Inspection·July 31, 2025

F 0677 his brief was saturated and clothing was wet with urine. Level of Harm - Minimal harm or potential for actual harm 2. According to the Electronic Medical Records (EMR), R178 has multiple diagnoses including osteoarthritis, attention and concentration deficit, and dementia. Residents Affected - Some The Minimum Data Set (MDS) dated [DATE], showed R178 had severe cognitive impairment and required maximal assistance for personal hygiene. The Care Plan dated January 18, 2021, showed R178 had functional and self-care deficit in performing ADL, and the interventions included staff to assist the resident with proper dressing and grooming every day, and ensure the resident is well groomed upon getting up daily and as needed. On July 28, 2025, at 12:56 PM. R178 was in the dining room sitting in the wheelchair, ate all his meal for lunch except the salad. Black substances were noted under R178's fingernails on both hands. R178 picked up crumbs of food from the table and put it in his mouth after his plate had been taken away. On July 29, 2025, at 12:14 PM. R178 was in the dining room sitting in the wheelchair eating lunch. Black substances were noted under R178's fingernails on both hands. R178 picked up the beef patty melt sandwich with his fingers which has the black substances under the nails. On July 29, 2025, at 12:16 PM, V15 CNA (Certified Nursing Assistant/Supervisor) said the CNAs takes care of grooming of the residents and as needed. She stated that the residents' nails should be trimmed, and fingernails should be free of black substances. 3. R30 had multiple diagnoses including central cord syndrome at C3 and C4 level of cervical spine, based on the face sheet. R30's annual MDS (minimum data set) dated July 3, 2025 showed that the resident was cognitively intact and required total assistance from the staff with personal hygiene. On July 28, 2025 at 11:18 AM, R30 was in bed, alert and oriented. R30's fingernails were long, jagged with black substances under the nails. R30 stated that he wants the staff to trim and clean his fingernails. On July 29, 2025 at 12:02 PM, R30 was in bed, alert and oriented. The resident's fingernails remained long, jagged with black substances under the nails. In the presence of V16 (LPN (Licensed Practical Nurse)/Wound care nurse), R30 stated that he wants the staff to trim and clean his fingernails. R30's active care plan initiated on September 22, 2024 showed that the resident has an ADL (activities of daily living) self-care performance deficit. The same care plan showed that R30 is dependent on staff with personal hygiene and to provide assistance with grooming. 4. R74 had multiple diagnoses including dementia without behavioral disturbance, based on the face sheet. R74's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition and required maximum assistance from the staff with personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 2 of 22 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 07/31/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On July 28, 2025 at 11:33 AM, R74 was in bed, alert and verbally responsive. R74's fingernails were long, and some had black substances under the nails. R74 stated that she wants the staff to trim and clean her fingernails. On July 29, 2025 at 12:05 PM, R74 was in bed, alert and verbally responsive. R74's fingernails remained long with black substances under some of the nails. In the presence of V16, R74 stated that she wants the staff to trim and clean her fingernails. R74's active care plan initiated on March 2, 2022 showed that the resident has an ADL self-care performance deficit. The same care plan showed that R74 requires maximum assistance from staff with personal hygiene and for staff to provide assistance with grooming. The facility's ADL policy last revised by the facility in July 2025 showed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Under the guidance it showed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene (Bathing, dressing, grooming, and oral and nail care: .3. Elimination (toileting). On July 30, 2025 at 11:05 AM, V2 (Director of Nursing) stated that it is part of the nursing ADL care and service of all residents at the facility to be assisted with their ADL care, including nail care. According to V2, staff are expected to provide ADL assistance to all residents to ensure and maintain the resident's hygiene and grooming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 3 of 22 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 07/31/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident that was receiving hemodialysis was weighed daily as ordered by the medical provider.This applies to 1 of 3 residents (R16) reviewed for dialysis in the sample of 35. Findings include:R16's admission record showed R16 was admitted on [DATE] with diagnoses that included chronic kidney disease, stage 3 unspecified, type 2 diabetes mellitus with diabetic neuropathy, and polyneuropathy.R16 had an active physician order dated April 26, 2025 that showed the following: Daily weight related to dialysis, one time a day related to chronic kidney disease, stage 3 unspecified.The facility did not provide documentation that showed R16's daily weight was checked as ordered by the physician.On July 30, 2025 at 4:14 PM, V2 (Director of Nursing) stated that the nursing staff is responsible for weighing residents. V2 stated he expects nursing staff to follow physician orders. V2 stated that residents who are on dialysis, are at risk for fluid overload. V2 stated that they do not have any other recorded weights done for R16 other than the weight summary provided to the surveyor and weights done by the dialysis provider on resident's dialysis days.The facility's Physician Orders policy dated April 2025 showed the following: Physician orders are followed as written: if there is a question about the order, contact the physician for clarification. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 4 of 22 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 07/31/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to educate a resident regarding the consequences of refusal of wound treatment, for a resident with a worsening facility acquired pressure injury.This applies to 1 of 9 residents (R11) reviewed for pressure injury in the sample of 35. Findings include:R11's admission record showed R11 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, personal history of transient ischemic attack (TIA) and cerebral infarction without residual affects, bilateral osteoarthritis of knee, hydronephrosis with renal and ureteral calculous obstruction, acute osteomyelitis left ankle and foot and generalized atherosclerosis.R11's MDS (Minimum Daily Set) dated May 13, 2025, showed R11 was cognitively intact and required assistance with ADLs (Activities of Daily Living) including set up assistance with eating, supervision with oral hygiene, partial assistance with personal hygiene, substantial assistance with bathing, rolling left to right, and upper body dressing and dependent on staff assistance for toileting hygiene, and lower body dressing and resident refused the sitting up while in bed. On July 30, 2025, at 3:36 PM, V16, (RN Wound Care Nurse) stated R11 developed a DTIP (Deep Tissue Injury due to Pressure) on his coccyx identified on December 5, 2024. V16 stated R11 was on a regular pressure redistribution mattress at the time. V16 stated R11 previously was getting up out of bed and sitting in the wheelchair when he was first admitted but at the time of the wound development had stopped getting out of bed. V16 stated R11 was incontinent of bowel and also developed MASD (Moisture Associated Dermatitis) on his coccyx around the same time. V16 stated R11 was offered a low air loss mattress but that R11 had refused. V16 was unable to provide documentation that R11 was educated on the need for repositioning, need for pressure reducing mattress and need to manage fecal incontinence to prevent further wound decline and nor was educated on the consequences of refusal of care. V16 could not describe what type of bed, what was used to reduce friction and shear during bed mobility or interventions for fecal incontinence management were offered. V16 could not provide documentation regarding education of R11 for consequences of refusals of care.V16 provided a Risk Notification document, dated December 5, 2024, that showed it was reviewed with R11's POA (Power of Attorney), but did not indicate the risk factors were reviewed with the resident. V16 stated R11's POA visited once or twice a month.R11's Wound Assessment Details report dated January 1, 2025, documented by V37 (RN 2nd Wound Care Nurse) showed R11 had a facility acquired pressure ulcer stage 3 identified on December 5, 2024. The Wound Assessment showed R11's wound had declined. R11's note showed R11 refused repositioning and refused a low air loss mattress however did not include if education was provided regarding consequences for continued refusals. The wound assessment showed the coccyx wound measured 6.0 cm (centimeter) x 2.00 cm x 0.10 cm, length x width x depth.R11's care plan initiated on December 5, 2024, showed R11 developed a pressure injury to the coccyx, and had a Braden score of 11, indicating at risk for developing pressure ulcers, and was at risk for developing unavoidable skin breakdown. The care plan did not address resident refusals regarding repositioning until the care plan was updated on May 20, 2025.R11's care plan dated February 3, 2025, showed R11 agreed to add a low air loss to the bed. The wound healthcare provider progress notes dated February 27, 2025, showed R11's coccyx wound was worse due to the low air mattress staying inflated and a new low air loss mattress had to be ordered.R11's healthcare provider wound care note dated July 9, 2025, showed R11's coccyx wound was reclassified as an unstageable pressure injury to sacrococcygeal extending to the buttocks. The wound measured 13 cm x 12 cm x 2 cm with undermining of 2.8 cm from 12:00 o'clock to 3oclock with 70% necrotic tissue and 30% granulation tissue.The facility's policy titled Wound Prevention and Healing dated April 2025, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 5 of 22 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 07/31/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm showed Procedures .9. Continue/Ongoing Treatment.a.Nurse.will evaluate the plan of care based on the effectiveness of treatment.d. if patient is not responding to established treatment regimen the Wound MD/NP nurse/therapist shall evaluate for .d. re-assess need for interdisciplinary services and/or appropriate DME. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 6 of 22 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 07/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate diet consistency for a resident with risk for aspiration and failed to implement safety intervention for a resident identified with highfall risk.This applies to 2 of 5 residents (R6 and R13) reviewed for accidents and supervision in a sample 35.The findings include:1. The EMR (Electronic Medical Record) showed R13 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, cognitive communication deficit, dementia, and oropharyngeal dysphagia. R13's MDS (Minimum Data Set) dated May 9, 2025, showed R13 was cognitively intact. The MDS continued to show R13 was on a mechanically altered diet. R13's Order Summary Report dated July 29, 2025, showed an order dated October 9, 2024, for Low Concentrated Sweets diet, pureed texture, nectar consistency, until seen by speech therapist for aspiration. R13's nutritional problem care plan dated May 14, 2025, showed [R13] has nutritional problem or potential nutritional problem, on a therapeutic mechanically altered diet, NCS (No Concentrated Sweets) pureed, nectar thickened liquid diet per physician. Decreased ability to chew/swallow properly, noted, staff to provide supervision for safety precautions. Oral intake to be adequate, fair, staff to provide encouragement to eat adequately per nursing. Enjoys consuming liquids, requires assistance feeding, per staff. Particularly orange juice, per staff. Will follow. The care plan showed multiple interventions dated May 9, 2025, including Provide and serve diet as ordered. On July 29, 2025, at 2:31 PM, R13 was sitting in his wheelchair in the dining room. R13 was served ice cream. On July 29, 2025, at 2:34 PM, R13 started eating his ice cream. R13 had melted ice cream dripping down his chin. On July 29, 2025, at 2:35 PM, V22 (Activity Aide) said she provided R13 with the ice cream. V22 said she provided R13 the same ice cream as all the other residents in the dining room, R13 did not get a special ice cream. V22 said she did not know R13 needed thickened liquids or needed to be supervised while eating. On July 30, 2025, at 11:19 AM, V23 (Director of Rehab/Speech Therapist) said R13 was most recently seen by speech therapy on March 19, 2025, to April 17, 2025, and speech therapy's recommendation at the end of services was for a pureed diet with nectar thick consistency. V23 said R13 needs a pureed diet with nectar thick consistency for swallow precautions due to oropharyngeal dysphagia. V23 said staff are requesting for R13 to be evaluated by speech therapy again because R13 is coughing while consuming nectar thick liquids. V23 said plain ice cream is considered a thin liquid and should not be served to someone on nectar thick consistency. V23 said R13 is at risk for aspiration if he consumes thin consistency liquids. On July 30, 2025, at 2:28 PM, V23 said R13 was evaluated by speech therapy and R13 still requires nectar thick consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 7 of 22 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 07/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On July 30, 2025, at 3:23 PM, V2 (DON/Director of Nursing) said R13 should not have received ice cream if he is on a nectar thick consistency diet. The facility's policy titled Physician Orders dated April 2025, showed General: Physician orders may be written by the provider or received by telephone by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Policy Explanation and Compliance Guidelines: 1. Physician orders are followed as written; if there is a question about the order, contact the physician for clarification. 2. According to the (EMR) Electronic Medical Records, R6 has multiple diagnoses including, history of falling, unsteadiness on feet, other polyosteoarthritis, dementia, encounter for palliative care. The (MDS) Minimum Data Set, dated , May 8, 2025, showed had moderate cognitive impairment, used a wheelchair for mobility, and required maximal assistance for mobility transfers. R6's Resident/Family Notification Fall Risk assessment dated [DATE], showed a score of 24 and he was high risk for falls. The facility's Incident Reports showed R6 had falls on May 18, 2025, April 19, 2025, and February 18, 2025. The reports showed on May 18, 2025, R6 had an unwitnessed fall and was found on the floor in his room. On April 19, 2025, R6 had an unwitnessed fall, sustained an abrasion to the right side of his head, and was found lying on the floor in his room. On February 13, 2025, R6 also had an unwitnessed fall and was found on the floor in his room. The Fall Care Plan dated March 8, 2024, showed R6 is at risk for falls due to unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and abnormal posture. ADL (Activities of Daily Living) Care Plan dated March 10, 2024, showed R6 required maximal assistance of 1 staff for transfer using gait belt. The ADL (Activities of Daily Living) Care Plan interventions initiated on May 18, 2025, included, staff to assist resident back to bed after meals and remove wheelchair away from resident for safety. The POS (Physician Order Sheet) dated May19, 2024, showed, Alert high-risk fall, staff to assist resident back to bed after meals and remove wheelchair away from resident for safety. Resident needs assistance with ADLs transferring please ensure to communicate with staff, CNA [Certified Nursing Assistant] etc. toilet or check and change. On July 29, 2025, at 3:26 PM. R6 was lying in bed, with the bed in the lowest position, and his wheelchair positioned right next to the bed. R6 had his lower extremity from waist to the feet positioned close to the edge of the bed. On July 29, 2025, at 4:16 PM, R6's wheelchair was right next to his bed. R6 was sitting at the edge of his bed while holding on to the wheelchair with his right hand, and R6 was attempting to get out of bed. V19 (CNA) was at the nurses' station and was notified to assist R6. V19 came into R6's room and stated that R6's wheelchair was positioned right next to his bed because R6 always attempts to get out of bed and might fall attempting to get to his wheelchair if positioned away from him. On July 29, 2025, at 4:19 PM, V14, (CNA) said she was the assigned (CNA) for R6, and she had been told to put wheelchairs of residents who are at risk for falls in the hallway and she did not know if R6 was at risk for fall. There was a yellow falling leaf signage with the letter B on R6's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 8 of 22 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 07/31/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm doorframe. When asked why R6 had the yellow signage on his doorframe, V14 responded that she did not know, and her best guess was that it meant R6 was in bed B. On July 29, 2025, at 4:24 PM, V13 (CNA) said the yellow falling leaf signage with the letter B on R6's doorframe meant R6 is at risk for fall. Residents Affected - Few On July 29, 2025, at 4:17 PM, V20, RN (Registered Nurse/Fall Coordinator) said she was in charge of reviewing residents' fall care plans and entering interventions for each fall and providing education and in-services for the nursing staff regarding falls. V20 stated that she was aware that R6 had history of falls. V20 stated the fall prevention interventions that has been put in place for the R6 included, staff should assist R6 back to and remove the wheelchair away from the resident for safety and put it in the hallway so that the resident can call staff for assistance. V20 added that there is a fall risk signage on residents' door if they are at risk for falls. She also stated that she created a green binder for each nurses' station with interventions for CNAs to check and know the residents at risk for fall and the interventions for each resident. V20 stated that she also provides education and in-services to the nursing staffs, including (CNAs), especially when they float to different units. On July 30, 2025, at 3:10 PM, V2 DON (Director of Nursing) stated that staff and CNAs should follow the orders and care plan interventions for R6 and should remove the wheelchair away from the resident's bedside for safety. The facility's Fall Prevention and Management policy (revised on June 2025) included the following: 2. Fall interventions b. High-Risk Precautions d. Interventions will depend on identified and assessed risk factors, including root cause/s every after each fall or when a pattern has been identified. c. High-Risk for Fall interventions i) All Universal and High-Risk Precautions Interventions, plus the following: falling leaf sign on doorframe, headboard as indicated. Nurse to communicate and endorse to staff during stand up/huddle meetings and shift to shift report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 9 of 22 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 07/31/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess a resident with cognitive deficits for risk of entrapment prior to installation of bed rails. This applies to 1 of 1 resident (R18) reviewed for bed rails in the sample of 35. The findings include: R18's diagnoses include unspecified dementia, unspecified severity, with other behavioral disturbance, depression, bipolar disorder, other symptoms and signs involving cognitive functions and awareness, other symptoms and signs involving appearance and behavior, need for assistance with personal care. R18's quarterly Minimum Data Set, dated [DATE], showed that R18 is moderately impaired in cognition and requires supervision or touching assistance for bed mobility. On July 28, 2025, at 10:30 AM, R18's room door was closed. On entering the room, R18 was lying in bed with the left side of bed against wall. R18's bed had (half) bed side rails raised up in the middle of the bed on both sides. A bed alarm was on the bed. R18 stated I am tired, I did not sleep for two nights, they kept waking me up asking stupid questions. R18's wheelchair was at side of bed and R18 stated I can get up by myself. I hold on to wheelchair while walking. On July 28, 2025, at 10:30 AM, V9 (Certified Nursing Assistant) was in the dining room with other residents who were at activities. When asked about R18's side rails, V9 stated that bed rails are put down (raised up) at side of bed as R18 is a fall risk. V9 stated that R18 is able to get up by herself. When asked, how R18 is able to get out of bed with the side rails up in the middle of the bed, V9 responded that R18 can slide down to the foot of the bed and get out through the (small) space beyond the bed rail at the foot of the bed. V9 added that when R18 attempts to get up out of bed we hear the bed alarm, and we go and check. V9 was made aware that the door was closed and the possibility of hearing the alarm was questionable. On July 29, 2025, at 11:17 AM, and on July 30, 2025, at 3:18 PM, V10 (Restorative Director) stated that the side rails are put down (raised up) on right side while resident is in bed to assist with bed mobility during care. V10 stated that the bed rails can be put down even while the resident is sleeping after care. V10 also stated that if the resident wants to get out of bed while side rails are up, she can move to the bottom of the rails and get out. When asked if V10 has assessed R18 for entrapment as R18 is confused, V10 stated that even though R18 is confused, so far nothing has happened. V10 also stated that the facility does not have a separate risk assessment form for entrapment prior to installation of bed rails. V10 stated she considered the consent form signed by R18's Power of Attorney as the risk assessment form. R18's Devise Observation, Education and Consent form dated May 26, 2025, included that 1/2 (half) side rail was added as an intervention: utilize bilateral partial side rails for bed mobility and repositioning in bed from lying to seated and vice versa, and to serve as bed parameters during care. Provide a hand hold for getting into or out of bed. Additional comments or notes for the same included: Resident impulsive, attempting to get up from chair and bed unattended, gait unsteady. Resident in frequent need of reorientation, poor safety awareness diagnosis of Dementia with other behavioral disturbances, bipolar disorder, anxiety disorder. R18's ADL (activities of daily living) care plan revised March 6, 2025 included the following: R18 has ADL Self Care Performance Deficit [related to] impaired balance, limited mobility, weakness, decreased strength/endurance, AMS (altered mental status). Able to walk with assist wheelchair for mobility.Interventions included as follows: To utilize bilateral partial side rails for bed mobility and repositioning in bed from lying to seated and vice versa, and to serve as bed parameters during care. Provides a hand hold for getting into or out of bed, cognitively impaired: Resident is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 10 of 22 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 07/31/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete confused and due to cognitive deficits, resident will be unable to use call light effectively (revised January 31, 2024). R18's mood/behavior care plan initiated on February 3, 2025, included that [R18] has diagnosis that includes dementia. Resident is evidencing flux in mentation as well as overestimation of her physical abilities. She is at risk to make poor choices and at risk for self-injury with her self-determination. Care plan-initiated on October 11, 2024, included that R18 has alteration in thought process and cognitive communication status issues related to resident is disoriented and/or confused. The resident's memory appears impaired. Consequently, the resident has problems with decision making, insight, logic, calculation, reasoning, planning, organization, sequencing, social skills and judgement. This problem is related to diagnosis of Alzheimer's disease or other form of Dementia. Facility's policy titled Bed or Side Rails revised April 2025 included as follows: General: The facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practical physical, mental, and psychological well-being. Procedure: 2. If a bed or side rail is used, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.a) Assess the resident of risk of entrapment from bed rails prior to installation. 3. Facility will allow side rails to aid in positioning, turning, transfers and or mobility. Event ID: Facility ID: 145710 If continuation sheet Page 11 of 22 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 07/31/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow physician order with regards to dosage of a resident's nasal spray and failed to follow medication administration policy and procedures during medications pass. There were 26 medication opportunities with 6 errors resulting to 23.07% error rate. This applies to 2 of 5 residents (R6, R95) reviewed for medication pass in the sample of 35. The findings include: 1. On July 28, 2025, at 5:49 PM, V30 administered medications (Allopurinol, Hydralazine, Torsemide) to R6. V30 placed these medications in a small plastic bag and crushed it all together. V30 then mixed it with pudding and gave it to R6. Facility's Medication Administration Policy and Procedure dated April 2025 shows:General: Facility will ensure that medications are administered in a safe and timely manner and as prescribed. Procedure: 23. Medications may be crushed with MD/NP order. Each medication should be crushed separately and administering each with food.2. On July 29 at 9:24 AM, V31 (Nurse) administered medications to R95 which include Spiriva Respimat Inhaler, Symbicort Inhaler, and Fluticasone Propionate nasal spray. During the medication administration V31 administered 2 sprays of Fluticasone to each nostril of R95. V31 then administered 2 puffs of Symbicort inhaler with 3 seconds interval between puffs, followed by Spiriva inhaler 15 seconds later. V31 administered 2 puffs of Spiriva with 5 seconds interval between puffs. R95's Medication Administration Record (MAR) dated July 2025, shows Fluticasone Propionate Nasal Suspension 50 MCT/ACT. Give 1 spray each nostril one time a day for respiratory condition/symptom. Facility's Medications through Metered Dose Inhalers Policy and Procedure dated April 2025 shows: General: The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications.Procedure: 15. Repeat inhalation, if ordered. Allow at least one (1) minute between inhalations of the same medication and at least 2 minutes between inhalations of different medications. On July 29, 2025, at 4:03 PM, V2 (Director of Nursing/DON), stated the nurse must follow physician order for medication administration, and the 5 rights of medication administration such as the right resident, medication, dose, time, and route. Medications should be crushed separately to prevent potential negative interactions to one another. When staff is administering two different inhalers, the staff should wait 5 minutes in between administrations of 2 different inhalers. For the same inhaler the staff must administer 1 minute interval in between dose. This is for better absorption of medication and prevent potential side effects. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 12 of 22 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 07/31/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to label and date medications to determine its expiration date and failed to store unopened insulins in the refrigerator. This applies to 7 of 7 residents (R176, R182, R207, R220, R226, R231, R232) reviewed for medication storage and labeling in the sample of 35.The findings include:On 7/29/25 from 4:31 PM to 5:28 PM, medication cart observations were conducted with V32, V33, V34, and V36 (All Nurses). The following were observed:1. R226's has two Budesonide Formoterol 160-4.5 mcg inhaler that were open and not dated. Pharmacy recommendation shows to discard when the dose counter reaches 0 or 3 months after it is taken out of its foil pouch, whichever comes first. 2. R176's one bottle of Systane 0.4%-0.3% eye drop and one bottle Brimonidine 0.2% eye were open and not dated. The medication plastic wrapper of both medications had a sticker which showed to date these medications when it was opened.3. R182's Humalog 100 units/ml was unopened but was stored in the cart. Pharmacy instruction showed to refrigerate until open, then store at room temperature.4. R231's Lantus Pen 100 units/ml was unopened but was stored in the cart. Pharmacy instruction showed to refrigerate until open, then store at room temperature.5. R220's Timolol Maleate Ophthalmic 0.5% eye drop was open and not dated. The medication plastic wrapper of this medication had a sticker which showed to date this medication when it was opened.6. R207's Latanoprost 0.005% was open and not dated. Pharmacy recommendation shows, date when opened and discard after 6 weeks. R207's Dorzolamide HCl 2% eye drop solution was open and not dated 7. R232's Brimonidine 0.2% eye drops was open and not dated. The medication plastic wrapper of this medication had a sticker which showed to date this medication when it was opened.On July 30, 2025, at 5:14 PM, V3 (Assistant Director of Nursing/ADON) stated staff must follow pharmacy recommendations with regards dating and labeling of medications to determine expiration dates this includes insulin, eye drops, and inhalers. The insulin should be refrigerated when it's not open to avoid premature expirations. Pharmacy Administration Guide for eye medications shows: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow manufacturer instructions, or facility policy. (e.g., Latanoprost - 42 days) Most common examples include: Artificial Tears, Tears Naturale, TheraTears Trusopt (dorzolamide) Combigan (brimonidine/timolol) Cosopt (dorzolamide-timolol) Alphagan (brimonidine) Zatidor (ketotifen) Lumigan (bimatoprost) Event ID: Facility ID: 145710 If continuation sheet Page 13 of 22 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 07/31/2025 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 0791 Provide or obtain dental services for each resident. 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 ensure a resident received dental care for teeth that were painful and decaying.This applies to 1 of 1 resident (R236) reviewed for dental care in the sample of 35.The findings include:R236's face sheet showed that R236 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, unspecified, unspecified dementia, unspecified severity, with agitation, aphasia following cerebral infarction edema, cerebral infarction without residual deficits, chronic systolic heart failure, and type 2 diabetes mellitus.On July 28, 2025 at 10:22 AM, R236 stated he needs to see a dentist. R236 stated he has been telling the staff for a while that he has tooth pain and needs to see a dentist and they have not done anything about it. R236 stated they wrote it on a piece of paper, but nothing else has happened. R236 stated this is important because it hurts when he chews. R236 stated he told the staff last 3 days ago. On July 30, 2025 at 10:10 AM, V8 (Social Services Director) stated that she arranges dental appointments for residents. R236 has not seen a dentist since he has been in the facility. V8 stated that R26 is not on the facility's dental insurance to be seen by the dentist that comes to the facility. On July 30, 2025 at 11:24 AM, V17 (Ward Clerk) stated she is responsible for making appointments for residents to see dentist outside of the facility and she also helps the social worker for doing inside dental appointments with their Dentist that comes into the facility. V17 stated that R236 has not ever seen an outside dentist, nor has he seen their inside dentist. On July 30, 2025 at 2:22 PM, viewed R236 teeth more closely and observed R236 has missing lower teeth and one of his lower left molars had a large black area on the top eating surface that covers about 90% of the tooth. On July 30, 2025 at 2:24 PM, V37 (Licensed Practical Nurse) stated that R236 was put on an antibiotic today for decaying teeth. On July 30, 2025 at 4:41 PM, R236 reiterated and stated that his teeth have been hurting for about three months, and he was telling the staff that he was in pain and needed to see the dentist. The facility's routine dental care policy dated April 2025 showed the following: each resident will receive routine dental care. Routine dental care includes, but is not limited to, preventative care and treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 14 of 22 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 07/31/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to serve portion sizes of pureed chili as planned for the lunch meal.This applies to 5 of 5 (R17, R41, R46, R72, R223) residents reviewed for pureed diets in the sample of 35.The findings include:Daily Menu Spreadsheet for Week 2 Monday showed that pureed meals should receive #6 scoop of pureed Homemade Chili.Facility Dipper/Ladel Equivalents chart showed that dipper /scoop #8 =1/2 cup or 4 fluid oz/ounce and dipper/scoop #6=2/3 cup or 5.3 fluid oz. On July 28, 2025 starting at 11:40 AM, the lunch meal tray line service was observed in the facility kitchen with V5 (Cook) serving the main entree that included Homemade Chili. V5 used a #8 scoop and served R17, R41, R46, R72, R223 pureed Homemade Chili.On July 28, 2025 at 12:07 PM, V4 (Food Service Director) stated that V5 should have used a #6 scoop to serve pureed Homemade Chili if the menu showed the same.On July 30, 2025 at 12:03 PM, V18 (Dietitian) stated that the facility should follow the menu spread sheet. V18 stated that the staff should have used the #6 scoop as the menus are planned ahead to provide the appropriate nutrients that is needed. Facility policy and procedure titled Serving Portions included as follows:Policy: Food will be served in portions indicated on the cycle menu and on standardized recipes.Procedure: Serving portions will be controlled by use of the following utensils: Ladles, Scales, Scoops, Spoodles. Prior to serving the meal, the director of food and nutrition services or person in charge will check the serving utensils to ensure that the correct ones will be used. Facility Client Listing Report of diet orders of residents printed on July 28, 2025 showed that R17, R41, R46, R72 and R223 were on pureed diets. Event ID: Facility ID: 145710 If continuation sheet Page 15 of 22 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 07/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to follow sanitary practices during food storage in freezer, pots and pans storage and meal service.This apples to 225 residents that receive food prepared in the facility kitchen.The findings include: Facility's CMS Application Form for Medicare/Medicaid dated July 28, 2025 showed that the facility census was 226 residents. Facility provided information that there was one resident on NPO (nothing by mouth) status.1.On July 28, 2025 starting at 9:07 AM the initial tour was done in presence of V4 (Food Service Director).The walk-in freezer had ice built up on the floor at the entrance and at the back of the freezer. Two strips of the PVC (Polyvinyl Chloride) strip curtains inside the door at the entrance was torn and/or broken in half. Ice crystals were noted formed on the entire PVC strip curtains and also on several individual portion servings (4 ounce/serving) of vanilla ice-cream and chocolate nutrition treats that were stored on shelving in cardboard boxes. V4 stated that the ice built-up is due to the door not closing properly and the condensation from the pipes. V4 added that the maintenance is aware of it.In the dish room, there were two free standing racks with shelving that stored pots and pans which were inverted on the shelves that had brownish coloring that had the appearance of rust. V4 stated A lot of this stuff [racks] is old and needs to be replaced. 2. On July 28, 2025 at 11:40 AM, the tray line service was observed in the facility kitchen with V5 (Dietary Aide) and V6 (Cook) plating the lunch meal items. V5, wearing gloves, was plating the chili into bowls and the sauce from the chili was falling onto her gloves. With the same soiled gloves, V5 picked up corn bread from a tray and placed them on the plate and this process continued as she platted for several residents. V6 also had his gloves soiled with food items and was seen platting the salad onto the same plate that held the bowl of chili and cornbread and moving the salad with his soiled gloves onto the plate.On July 28, 2025 at 11:46 AM, V4 who was in the vicinity, was notified of the same and V4 stated that V5 and V6 should only use tongs during meal service. V4 also added that soiled gloves should be changed after washing hands.On July 30, 2025 at 12:07 PM, V18 (Dietitian) stated that the pots and pans storage racks should not have rust as there is potential that it can be flaked off to come on to the food storage pans. V18 added that the racks should be made of food grade material, or a barrier should be placed in-between the racks and the pots and pans. V18 added that utensils should be used to serve food. Facility policy titled Refrigerators and Freezers dated June 2021 included as follows:9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed.Facility policy titled Food Preparation and Storage included as follows:Food Service/Distribution: 6. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Event ID: Facility ID: 145710 If continuation sheet Page 16 of 22 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 07/31/2025 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 0880 Provide and implement an infection prevention and control program. 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 follow standard infection control practices related to EBP (Enhance Barrier Precaution) policy, hand hygiene, and glove use during provisions of care and medication administration. This applies to 7of 35 residents (R2, R13, R127, R162, R176, R178, R204) reviewed for infection control in the sample of 35. The findings include: 1. On July 28, 2025, at 10:42 AM, during initial facility rounds, R176 was in bed resting. There was an EBP signage at his door. V27 (Certified Nursing Assistant/CNA) stated R176 was on EBP because he has gastrostomy tube (g-tube), indwelling urinary catheter, pressure ulcer to his buttocks and wounds to both anterior part of his lower legs. Residents Affected - Some On July 29, 2025, at 9:37 AM, R176 remained on enhance barrier precautions. V26 (Nurse) assessed R176's gastric-tube (g-tube) and checked his vital signs. After she checked the g-tube placement and vital signs, V26 administered nutritional supplement via g-tube. V26 did all these tasks without wearing a gown. 2. On July 29, 2025, at, 10:37 AM, R127 was resting in bed, she was receiving enteral feeding through g-tube. There was an EBP signage at her bedroom door. V27 (CNA) placed an enteral the enteral feeding on hold and proceeded to provide bed bath to R127. V27 cleaned R127 from head to toe, she wore gloves but did not wear a gown all throughout the care. 3. On July 29, 2025, at 11:42 AM, R204 was resting in bed, there was and EBP signage at her bedroom door. V25 (Nurse) assessed R204 for g-tube placement, then she flushed the g-tube and administered medications. V25 only wore a pair of gloves and did not wear a gown all throughout the procedure. On July 29, 2025, at 4:20 PM, V2 (Director of Nursing/DON), stated the staff must follow the EBP (Enhance Barrier Precautions) protocol of wearing complete PPE (Personal Protective Equipment) such as gowns and gloves during provisions of care and administration of medication. This must be done for infection prevention. The Enhance Barrier Precautions signage shows: Providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities. - Bathing/Showering - Device care or use: urinary catheter and feeding tube 4. The EMR (Electronic Medical Record) showed R13 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, cognitive communication deficit, dementia, and oropharyngeal dysphagia. R13's MDS (Minimum Data Set) dated May 9, 2025, showed R13 was cognitively intact. The MDS continued to show R13 was dependent on facility staff for toileting hygiene and was always incontinent of bladder and bowel. On July 29, 2025, at 2:04 PM, V11 (CNA/Certified Nursing Assistant) said she was taking R13 to his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 17 of 22 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 07/31/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room to provide R13 with incontinence care. V11 and V12 (CNA) performed hand hygiene and donned gloves and transferred R13 back to bed. V11 removed R13's soiled incontinence brief. V11 said R13's incontinence brief was saturated with urine. V11 wiped R13 with premoistened wipes. V11 said she wiped feces from R13's buttocks. V11 applied ointment to R13's buttocks, applied a new incontinence brief, adjusted R13's bed linens, put on new shorts, and transferred R13 back to the wheelchair, with the same soiled gloves and without performing hand hygiene between care. On July 30, 2025, at 3:23 PM, V2 (DON/Director of Nursing) said during incontinence care, staff should change gloves and perform hand hygiene after removing soiled items, after cleaning the resident, and after care. V2 said V11 should have performed hand hygiene and changed her gloves when going from dirty to clean during R13's incontinence care, including after wiping the R13 and before applying skin ointment to R13. V2 said V11 should not have worn the same gloves throughout the incontinence care. 5. The EMR showed R162 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, urinary tract infection, and partial traumatic amputation of two or more right lesser toes. R162's Order Summary Report dated July 30, 2025, showed an order dated July 30, 2025, for Enhanced Barrier Precautions (EBP): related to chronic wound to left heel. Everyone must clean their hands before entering and leaving the room. Providers and staff must wear PPE (Personal Protective Equipment) during high contact resident care activities. R162's EBP care plan dated July 30, 2025, showed [R162] Enhanced Barrier Precautions: related to chronic left heel wound. The care plan continued to show multiple interventions dated July 30, 2025, including Wound care: any skin opening requiring a dressing. On July 30, 2025, at 12:54 PM, R162's door had a sign showing Enhanced Barrier Precautions. Everyone Must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Wound Care: any skin opening requiring a dressing. V16 (Wound Nurse) and V21 (CNA/Certified Nursing Assistant) entered R162's room without wearing a gown. V16 provided wound care and V21 held R162's leg while V16 provided wound care. V16 said R162's wound was debrided by the wound doctor yesterday. V16 and V21 did not wear a gown throughout R162's wound care. 6. According to the EMR (Electronic Medical Records), R178 has multiple diagnoses including osteoarthritis, attention and concentration deficit, and dementia. The Minimum Data Set (MDS) dated [DATE], showed R178 had moderate cognitive impairment and was dependent on staff for toileting. The ADL (Activities of Daily Living) Care Plan dated January 8, 2024, showed that R178 had functional and self-care deficit in performing ADL and was dependent on staff with incontinence care and toilet hygiene. On July 29, 2025, at 3:11 PM, V13 and V14 both CNAs (Certified Nursing Assistant) performed incontinence care for R178. R178 had some healing rashes and redness on his buttock. V14 cleaned R178's buttock with wipes wearing gloves and then applied some cream to R178's buttocks using the same gloves she wore to clean the resident's buttocks. R178 was lying on his back and both R13 and R14 removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 18 of 22 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 07/31/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm their gloves, performed hand hygiene using hand sanitizer, donned gloves, then began to apply a clean incontinence brief for R178. R178 started urinating, V13 placed a clean washcloth over R178's penis and enlarged scrotum to catch the urine. V14 cleaned the urine on R178's enlarged scrotum with some wipes, without removing the soiled gloves and without performing hand hygiene, proceeded to assist V13 to finish applying and strapping the clean incontinence brief for R178. Residents Affected - Some 7. Based on the face sheet R2 has multiple diagnoses including unstageable pressure injury on the sacral region. On July 30, 2025 at 8:42 AM, an EBP (Enhanced Barrier Precaution) sign was posted on the outside door of R2's room. The EBP sign instructions showed that everyone must, Clean their hands, including before entering and when leaving the room. The same instructions showed, providers and staff must also wear gloves and a gown for the following high-contact resident care activities including, wound care: any opening requiring a dressing. At 8:56 AM, V16 and V24 (both LPN [Licensed Practical Nurse]/Wound care nurses) entered R2's room to provide wound treatments to the resident. Upon entering R2's room, V24 immediately put on a pair of gloves without performing hand hygiene (hand washing or hand sanitation). Both V16 and V24 did not wear a gown. V24 assisted R2 with turning and repositioning in bed for the wound care, while V16 administered multiple treatments to R2's wounds including the unstageable pressure injury on the sacrum which had approximately 80% sloughing and 20% bright pink/red tissue with minimal bleeding. During the entire wound treatment, and turning and repositioning of R2, both V16 and V24 were not wearing gown. R2's active order summary report showed an order dated July 24, 2025 for, EBP related to indwelling medical devices and unhealed wounds. The same order showed, Everyone must clean their hands before entering and leaving the room. Providers and staff must wear PPE (Personal Protective Equipment) during high contact resident care activities, every shift for care. R2 had an active care plan in place initiated on May 14, 2025 that showed that the resident is on EBP. The same care plan under interventions showed, Clean hands, including before entering and when leaving the room and Ensure that gown and gloves are used during high-contact resident care activities. The facility's policy regarding Enhanced Barrier Precaution last reviewed by the facility on April 2025 showed, Enhanced Barrier Precautions (EBP) are a proactive infection control strategy designed to reduce the spread of multidrug-resistant organisms (MDROs)in nursing homes. Unlike Standard Precautions, which are based on anticipated exposure to blood or body fluids, EBP target high-contact care activities that have been shown to transfer MDROs – even when no visible exposure is expected. The policy showed that, EBP involves the use of gown and gloves during high-contact resident care activities including, Residents at increased risk for MDROs, such as those with wounds, indwelling medical devices, or who require extensive hands-on care. The same policy showed, These precautions are intended to supplement, not replaced, Standard Precautions and are implemented even in the absence of active infection, recognizing that MDRO colonization may occur without symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 19 of 22 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 07/31/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer and administer influenza and pneumococcal vaccines in accordance with CDC (Centers for Disease Control and Prevention) guidelines.This applies to 4 of 5 residents (R13, R63, R90, and R126) reviewed for immunizations in the sample of 35. The findings include:1. The EMR (Electronic Medical Record) showed R126 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, malignant neoplasm of breast, acute embolism and thrombosis of right femoral vein, and heart disease.R126's Immunization Report dated July 30, 2025, showed R126 had not received the influenza vaccine and had not received a pneumococcal vaccine.The facility does not have documentation to show R126 or R126's resident representative was provided education and offered the influenza immunization during the 2024/2025 influenza season. The facility does not have documentation to show R126 or R126's resident representative was provided education and offered the pneumococcal vaccine. 2. The EMR showed R90 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, patent foramen ovale, and dependence on supplemental oxygen.R90's Immunization Report dated July 30, 2025, showed R90 had not received a pneumococcal vaccine and R90's pneumococcal vaccine was pending immunization. R90's Consent/Education Pneumonia Vaccine dated October 3, 2024, showed R90's resident representative consented for R90 to receive the pneumococcal vaccine.As of July 30, 2025, at 2:00 PM, R90 had not received the pneumococcal vaccine.3. The EMR showed R63 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including atherosclerosis of aorta, dementia, and history of nicotine dependence.R63's Consent/Education Influenza Vaccine dated June 12, 2024, showed R63's resident representative refused for R63 to receive the influenza vaccine because the influenza season was over.The facility does not have documentation to show R63 was provided education and offered the influenza vaccine during the 2024/2025 influenza season. R63's Immunization Report dated July 30, 2025, showed R63 received the PCV13 (13-Valent Pneumococcal Conjugate Vaccine) on January 17, 2020. As of July 30, 2025, at 11:30 AM, the facility does not documentation to show R63 was provided education and offered an additional pneumococcal vaccine.4. The EMR showed R13 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, alcohol abuse, and type 2 diabetes mellitus.R13's Immunization Report dated July 30, 2025, at 2:22 PM, showed R13 had not received a pneumococcal vaccine.The facility does not have documentation to show R13 was provided education and offered the pneumococcal vaccine prior to July 30, 2025, at 11:30 AM.On July 30, 2025, at 10:09 AM, V29 (Educator) said he is responsible for resident immunizations. V29 said he assumed the responsibility of resident immunizations within the last couple of weeks, and prior to V29, resident immunizations were the previous DON's (Director of Nursing's) responsibility. V29 said the facility follows CDC guidelines for immunizations.On July 30, 2025, at 3:23 PM, V2 (DON) said residents should be educated and offered vaccines in accordance with the facility's policies and CDC guidelines. V2 said R90 should have been given the vaccine she consented to receive, and R13, R63, R126 should have been educated and offered the vaccines.The CDC's Pneumococcal Vaccine Timing for Adults dated October 2024, showed Adults 50 years or older, Complete pneumococcal vaccine schedules: No prior vaccines, Option A: PCV20 (Pneumococcal 20-valent Conjugate Vaccine) or PCV21 (Pneumococcal 21-valent Conjugate Vaccine); Option B: PCV15 (Pneumococcal 15-valent Conjugate Vaccine) then one year or later PPSV23 (23-valent Pneumococcal Polysaccharide Vaccine). Prior Vaccines: PCV13 only, Option A: one year or more later PCV20 or PCV21.The Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145710 If continuation sheet Page 20 of 22 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 07/31/2025 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete facility's policy titled Influenza Vaccination dated April 2025, showed General: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Policy: The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. Procedure: 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized.The facility's policy titled Pneumococcal Vaccination dated April 2025, showed General: To provide information on the process for giving the pneumococcal vaccinations. Policy: All residents will be offered pneumococcal vaccines to air in preventing pneumonia/pneumococcal infections. Guidance: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted to prior to admission. 3. A consent will be obtained and serves as the education tool for the vaccine. If the resident has previously received any of the pneumonia vaccines previously, the date and location will be entered into the Immunization Tab of the EHR (Electronic Health Record). 4. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. 5. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per or facility's physician-approved pneumococcal vaccination protocol. 6. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. 8. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Event ID: Facility ID: 145710 If continuation sheet Page 21 of 22 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 07/31/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide education and offer a resident the COVID-19 immunization.This apples to 1 of 5 residents (R126) reviewed for immunization in the sample of 35. The findings include:The EMR (Electronic Medical Record) showed R126 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, malignant neoplasm of breast, acute embolism and thrombosis of right femoral vein, and heart disease.R126's Immunization Report dated July 30, 2025, showed R126 had not received any previous COVID-19 immunizations.As of July 30, 2025, at 11:30 AM, the facility does not have documentation to show R126 or R126's resident representative was provided education and offered the COVID-19 immunization. On July 30, 2025, at 10:09 AM, V29 (Educator) said he is responsible for resident immunizations. V29 said he assumed the responsibility of resident immunizations within the last couple of weeks, and prior to V29, resident immunizations were the previous DON's (Director of Nursing's) responsibility. V29 said the facility follows CDC guidelines for immunizations.On July 30, 2025, at 3:23 PM, V2 (DON) said residents should be educated and offered vaccines in accordance with the facility's policies and CDC guidelines. V2 said R126 should have been provided education and offered the COVID-19 vaccine.The facility's policy titled COVID Vaccination dated April 2025, showed General: To ensure the health and safety of all residents, staff, and visitors, the facility shall implement and maintain a COVID-19 vaccination policy in alignment with the latest guidance from the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and applicable state and local health authorities. Policy: All eligible individuals, including residents and staff, are encouraged to receive the most recent seasonally updated COVID-19 vaccine, as appropriate based on age, prior vaccination history, and immunocompromised status. Guidance:. 3. The number of updated 2024-2025 COVID-19 vaccine doses and individual needs is based on age and vaccination history. For residents who are not moderately or severely immuno-compromised: a. Routine COVID-19 vaccination: i. CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older. ii. It is especially important to offer COVID-1 vaccination to residents if they are 65 years and older, are at high risk for severe COVID-19, or have never received a COVID-19. 4. The recommendations for updated 2024-2025 COVID-19 vaccine doses for individuals who are moderately or severely immunocompromised, based on age and vaccination history, are as follows: a. Unvaccinated: Should receive a multidose initial series with an age-appropriate 2024-2025 COVID-19 vaccine and one does of a 2024-2025 COVID-19 vaccine since months (minimal interval two months) after completing the initial series. b. Previously completed an initial series: should receive two doses of an age-appropriate 2024-2025 COVID-19 vaccine, spaced six months (minimal interval two months) apart. c. May receive additional age-appropriate 2024-2025 COVID-19 vaccine doses under shared clinical decision-making. Event ID: Facility ID: 145710 If continuation sheet Page 22 of 22