Health inspection·September 20, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm posted in the resident's room unless specifically requested by the resident or family member .Please note: In the interest of public health, posting the resident's isolation status or transmission-based precautions is permissible as long as the type of infection remains confidential .12. Demeaning practices and standards of care that compromise dignity are prohibited. Associates should promote dignity and assist residents; for example: a. Helping the resident to keep urinary catheter bags covered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Residents Affected - Some Based on observation, interview, and record review, facility failed to provide showers and nail care to residents who need assistance with ADLs (activities of daily living). This applies to 4 of 4 residents (R26, R151, R301 and R302) reviewed for ADLs in a sample of 23. Findings include: 1. R301's face-sheet showed R301 was admitted to the facility on [DATE], with diagnoses to include Covid-19, weakness, bilateral osteo-arthritis, mild cognitive impairment and cerebral infarction. R301's MDS (Minimum Data Set) showed R301 was cognitively intact. R301's Functional Abilities Assessment, dated 9/13/24, showed R301 needed substantial/maximum assist to shower/bathe and upper/lower body dressing up. R301's care plan, dated 9/11/24, did not address the need for ADLs care. On 9/17/24 at 12:36 PM, observed R301 sitting on her WC (wheelchair), in her room, unhappy. R301 stated she has not had a shower since she was admitted to the facility. R301 stated she had requested the staff multiple times for a shower and she did not get one. 2. R302's face-sheet showed R302 was admitted to the facility on [DATE], with diagnoses to include Covid-19, Diabetes Mellitus type 2, Depression, Morbid Obesity, and Pulmonary Embolism. R302's MDS (Minimum Data Set) showed R302 had moderate cognitive impairment. R302's Functional Abilities Assessment, dated 9/13/24, showed R302 needed partial/moderate assist to shower/bathe and supervision/touching assist for dressing up. R302's care plan, dated 9/12/24, revised on 9/18/24, addressed the problem of ADLs self-care performance deficit, interventions did not include showers. On 9/17/24 at 1:10 PM, observed R302 lying on her bed, with a grumpy face. R302 stated she has not had a shower since she was admitted to the facility. R302 stated she had requested the staff multiple times for a shower and she did not get one. On 9/18/24 at 1:08 PM, R302 stated she wanted to be showered, had made multiple requests, and did not receive a shower. R302 stated she had given up on that dream. On 9/18/24 at 12:21 PM, V12 (RN-Registered Nurse) stated, Every resident is usually given showers twice a week. (R301) is scheduled to get showers on Saturdays and Thursdays and (R302) is scheduled to get showers on Mondays and Fridays. V12 (RN) reviewed electronic documentation for showers and it showed, No records. V12 stated, (R301) and (R302) did not receive any showers since admission. On 9/18/24 at 1:30 PM, V19 (Licensed Practical Nurse/LPN) stated, (R301) and (R302) are scheduled to receive showers twice a week. V19 (LPN) reviewed electronic documentation for showers and it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 showed, No records. V19 stated, (R301) and (R302) did not receive any showers. Level of Harm - Minimal harm or potential for actual harm On 9/19/24 at 11:05 AM, V2 (DON-Director of Nursing) stated, If (R301) and (R302) wanted showers, they should have been given one after all other residents are done for the shift, so that housekeeping can clean and sanitize the bathroom after they use it. They should have been given bath or shower twice in a week. Showers are documented electronically and not on paper. Residents Affected - Some Facility policy on 'Supporting Activities of Daily Living, dated 02/2024, showed, Residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene.3. On 9/17/2024 at 10:10 AM, R26 was observed to have long, dirty, and jagged nails. She said she asks staff to help her cut her nails, but nothing happens. R26's MDS (Minimum Data Sheet), dated 8/16/2024, documents BIMS (Brief Interview for Mental Status) of 15, which means her cognitive functions are intact. She requires set-up or clean up assistance with personal hygiene. 4. On 9/17/2024 at 10:15 AM, R151 was observed with long, dirty, and jagged fingernails. On 9/17/2024 at 2:06 PM, R151 said she does not like having her nails long and dirty, but nobody offered to cut her nails. R151's face sheet documents she was admitted to facility on 9/13/2024. R151's MDS has not been completed during the survey. R151's Functional Abilities and Goal Form, dated 9/16/2024, documents she is dependent on staff for personal hygiene. BIMS Form documents score is 11, which means she has moderately impaired cognitive functions. On 9/19/2024 at 10:54 AM, V2 (DON-Director of Nursing) said she expects staff to be checking nails when they are doing showers, hygiene care, and as needed. She said if nails are not kept clean and well-trimmed, it can be a source of infection, and resident can end up scratching themselves causing injury. Facility's Policy titled Supporting Activities of Daily Living, dated 4/2022 and revised on 2/2024, documents : 2. Appropriate care and services should be provided for residents who are unable to carry out ADLS (Activities of Daily Living) independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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. 2. On 9/17/24 at 10:57 AM, there was used dirty disposable razor (3 blades) on R356's bedside dresser. At 12:15 PM, R356 said he shaves himself. On 9/18/24 at 10:02 AM, razor still noted on the bedside dresser. There was a sharps container in resident's bathroom. R356's MDS (Minimum Data Set) of 9/17/24 shows R356's cognition is intact and needs partial to moderate assistance with personal hygiene. On 9/18/24 at 10:14 AM, V12 (Registered Nurse/RN) said R356 is not able to shave himself, the staff does his grooming. V12 said the disposable razor should not be in the resident's room when not in use; it should either be discarded after use or stored in a clear plastic bag because it is a potential hazard, and the resident could hurt himself. On 9/19/24 at 10:46 AM, V2 (Director of Nursing/DON) said staff should dispose of disposable razor after use; each room has a sharps container to dispose of disposal razors/single use razors to eliminate cross contamination and for safety concerns. V2 said the facility does not have a policy for disposing of disposable razors. The facility's Sharps Container Disposal policy (revised 11/2019) states contaminated sharps shall be discarded immediately or as soon as feasible into designated containers. Based on observation, interview, and record review, the facility failed to properly transfer resident and failed to properly dispose of a sharp disposable razor. This applies to 2 out of 2 residents (R42, R356) reviewed for accidents in a sample of 23. Findings include: 1. R42's MDS (Minimum Data Sheet), dated 8/23/2024, documents her BIMS (Brief Interview for Mental Status) score is 14, which means her cognitive functions are intact. On 9/18/2024 at 9:45 AM, R42 said she transfers with the use of a mechanical lift, with help from two staff. She said on 8/30/2024, V16 (CNA-Certified Nurse Assistant) attempted to transfer her by physically lifting her from her bed to wheelchair. She said before V16 lifted her, she reminded V16 she uses a mechanical lift for transfers and there must be two staff doing it, but V16 said she could transfer R42 without using the mechanical lift. R42 said her sling was on her wheelchair She said V16 was unable to safely transfer her and flung her to the floor. She said she was sore after the fall, but had no injury. On 9/19/2024 at 10:54 AM, V2 (DON-Director of Nursing) said V16 was employed by the facility and has worked with R42 multiple times. She said she is sure V16 was aware R42 was transferred using a mechanical lift with two people assist. V2 said V16 said she could not find the sling during that time and decided to transfer R42 without using the mechanical lift. She said she expects her staff to follow transfer status of all residents as documented in the Kardex of each resident's Plan of Care. She said nurses also remind staff, especially agency staff, of resident's transfer status. She said if resident is not transferred following the plan of care, there is a potential for serious injury that can happen to both resident and staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 FORM CMS-2567 (02/99) Previous Versions Obsolete V2's investigation of incident, dated 9/3/2024, documents V16 attempted a self-transfer of resident without using the proper equipment. V16 was aware of R42's transfer mode of mechanical lift, but attempted to transfer R42 by lifting her physically from her bed. R42 is physically unable to support self or assist in physical transfer. Facility's Policy titled Supporting Activities of Daily Living, dated 4/2022 and revised on 2/2024, documents : 2. Appropriate care and services should be provided for residents who are unable to carry out ADLS (Activities of Daily Living) independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with: .b. mobility (transfer and ambulation, including walking). Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 - Few 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 obtain physician orders for over the counter medications and to have medications stored in resident rooms. This applies to 2 of 2 residents (R29 and R354) reviewed for medications in the sample of 23. The findings include: 1. On 9/17/24 at 11:08 AM, there were 3 tubes of Clobetasol Propionate Gel 0.05% on R29's bedside table. R29 said she has irritation due to diarrhea, and staff applies on her buttocks after every brief change. On 9/18/24 at 10:01 AM, the tubes of Clobetasol were still noted on R29's bedside table. On 9/18/24 at 10:12 AM, V12 (Registered Nurse/RN) said staff uses the Clobetasol on R29 after incontinent care, and she has an order for it to be kept at bedside. On 9/18/24 at 3:05 PM, V2 (Director of Nursing/DON) said R29's previous order did not state she could store the Clobetasol cream in her room. Review of R29's order shows, Clobetasol Propionate External Gel 0.05% apply to perineum and rectal area topically every morning at bedtime for irritation. Order for it to be left at bedside was received during the survey. 2. On 9/17/24 at 11:19 AM, there was a tube of generic Ultra Strength Topical Analgesic Cream on R354's bedside dresser. AT 9/17/24 at 11:27 AM, R354 said she uses the cream when her back hurts. On 9/18/24 at 9:53 AM, the tube of generic topical analgesic cream was still on R354's bedside dresser. On 9/18/24 at 10:10 AM, V12 (RN) said R354 does not have a physician order for the topical analgesic cream. On 9/19/24 at 10:52 AM, V2 (DON) said there has to be a physician order for medications to be stored in the resident's room; also, to ensure that the medication is safe to use. Review of R354's records, R354 does not have an order for the ultra-strength topical analgesic cream. The facility's Medication Storage policy (last reviewed 12/2020) states medications are to be stored in designated locations such as lockbox, locked cabinet, or secured areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 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 properly label/date/seal/store items, remove expired items, and wear hair restraints in the facility kitchen. Residents Affected - Many This applies to all resident that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 9/17/24, documents the total census was 52 residents. On 9/17/24 at 11:10 AM, V25 (Associate Director of Dining Services) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On 9/17/24 starting and 10:10 AM, the facility kitchen was toured in the presence of V20 (Associate Director of Dining Services). For the entirety of the kitchen tour, V20 did not wear a hair restraint in the facility kitchen. During the kitchen tour, the following was found: In food prep area: 1. A tall uncovered rack of prepared plated salads located within 1 foot of the handwashing sink and 2 inches from the hand towel dispenser for drying hands after washing. 2. V21 (Ice Cream Parlor Clerk) prepping food without a hair restraint on. In the walk-in cooler: 3. An expired, opened 5 pound bag of feta cheese, with use by date of 9/16/24. 4. 3-16 ounce undated bags of whipped topping. The bags say to use within 14 days of thawing, but there is no date anywhere on the bags. 5. 3-30 count packs of hot dogs, unlabeled and undated. 6. 3-16 ounce bags of expired guacamole with use by date of 9/3/24. 7. 2- 5 pound containers of sliced mushrooms with a packed on date of 9/3/24 and no expiration date. 8. 12-60 count bags of yellow corn tortillas, undated. 9. 1-24.5 ounce bag of 6 inch flour tortillas with expiration date of 6/25/24. In the dry storage: 10. 1-32 ounce opened package of hot cocoa mix not properly sealed with contents of package spilling out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 11. 2- 16 ounce packages of coconut flakes, opened and undated. Level of Harm - Minimal harm or potential for actual harm 12. 1 large (estimated greater than 5 pounds) chocolate bar opened, and undated. 13. 1 expired opened bag of peanuts without ounce description, with use by date of 9/8/24. Residents Affected - Many 14. A medium silver bin of unlabeled and undated croutons. On 9/17/24 at 10:59 AM, two additional kitchen staff, V22 (Dining Room Supervisor) and V23 (Server) were observed working in the kitchen without wearing hair restraints. On 9/18/24 at 11:13 AM during a return to kitchen tour, V25 (Associate Director of Dining Services) was observed in the kitchen with hair restraint on, but only covering the top half and back of her head. V25's bangs on the front of her head were not restrained. V25 then traveled with surveyor to the 2nd floor food pantry where lunch service was observed. V25 assisted in food plating and delivery to residents, and her hair restraint remained in the same position, not properly containing all of her hair. On 9/19/24 at 12:46 PM, V25 (Associate Director of Dining Services) said all food items in the kitchen should be labeled and dated for food safety. V25 said food trays/carts in the food prep area should not be stored next to the handwashing sink because of the risk of cross contamination from splashing. V25 said all staff in the kitchen need to wear hair restraints so hair does not fall into the resident food and cause foodborne illness. V25 said all expired food items should be removed from food storage, so no outdated food items are accidentally served to the residents causing illness. V25 said all opened food items need to be tightly resealed to prevent contamination from insects and to maintain the freshness and quality of the food item. V25 said she would be more careful about making sure all of her hair is contained under her hair restraint. V25 said the facility did not have policies regarding: keeping food away from handwashing sink, removing expired foods, or resealing opened food items. The facility's policy titled, Hair Restraints, last revised 4/2019, states, Policy Overview: All associates working in food preparation areas must wear hair restraints . Policy Detail: 1. All hair must be kept covered. The facility provided document titled, Refrigerator Storage Chart, last revised 12/28/2020, shows mushrooms are okay to store unopened for 5-7 days. The facility policy titled, Food Storage, last revised 6/24, states, Policy Overview: All foods must be stored in a manner that maximizes nutrient retention, quality, and food safety The facility's policy titled, Labeling, last revised 9/24, states, Policy Overview: All food items must be labeled and dated before storing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 Based on observation, interview, and record review, facility failed to follow infection control precautions. This applies to 6 residents (R2, R21, R33, R37, R46, and R301) reviewed for infection control in a sample of 23. Residents Affected - Some Findings include: 1. On 9/17/24 at 10:45 AM, observed V9 (CNA-Certified Nursing Assistant) and V10 (CNA) give perineal care to R33, and transfer him to the recliner. V9 (CNA) and V10 (CNA) cleaned R33's perineal area with wet wipes. Both V9 and V10 did not remove soiled gloves or use hand sanitizer after wiping the perineal area. Using the same gloves, they turned R33 to left lateral position. V9 (CNA) cleaned R33's bottom. With the same gloves, V9 (CNA) took the tube of barrier cream from the night stand and applied some on his sacral area. V9 (CNA) changed gloves after applying the barrier cream, but did not wash hands or use hand sanitizer. V9 (CNA) and V10 (CNA) turned R33, applied the sling for the mechanical lift, (V10 using the same soiled gloves and no hand hygiene) and transferred R33 to the recliner. V9 (CNA) tied the garbage, removed her gloves. No hand sanitizer used or hand washing done. V9 (CNA) touched her face and rubbed her hands onto her uniform. V10 touched the curtains and parts of the bed with the same soiled gloves. Then V10 removed gloves, no hand hygiene was done, and wheeled R33 out of the room to the dining room for lunch. 2. On 09/17/24 at 12:34 PM, observed V18 (R301's Daughter) sitting in R301's room without any PPE (Personal Protective Equipment). Per V18, nobody told her =she had to wear the PPE. On 9/17/24 at 1:00 PM, V11 (CNA-Certified Nursing Assistant), came into R301's room with lunch tray, and no gloves on. Without gloves, V11 (CNA) set up her tray, moved R301's wheelchair to position her to eat lunch, touched the bedside table, and moved items to accommodate the tray on the table, touched R301's bed, and before she left room, she used hand sanitizer. On 9/17/24 at 1:10 PM, V11 (CNA-Certified Nursing Assistant), came into R302's room with lunch tray and no gloves on. Without gloves, V11 (CNA) set up her tray, touched the bed and bedside table, moved items on the bedside table to make space to keep the tray. On 09/18/24 at 1:30 PM, V19 (LPN-Licensed Practical Nurse) stated, Everyone entering the room of a resident with Covid + and on isolation must wear PPE. On 9/18/24 at 12:03 PM, V28 (RN-Registered Nurse) stated, Every person entering the room of a resident with Covid + and on isolation must wear PPE. V28 (RN) stated, During ADL care, when gloves are removed after use and before wearing new gloves on, hands must be washed or use hand sanitizer. On 9/19/24 at 11:10 AM, V2 (DON-Director of Nursing) stated, The CNAs should have either washed their hands or used hand sanitizer as they went from the soiled to clean area of the perineal care procedure. Every time they are done with cleaning a soiled part of the body, they should do hand hygiene and change gloves. Nursing staff have been educated on the isolation precautions for residents with Covid-19. Anyone entering the Covid-19 isolation room must wear PPE and do hand hygiene after care. The facility's polity titled Handwashing/Hand Hygiene IC-13, dated 10/2021, showed, Policy Detail: 7. CDC recommends using Alcohol Based Hand Sanitizer b) Before and after contact with residents h) Before moving from a contaminated body site to a clean body site during resident care 9. The use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 3. R21's EMR (Electronic Medical Record) shows diagnoses urinary tract infection, retention of urine and obstructive and reflux uropathy. Residents Affected - Some R21's Care plan (initiated 8/19/24) states resident has chronic use of indwelling catheter, is at risk of recurrent Extended-Spectrum Beta-Lactamases Urinary Tract Infection (ESBL UTI). On 9/17/24 at 10:08 AM, R21 was observed sitting up in bed eating his breakfast. R21's indwelling catheter drainage bag was on laying on the floor. The catheter drainage bag was in privacy bag. On 9/18/24 at 8:36 AM, during medication administration, R21 was in bed resting, R21's indwelling catheter was on laying on the floor. On 9/18/24 at 8:34 AM, V13 (Registered Nurse/RN) said R21's indwelling catheter drainage bag should not be on the floor for contamination reasons, and so the urine can flow better. On 8/18/24 at 10:50 AM, V2 (Director of Nursing/DON) said, Indwelling catheter bags should be always in privacy bags and the drainage bag should not be on the floor, and if the bed is too low, the drainage bag should be in a basin to avoid potential contamination and infection control reasons. The facility's Urinary Catheter Care policy (revised 08/2023) states drainage bags to be kept off of direct contact with the floor. 4. R46's Face sheet shows an admission diagnosis of enterocolitis due to clostridium difficile (CDIFF), dated 9/12/24. R46's EMAR (Electronic Medical Administration Record) shows an order for Stool C-DIFF contact isolation precautions, dated 9/12/24 at 1400, and order dated 9/12/24 at 1600, for vancomycin HCl oral suspension 2.5 mL (milliliter) by mouth four times a day for CDIFF until 9/19/24 at 2359. R46's Care Plan, revised on 9/12/24, shows the resident has C.Difficile and is on oral antibiotics. Interventions include educate resident/family/staff regarding preventative measures to contain the infection and place in a private room with stool contact isolation precautions. On 9/17/24 at 11:35 AM, R46's door was observed with a contact isolation sign on it and a stocked cart with PPE (Personal Protective Equipment) outside the room. On 9/19/24 at 11:09 AM, R46 was observed lying in her bed with the door open, and the contact isolation sign was no longer on her door. V25 (CNA/Certified Nurse Assistant) walked into the resident's room to assist her to the bathroom without putting on a gown. V25 closed the door behind her. R46's nurse, V15 (RN/Registered Nurse), stated R46 was still receiving antibiotics to treat the CDIFF, and she was still on contact isolation precautions. V15 then opened R46's door and notified V25 that R46 was still on contact isolation, and V25 then came out of R46's room and put on a gown and reentered R46's room to continue assisting her with toileting. V12 (RN) then said V2 (DON/Director of Nursing) told her she took the contact isolation sign off the door, but R46 was still contact isolation, so V12 was going to put the sign back on R46's door. On 9/19/24 at 11:15 AM, V25 walked out of R46's room after finishing assisting her with toileting, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 and said she did not know R46 was isolation for CDIFF. V25 (CNA) said she took R46 to the bathroom this morning, changed her, and washed her, and she did not wear PPE, because she did not know the resident was isolation for CDIFF. V25 said she did not know until just now when V15 (RN) told her to put a gown on while providing care to R46. On 9/19/24 at 1:05 PM, V2 (DON) said R46 is still on isolation for CDIFF until her antibiotics (oral vancomycin) are completed and she is no longer symptomatic having loose stools. V2 said gown and gloves are required to be worn by all staff in a contact isolation CDIFF room at a minimum, because CDIFF is one of the most resistant bacteria and it is more easily spread by contact with the CDIFF spores. V2 said the isolation sign showing the type of isolation (contact, droplet, etc.) should be posted on isolation room doors at all times, so staff and visitors know what PPE to wear inside the resident's room. The facility's policy titled, Clostridium Difficile, last revised 10/2018, states, Policy Statement: Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. Policy Interpretation and Implementation . 3. The primary reservoirs for C. difficile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods .9. Residents with diarrhea associated with C. difficile are placed in contact isolation. 5. R2's Face sheet shows the following diagnoses: pressure ulcer, urinary tract infection, dementia, and retention of urine. R2's POS (Physician Order Sheet) shows order, dated 9/12/24, for enhanced barrier precautions related to wounds and urinary catheter. R2's Care Plan, initiated on 7/18/24, shows the resident has urinary catheter related to neurogenic bladder and pressure ulcer. Interventions include using enhanced barrier precautions to prevent infection. Care Plan, initiated on 9/16/24, shows R2 recently had a urinary tract infection. On 9/19/24 at 10:43 AM, V12 (RN/Registered Nurse) was observed providing wound care without following enhanced barrier precautions. Enhanced barrier precautions sign was on R2's door and PPE (Personal Protective Equipment) was located hanging off the door. V12 was wearing gloves, but not wearing a gown. V25 (CNA) was assisting V12 with wound care and was not wearing a gown. V12 then saw surveyor put a gown on before entering R2's room and she said, Oh yeah, I have to put a gown on. R2's urinary catheter drainage bag was observed hanging over the right side of her bed, sitting on the floor. V12 finished wound care and left R2's room while V25 (CNA) continued to assist R2 with dressing, without following enhanced barrier precautions and putting a gown on. While V25 assisted R2 with dressing, R2's urinary catheter drainage bag remained on the floor. V25 walked to the right side of R2's bed where the drainage bag was on the floor and she used her foot/shoe to move the drainage bag over. On 9/19/24 at 1:05 PM, V2 (DON) said, Staff gowns and gloves are required while providing care for residents on enhanced barrier precautions, including wound care and any contact with urinary catheter, including helping a resident get dressed. Enhanced barrier precautions are put in place to prevent the spread of potential infection to staff and residents. A urinary catheter drainage bag should never be sitting on the floor because of the risk of cross contamination and urinary tract infection. The facility's policy titled, Enhanced Barrier Precautions Policy, last revised 10/2023, states, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 Policy Overview: Enhanced barrier precautions (EBPs) should be utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Detail: .2. EBPs employ targeted gown and glove use during high contact resident care activities .3. Examples of high- contact resident care activities requiring the use of gown and gloves for EBPs include: Dressing .Wound Care .10. Signs are posted on the door or wall outside the resident room indicating EBP precautions and PPE are required. Residents Affected - Some The facility's policy titled, Procedure: Urinary Catheter Care last revised 1/2016 states, The purpose of this procedure is to prevent infection of the resident's urinary tract .Procedure: A. General .7.Verify the catheter tubing and drainage bag are kept off direct contact with the floor . 6. R37's MDS (Minimum Data Set), dated 8/29/2024, showed R37 was dependent on staff for his toileting needs. On 9/17/2024 at 10:31 AM, R37 was in bed. V9 (Certified Nurse Assistant/CNA) and V10 (CNA) said they were going to change R37's incontinence brief. V9 did not wash her hands, and applied a pair of gloves she obtained from her uniform pocket. R37's incontinence brief was soiled with urine and had dry stool. V9 proceeded to provide R37 with incontinence care, and then applied a clean incontinence brief. V9 did not wash her hands or remove her gloves during the process. Then V9 said she was going to inform V15 (Registered Nurse/RN) that R37's sacral dressing needed to be changed. V9 removed her soiled gloves and left the room without washing her hands. Then V9 returned to the room, and again failed to perform hand hygiene. V9 applied a set of gloves she obtained from her uniform pocket again. On 9/19/2024 at 11:00 AM, V2 (Director of Nursing/DON) said she expects staff to properly perform hand hygiene before starting incontinence care. V2 said staff should remove their gloves and repeat hand hygiene when going from dirty to clean or changing to another task. V2 also said staff should never place or obtain gloves from their uniform pockets because it is considered unclean. V2 said proper hand hygiene and gloving practices are required to maintain appropriate infection control practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement an antimicrobial stewardship program, providing antibiotic use protocols, and monitoring to prevent antibiotic resistance. This applies to 8 of 8 residents (R1, R7, R32, R42, R46, R303, R353, R354) reviewed for antibiotics in a sample of 23. Residents Affected - Some The findings include: On 9/18/2024 at 10:08 AM, surveyor reviewed facility's Infection Control Program with V3 (ADON-Assistant Director of Nursing/IC- Infection Preventionist). V3 said Antibiotic Stewardship is not being done in the facility. She said infections were logged, but antibiotic use was not monitored. She said she knows the facility need to start doing Antibiotic Stewardship. 1. R1's POS (Physician Order Sheet), dated 9/13/2024, shows an order for Ciprofloxacin HCL (Hydrochloride) tablet 500 mg (milligram), give 1 tablet by mouth every 12 hours for UTI (Urinary Tract Infection) for 7 days. Stop date is 9/20/2024. 2. R7's POS, dated 3/21/2024, shows an order for Methenamine Hippurate oral tablet, 1 gm (gram). Give one tablet by mouth two times a day related to personal history of UTI. The order has no stop date. 3. R32's POS, dated 8/26/2024, shows an order for Metronidazole oral tablet 500 mg. Give one tablet by mouth every morning and at bedtime related to diverticulitis of intestine. Stop date is 10/05/2024. 4. R42's POS, dated 9/12/2024, shows an order for Acyclovir External Ointment 5% (Acyclovir Topical). Apply to left upper thigh vesicle topically every six hours for shingles left upper thigh. Apply until vesicles scab or crust over. R42 also has an order for Valacyclovir HCL oral tablet, 1 gm. Give one tablet by mouth three times a day for shingles for seven days. Stop date for Valacyclovir HCL is 9/20/2024. 5. R46's POS, dated 9/12/2024, shows an order for Vancomycin HCL Oral Suspension 50 mg/ml, give 2.5 ml (milliliter) by mouth four times a day related to Enterocolitis due to Clostridium Difficile. Stop date is 9/19/2024. 6. R303's POS, dated 9/17/2024, shows an order for Cephalexin Oral Capsule 500 mg. Give one capsule by mouth two times a day for UTI (urinary tract infection) until 09/20/2024. 7. R353's POS, dated 9/17/2024, shows an order for Cefadroxil Oral Capsule 500 mg. Give one capsule by mouth every 48 hours related to UTI until 09/26/2024. 8. R354's POS, dated 9/10/2024, shows an order for Entecavir Oral Tablet 0.5 mg. Give one tablet by mouth one time a day for prophylaxis related to viral hepatitis B with no stop date. There is also an order on 9/10/2024 for Moxifloxacin HCL Ophthalmic Solution 0.5 %. Instill 1 drop in both eyes three times a day for eyelid infection for 10 days, with stop date of 9/20/2024. There is also an order for Metronidazole External Cream 0.75 %. Apply to face topically two times a day for antifungal, with no stop date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 9/19/2024 at 10:54 AM, V2 (DON-Director of Nursing) said the importance of Antibiotic Stewardship is to minimize the use of antibiotics, make sure there is no unnecessary use of antibiotic, and to prevent system resistance from antibiotics. She said V3 (ADON-Assistant Director of Nursing) was trained to do Antibiotic Stewardship, and she is not aware V3 was not doing it. Facility's Community Antimicrobial Stewardship Mission Statement, dated 7/10/2024, stated the following: Our community embraces the importance of an infection prevention and control program. This includes an antimicrobial stewardship program, providing antibiotic use protocols and monitoring to prevent antibiotic resistance. We are committed to the prudent use of antimicrobials on behalf of all residents and are privileged to serve through a sustainable antimicrobial stewardship program. Event ID: Facility ID: 146061 If continuation sheet Page 15 of 15