 stated, as far as I know, this is the same information that [V1] got from [R2]. On February 11, 2025 at 4:40 PM, V1 (Administrator) stated that he was not aware of R1 and R2 making any false allegations towards any staff or residents in the past. V1 stated that during the investigation process before February 4, 2025 (cannot give the date) he watched the video footage of the second floor east hallway for January 25, 2025 and I could not make anything out, to believe that anything had transpired. V1 stated that the sexual assault allegation was reported to the police, and it was up to the resident to press a case. According to V1, V8 (Detective) came to the facility to talk to the residents but he (V8) did not tell him anything about what the resident said during his interview. V8 however told him that he showed pictures to R2, but the resident cannot identify anybody. V1 stated that he gave V8, V4's information because he fit the description of what R2 had said. V1 stated that during his interview of R2, the resident said that a black male with a broom or a mop came over and touched the top of her gown and had his hand inside her brief. According to V1, he asked R2 if the black male went under her hospital gown and she said, no. V1 added that during his interview with R2, the resident said that the black male mentioned something like, seems a long time since you had a penis. V1 stated that during his interview with R1, he asked the resident how she was doing and R1 responded that she was okay. He asked R1 if she was injured in any way, R1 responded, no. He asked R1 what year it is, and the resident responded, 2000. He asked R1, Did anything happened to you? and the resident responded, No and then R1 handed him the remote and said, I'm hungry. According to V1, based on his conversation with R1, the resident was not able to say that she was sexually abused by anyone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 7 of 15 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 02/21/2025 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)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few at the facility. V1 was asked the reason why the facility did not substantiate R2's sexual abuse allegations towards V4, since R2 is cognitively intact and had been consistent with expressing her sexual assault allegations on multiple interviews held by and/or made in the presence of the facility staff. V1 stated that R2 had a change in her mental status recently according to her physician. V1 added that when the facility interviewed the staff, no one heard or witnessed the sexual assault, and when other residents were interviewed, no one reported being sexually assaulted at the facility by any staff member, therefore the facility was not able to substantiate R2's allegation of sexual abuse and her (R2) allegation that her roommate (R1) was also sexually abused. On February 11, 2025 at 5:20 PM, V1 (Administrator) and V3 (acting Director of Nursing) confirmed that V4 was the only tall black man working at the second floor as a housekeeper on January 25, 2025. V1 was asked if he was notified by V3 and V14 (Nursing consultant) over the phone on January 30, 2025 about R1's allegation made in the presence of V3 and the surveyor, that she was inappropriately touched on her vaginal area by a black male and R1 commenting, he needs to be put away. V1 responded that he does not remember being informed about it. V1 and V3 were notified of R2's interview that day, after confirmation with V8 (Detective) with regards to the resident's allegation that on January 25, 2025, the tall black housekeeper had sucked her nipple in addition to what she (R2) had alleged during the interview on January 30, 2025 at 2:08 PM with V3. V1 and V3 were informed that according to V8, V4 admitted to V8 that he had physical contact with R2 because he wiped the food spill on R2's gown by the chest area on January 25, 2025 while he was inside the resident's room, cleaning. The facility submitted an addendum to their final report to the State Agency on February 12, 2025, 2025 at 2:15 PM. The addendum documented that on February 11, 2025, the facility re-interviewed R2 who stated that, she woke up to find the employee's mouth on her breast and screamed for him to stop. The addendum documented that R1 was re-interviewed to inquire about any inappropriate behavior from the former employee and R1 was unable to recall/provide details or information of any incident. The addendum showed that on February 12, 2025, the facility contacted the local police to confirm the new information provided by the surveyor on February 11, 2025. The local Police informed V1 (Administrator) that the former employee admitted to wiping food off of [R2's] shirt, then resident said, not to touch her like that and former employee left the room. Local police stated they could not share what [R2] said. Local police confirmed investigation is still pending. The same addendum showed, Housekeepers should not have physical contact with residents. With this new information the facility now sustains resident [R2's] allegation that she was touched inappropriately by the former employee. The facility's abuse policy and procedure dated November 15, 2022 showed, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The policy also showed that sexual abuse is non-consensual contact of any type with a resident. The Immediate Jeopardy began on January 25, 2025. The facility presented a removal plan to remove the immediacy on February 18, 2025 at 12:46 PM. The survey t[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 8 of 15 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 02/21/2025 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to thoroughly investigate the allegation of sexual abuse made by R1 and R2. R1 and R2 had consistently expressed being sexually assaulted by a housekeeper (V4) and the facility failed to investigate allegations after obtaining additional information, initially not substantiating R1 and R2's allegations of sexual abuse on January 25, 2025. These failures have the potential to affect all 237 residents who reside at the facility. Residents Affected - Many The findings include: The facility's daily census on January 30, 2025, showed that there were 237 residents in the facility. R2 had multiple diagnoses including chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, thrombocytopenia and need for assistance with personal care, based on the face sheet. R2's admission MDS (minimum data set) dated November 21, 2024, showed that the resident was cognitively intact (BIMS (Brief Interview for Mental Status) of 15) and required maximum to total assistance from the staff with all her ADLs (activities of daily living). R2's progress notes dated January 25, 2025 at 3:10 PM created by V5 (LPN/Licensed Practical Nurse) showed in-part, Resident reported alleged inappropriate touching by staff, prompting immediate head-toe assessment, which showed no new bruising, and resident denied pain, or distress. [Physician] immediately notified and ordered to send her to ER (emergency room) for evaluation, but resident refused to go to ER. Provided education resident continues to refuse to go. POA (Power of Attorney) made aware. R2's electronic records including, progress notes and care plans showed no documentation that the resident had behavior of falsely accusing staff and/or residents of any abuse or inappropriate behavior towards her or other residents. On January 30, 2025, at 2:08 PM, R2 was in bed, alert and oriented. In the presence of V3 (Acting Director of Nursing), R2 stated that on Saturday (January 25, 2025) a tall, black man wearing a mask, fondled her breast and placed his hand inside her disposable brief and touched her vaginal area. The same tall, black man told her (R2), It's been a long time since you had a penis. R2 stated that she asked the man to stop what he was doing. R2 added that after the sexual assault, the man told her, I will see you later. According to R2, the sexual assault happened after breakfast, and she believes that the tall black man who sexually assaulted her was a housekeeper because he had a mop or a broom with him. During the same interview, R2 stated that after her sexual assault, she heard her roommate (R1) saying, that hurts. R2 stated that she was unable to see what was going on with R1 because the curtain between them was drawn. R2 believes that the same tall black man was inside R1's room. R2 stated that she did not call for help and/or immediately report the sexual assault because she was in shock of what had happened to her. According to R2, she only reported the incident to her (family member) and her (family member) called the nurse. R2 stated that after her (family member) informed the nurse of the incident, multiple facility staff and police had talked to her, then she reported her sexual assault and what she had heard from her roommate (R1). On February 11, 2025, at 10:52 AM, R2 was again interviewed about the events of January 25, 2025. R2 was unable to recall the specific time but believed it was after breakfast and again stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 9 of 15 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 02/21/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many V4 had fondled her breast while his other hand was inside her disposable brief, touching her vaginal area. R2 repeated the statement that the man commented, It's been a long time since you had a penis. R2 stated that she told the man to stop and to go away and the man told her, I will see you later. R2 stated that after leaving her side of the room, she saw the tall black man went to her roommate's (R1) side of the room. R2 stated that the curtain between her and R1 was drawn, and she could not see what was going on in R1's room, but she heard R1 said, Ouch, it hurts then she saw the tall black man leave their room. R2 stated that she was in shock, and she just wanted the man to leave her alone. R2 stated, that she cried the next day because she cannot believe what happened. R2 added, even up to now, I would start crying when I remember it. According to R2 she was traumatized. R2's late entry progress notes dated January 30, 2025 at 3:13 PM, created by V11 (Licensed Clinical Psychologists) showed in-part under summary and treatment, Resident was referred secondary to allegations of being sexually assaulted by a janitorial staff member. Resident open and willing to address her emotions. Reported an increase of racing thoughts at night, feels uneasy at times, also reported feelings of anger secondary to incident. R2's late entry progress notes dated February 4, 2025 at 1:22 PM, created by V11 (Licensed Clinical Psychologist) showed in-part, Resident continued to discuss and work through negative emotions secondary to incident that occurred a few weeks ago. She shared that the thoughts have affected her ability to sleep some nights. She also expressed feeling angry at times. The progress notes documented under statements that pertain to treatment goals showed, The other day I couldn't sleep because it kept going on in my mind. How do you expect me to feel? one day I'm ok and the next day I'm not. On February 19, 2025 at 11:39 AM, V11 stated that she first saw R2 on January 30, 2025 because the resident was referred by the facility. Stated that during her talk to R2, the resident told her that that a male housekeeping staff had touched her breast and had his hand inside her brief. V11 stated that during this initial meeting with R2, the resident had verbalized increased of racing thoughts at night, feeling uneasy and angry due to being touched without her consent by the housekeeper. According to V11, she made a follow up visit to R2 on February 4, 2025. V11 stated that during this visit, R2 expressed having difficulty sleeping at some nights and feeling angry at times because of being inappropriately touched by the housekeeper. R1 had multiple diagnosis including, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, flaccid hemiplegia affecting left non-dominant side, vascular dementia without behavioral disturbance and severe morbid obesity due to excess calories, based on the face sheet. R1's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition (BIMS of 7) and required total assistance from the staff with most of her ADLs. R1's progress notes dated January 25, 2025 at 9:08 PM created by V5 (LPN) showed, [Physician] called back and was notified that alleged staff was touching resident inappropriately. [Physician] stated to let nursing supervisor know and follow protocol. R1's progress notes dated January 26, 2025 at 9:47 AM, created by V9 (Physician) as a late entry showed that the resident was seen because of an unusual incident at the facility were in R1's roommate (R2) alleged that a housekeeper had inappropriately touched her (R2). R1's electronic records including, progress notes and care plans showed no documentation that the resident had behavior of falsely accusing staff and/or residents of any abuse or inappropriate behavior towards her or other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 10 of 15 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 02/21/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On January 30, 2025 at 1:57 PM, R1 was in bed, alert and was able to respond verbally to simple questions and at times responds using gestures. In the presence of V3 (Acting Director of Nursing), R1 was asked if anyone had inappropriately touched her at the facility. R1 stated, he put his finger and using her right hand pointed at her disposable brief. R1 was asked if the person placed his finger inside her disposable brief and R1 nodded. R1 was asked if the person touched her vaginal area, and the resident nodded. R1 stated, he needs to be put away. R1 was asked to describe who had inappropriately touched her vaginal area and the resident stated, African American. R1 was not able to give further description, and she was not able to give the date and time of the incident. R1 was interviewed again on February 11, 2025 and once again verbally responded to the questions and used gestures. R1 confirmed the information obtained in the earlier interview of January 30, 2025. On February 3, 2025 at 2:13 PM, V8 (Detective) stated that the local police department had received the allegation of sexual abuse on January 25, 2025 and a police officer had made the report. V8 stated that on January 27, 2025 he went to the facility to speak to R2. During his conversation with R2, the resident informed him that a black man, wearing a mask fondled her breast and placed his hand inside her brief and touched her vagina. R2 described the man as the worker that comes to clean her room. V8 stated that a photo lineup was established but R2 was not able to identify the person that touched her because of the mask. According to V8, during his interview with R2, the resident also told him that she heard her roommate (R1) saying, don't touch me but she cannot see what was going on in her roommate's area because the curtain was drawn. V8 stated that he talked to R1 (roommate) and the resident had informed him that her private area was touched by someone that worked there, but no other information was given by R1. V8 stated that the facility identified the male housekeeper working on January 25, 2025 at R1 and R2's unit, to be V4 (Housekeeper). V8 stated that he spoke to V4 on January 27, 2025. He was told by V4 that he was inside R2's room in the morning (he does not remember the exact time) of January 25, 2025 to clean the room. V8 added that V4 told V8 that R2's gown had spills and V4 used a towel to clean the food spills by the chest area and during that time, R2 told V4 to stop and not to touch her. V8 stated that V4 was inside R2 and R1's room on January 25, 2025 and admitted that he had physical contact with R2. V8 added that V4 was a housekeeper and should have not touched R2. V8 was not able to share any additional information since the case was under investigation. According to V8, he had the video footage that the facility gave him but had not looked at the said video footage yet. V8 stated that his investigation of the case is still on going and that there is no final determination yet. According to V8, The good thing is that he (V4) acknowledged that he was inside their room. As a housekeeper he should not touch a patient. V8 added that there is no projected date when he can complete the investigation. On February 11, 2025, at 1:42 PM, V8 (Detective) stated that when he talked to V4 (housekeeper), V4 acknowledged that he was inside R1 and R2's room on January 25, 2025 to clean. V4 also admitted that he used a towel to clean the spill on R2's gown by the chest area, on January 25, 2025. According to V8, V4 admitted to having physical contact with R2, which should not have occurred because V4 was a housekeeper and not a nursing staff. During the same interview, V8 was asked if R2 had mentioned to him on January 27, 2025 when he talked to the resident about her allegation that the housekeeper had sucked her nipple and that the housekeeper told her, It's been a long time since you had a penis. V8 stated that R2 had told him about it. V8 stated that when he started to ask V4 about R2's allegation of being touched in her vaginal area, V4 requested to have an attorney and V4 was not questioned further about R1 and R2's case. According to V8 he had not shared any information to the facility about R1 and R2's case because the investigation was still an ongoing/open case. Review of the facility's final report to the State Agency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 11 of 15 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 02/21/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many made on January 30, 2025 at 5:52 PM, regarding R2's allegation of abuse on January 25, 2025 showed, Resident (R2) alleged to her family that a male staff member wearing a blue shirt touched her inappropriately. She also stated he spoke to her inappropriately. [R2] later stated, that her roommate [R1] had also been touched and spoken to inappropriately. [R2] would not have been able to determine this as the curtains between the beds were drawn. The residents were both assessed with no skin alterations, visible injuries, pain, and both remained at their baseline for cognition. Resident [R2] initially refused to go to the hospital and later went to appointment for medical treatment and currently being treated for UTI (urinary tract infection) with IV (intravenous) (antibiotic). [R1's] (family member) arrived and requested to have [R1] sent to ER (emergency room) for (evaluation). Resident [R1] (primary care physician) and hospital evaluation with no findings. The same final report showed, Interviews with staff and residents could not substantiate abuse. The facility presented the statement of V4 obtained by V1 (administrator) via phone made on January 25, 2025 (no time was documented), as part of the facility investigation. V4's statement showed that V4 worked at the facility on January 25, 2025, during the morning shift as a housekeeper. V4 acknowledged that he swept and mopped inside R1 and R2's room. The statement documented in-part, While in there I did speak with the ladies by saying good morning while they were eating breakfast. After cleaning the room, I took the garbage out. I never spoke to the residents inappropriately or touched them inappropriately. After my workday I clocked out and left the building. The housekeeping schedule for January 25, 2025, showed that V4 was assigned to multiple rooms at the second-floor east hallway, including the rooms of R1 and R2. V4's January 2025 time sheet showed that he clocked in on January 25, 2025, at 6:38 AM and clocked out the same day at 3:06 PM. Further review of V4's January 2025 time sheet showed no other activity past January 25, 2025. The facility presented documentation from Human Resources that on January 30, 2025, V6 (Housekeeping Supervisor) received a text message from V4 that he was resigning and will not be returning at the facility. On January 30, 2025, at 4:03 PM, V5 (Licensed Practical Nurse) stated that she was R1 and R2's nurse on January 25, 2025 during the morning (6:00 AM - 2:00 PM) and afternoon shifts (2:00 PM - 10:00 PM). V5 stated that on January 25, 2025 at around 3:00 PM, she received a call from V10 (R2's family) telling her to check on R2 because the resident was scared because a black guy was in her room. She told V10 that she was just inside R2's room, and the resident did not say anything to her. After hanging up the phone with V10 she went to talk to R2. While V10 was listening on R2's phone, the resident informed her that a tall black guy touched her breast and placed his hand inside her brief and told her that she hasn't had a penis for a long time. V5 stated that after hearing R2's allegation she immediately informed V12 (Nursing supervisor) and then called V1 (Administrator) on his cellular phone to report the allegation. According to V5, since she also worked during the morning shift, she was aware that there was only one black male staff in the unit, and it was the housekeeper (V4). According to V5, he had seen V4 cleaning resident rooms. V5 stated that R2 did not report to her any abuse allegation during the morning shift and that she only learned about the allegation after R2's family (V10) called her to check on the resident. V5 stated that when she received the report from R2, V4 was no longer in the building. V5 stated that after she reported to V1 she went back to R2 to assess the resident. R2 informed her that she was touched on her breast and on her private area by a black guy holding a mop. R2 had no bruising, no bleeding and no visible injury and/or complaint of pain. According to R2, she was touched on her vaginal area and no object was inserted. According to V5, R2 did not say anything to her after the sexual assault because she was scared and that the tall black guy told her (R2) that he will be back. V5 stated that V12 notified R2's physician about the allegation and the physician ordered for R2 to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 12 of 15 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 02/21/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sent to the hospital for evaluation. V5 added that R2 refused and that V1 (Administrator) also offered to send R2 to the hospital, but R2 refused. V5 added that after she completed assessing R2, the resident told her to check on her roommate (R1). R2 told her, Just check on her (R1). V5 stated that she assessed R1 with V12 (Nursing Supervisor). According to V5, R1 was hard of hearing. She asked R1 in the presence of V12, if she saw a black guy in her room and R1 nodded indicating yes. She asked R1 if he was touched by the black guy that she saw in her room and R1 nodded indicating yes. She asked R1, where she was touched and R1 pointed to her private area below her waist. V5 stated that she is a regular second floor nurse and had been assigned to R1 and R2. V5 stated that R1 is oriented x 1 (to person) and R2 is cognitively intact, good historian and reliable. According to V5, R1 and R2 had never made any false allegations towards any staff or other residents in the past. On February 18, 2025 at 9:42 AM, V5 confirmed the accuracy of the interview made to her by the surveyor on January 30, 2025 at 4:03 PM. V5 was asked if she informed V1 (Administrator) of the information she received from R1 during the resident's assessment and interview on January 30, 2025 after the resident's roommate (R2) told her to check on R1. According to V5 she did not inform V1 because I assumed that (V12/Nursing Supervisor) informed (V1), because she (V12) was present during the assessment. V5 added that after she and V12 assessed and interviewed R1 on January 25, 2025, both V1 and V12 went to R1 and interviewed the resident. On February 18, 2025 at 10:15 AM, V1 (Administrator) was asked if V5 (Licensed Practical Nurse) and/or V12 (Nursing Supervisor) had informed him about any information they obtained from R1 on January 30, 2025 during their interview and assessment of the resident. According to V1, he was not informed by either V5 or V12. On February 11, 2025, from 1:55 PM through 3:05 PM, the video footage for the second-floor east hallway and dining room for January 25, 2025 was observed with V3 (acting Director of Nursing). V3 explained that he had reviewed the footage on February 4 and 5, 2025 and that the video footage time was indicating daylight saving time and that one hour should be deducted from the posted time on the video to determine the actual time. To be able to watch the video clearly and identify the staff, the video footage must be zoomed in. On January 25, 2025 at 12:10 PM (actual time), a tall black man wearing a blue shirt, parked the housekeeping cart outside of R1 and R2's room (east hallway) and went inside the said room carrying a mop. V3 identified the tall black man as V4 (housekeeper). At 12:11 PM, V7 (CNA/Certified Nursing Assistant) went inside R1 and R2's room. From 12:11 PM through 12:30 PM, both V4 and V7 were observed going in and out of R1 and R2's room. At 12:30:26 PM, V4 went out of R1 and R2's room without the mop that he brought in the room (at 12:10 PM), he then moved the housekeeping cart away from R1 and R2's room. At 12:30:49 PM, V7 came out of R1 and R2's room with a food tray. At 1:28 PM, V4 was cleaning tables inside the unit dining room. At 1:30:20 PM, V4 went out of the unit dining room towards the east hallway without taking his housekeeping cart. While walking along the east hallway, V4 pulled out something from his back pocket which V3 believed was a towel or rug and on the same back pocket a small rectangular item was left hanging which according to V3 looks like a mask. At 1:30:44 PM, V4 went inside R1 and R2's room. According to V3, he had reviewed the same video footage and confirmed that prior to V4 entering R1 and R2's room at 1:30:44 PM, no other staff had entered the said room. At 1:37:08 PM, V4 went out of R1 and R2's room and was observed walking back and forth in the east hallway. V3 stated that V4 was inside R1 and R2's room for approximately seven minutes without staff present and without his housekeeping cart outside of the room for easy access to the cleaning supplies. At 2:30:26 PM, the housekeeping cart was observed along the east hallway, V4 came out of another resident's room, placed a broom and a dustpan in the housekeeping cart, then went inside R1 and R2's room without any visible cleaning supplies. At 2:31:40 PM, V4 went out of R1 and R2's room without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 13 of 15 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 02/21/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many any visible items or cleaning supplies at hand. At 2:32 PM, V4 went inside R1 and R2's room and at 2:32:01 PM, went back out and proceeded to go inside another resident's room at the east hallway. At 2:33:37 PM, V4 again went inside R1 and R2's room and at 2:34:20 PM, V4 came out of the room with a garbage bag and talked to a staff identified by V3 as V13 (CNA). According to V3, he asked V13 what they were talking about and V13 stated that according to V4, R2 wanted to be boosted up in bed. At 2:35:12 PM, V4 again went inside R1 and R2's room and came out at 2:37:09 PM carrying a mop (which he brought in the room at 12:10 PM and was only taken out). During the review of the video footage, V3 stated that he was wondering why V4 kept on going in and out of R1 and R2's room, after he was inside the same room from 12:10 PM through 12:30 PM cleaning while V7 (CNA) was inside the room. V3 added that he wanted to ask V4 what he was doing, going in and out of R1 and R2's room after 12:30 PM and what he was doing inside the room for at least seven minutes (from 1:30:44 PM through 1:37:08 PM). V3 stated that he attempted to call V4 on February 7, 2025, but he did not answer. On February 11, 2025, at 4:24 PM, V3 (acting Director of Nursing) stated that he had been working at the facility for two years. V3 stated that there was no documentation, and he was not aware of any history of false allegations from R1 and R2 towards any staff or other residents. According to V3 he only started to review the video footage for the second-floor east hallway for January 25, 2025 on February 4, 2025 until February 5, 2025 after being asked by the surveyor on February 3, 3025, if he had seen the footage. V3 stated that V1 (Administrator) had conducted the sexual abuse investigation of R2, including R1. V3 stated that he had assisted with the interviews with the nurses and the CNAs (Certified Nursing Assistants). According to V3, he had not spoken to R1 and R2 during the investigation and stated that it was his first time hearing the allegation from R1 and R2 when he was with the surveyor on January 30, 2025. V3 stated that after hearing R1 and R2's sexual assault allegation on January 30, 2025 (with the surveyor), he immediately informed their nursing consultant (V14) who was in the building. Stated that he and V14 then informed V1 (Administrator) of what R1 and R2 told the surveyor. V3 stated that over the phone, he informed V1 that R1 had pointed at her private area when R1 was asked, if anyone had touched her inappropriately. V3 also told V1 that R1 made a comment that the person needs to be punished or put away. V3 added that he also informed V1 that according to R2 a tall, black man wearing a mask which she (R2) identified as a housekeeper had touched her breast and had placed his hand inside her brief and touched her private area. V3 stated, as far as I know, this is the same information that [V1] got from [R2]. On February 11, 2025 at 4:40 PM, V1 (Administrator) stated that he was not aware of R1 and R2 making any false allegations towards any staff or residents in the past. V1 stated that during the investigation process before February 4, 2025 (cannot give the date) he watched the video footage of the second floor east hallway for January 25, 2025 and I could not make anything out, to believe that anything had transpired. V1 stated that the sexual assault allegation was reported to the police, and it was up to the resident to press a case. According to V1, V8 (Detective) came to the facility to talk to the residents but he (V8) did not tell him anything about what the resident said during his interview. V8 however told him that he showed pictures to R2, but the resident cannot identify anybody. V1 stated that he gave V8, V4's information because he fit the description of what R2 had said. V1 stated that during his interview of R2, the resident said that a black male with a broom or a mop came over and touched the top of her gown and had his hand inside her brief. According to V1, he asked R2 if the black male went under her hospital gown and she said, no. V1 added that during his interview with R2, the resident said that the black male mentioned something like, seems a long time since you had a penis. V1 stated that during his interview with R1, he asked the resident how she was doing and R1 responded that she was okay. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 14 of 15 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 02/21/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many asked R1 if she was injured in any way, R1 responded, no. He asked R1 what year it is, and the resident responded, 2000. He asked R1, Did anything happened to you? and the resident responded, No and then R1 handed him the remote and said, I'm hungry. According to V1, based on his conversation with R1, the resident was not able to say that she was sexually abused by anyone at the facility. V1 was asked the reason why the facility did not substantiate R2's sexual abuse allegations towards V4, since R2 is cognitively intact and had been consistent with expressing her sexual assault allegations on multiple interviews held by and/or made in the presence of the facility staff. V1 stated that R2 had a change in her mental status recently according to her physician. V1 added that when the facility interviewed the staff, no one heard or witnessed the sexual assault, and when other residents were interviewed, no one reported being sexually assaulted at the facility by any staff member, therefore the facility was not able to substantiate R2's allegation of sexual abuse and her (R2) allegation that her roommate (R1) was also sexually abused. On February 11, 2025 at 5:20 PM, V1 (Administrator) and V3 (acting Director of Nursing) confirmed that V4 was the only tall black man working at the second floor as a housekeeper on January 25, 2025. V1 was asked if he was notified by V3 and V14 (Nursing consultant) over the phone on January 30, 2025 about R1's allegation made in the presence of V3 and the surveyor, that she was inappropriately touched on her vaginal area by a black male and R1 commenting, he needs to be put away. V1 responded that he does not remember being informed about it. V1 and V3 were notified of R2's interview that day, after confirmation with V8 (Detective) with regards to the resident's allegation that on January 25, 2025, the tall black housekeeper had sucked her nipple in addition to what she (R2) had alleged during the interview on January 30, 2025 at 2:08 PM with V3. V1 and V3 were informed that according to V8, V4 admitted to V8 that he had physical contact with R2 because he wiped the food spill on R2's gown by the chest area on January 25, 2025 while he was inside the resident's room, cleaning. The facility submitted an addendum to their final report to the State Agency on February 12, 2025, 2025 at 2:15 PM. The addendum documented that on February 11, 2025, the facility re-interviewed R2 who stated that, she woke up to find the employee's mouth on her breast and screamed for him to stop. The addendum documented that R1 was re-interviewed to inquire about any inappropriate behavior from the former employee and R1 was unable to recall/provide details or information of any incident. The addendum showed that on February 12, 2025, the facility contacted the local police to confirm the new information provided by the surveyor on February 11, 2025. The local Police informed V1 (Administrator) that the former employee admitted to wiping food off of [R2's] shirt, then resident said, not to touch her like that and former employee left the room. Local police stated they could not share what [R2] said. Local police confirmed investigation is still pending. The same addendum showed, Housekeepers should not have physical contact with residents. With this new information the facility now sustains resident [R2's] allegation that she was touched inappropriately by the former employee. The facility's abuse policy and procedure dated November 15, 2022 showed, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The policy also showed that sexual abuse is non-consensual contact of any type with a resident. The facility's abuse investigation and reporting policy dated July 2017 showed in-part, All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 15 of 15