Health inspection·July 25, 2025

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R16’s face sheet showed she was admitted to the facility with diagnoses including osteomyelitis of the right ankle and foot, erosive osteoarthritis, and sepsis. R16’s POS dated July 24, 2025 did not show any orders for R16 to self-administer medications. R16’s MDS dated [DATE] showed R16 had modified independence with cognitive skills for daily decision making. R16’s care plan showed [R16] has actual impairment to skin integrity and potential for further impairment to skin integrity…with interventions including [Registered Dietitian] evaluate and recommend nutritional supplement to promote wound healing. Proheal (nutritional supplement) and Nepro. The care plan dated June 11, 2025 also showed she displayed compromised mental status…R16’s care plan did not show R16 was able to self-administer medications. R16’s EMR was reviewed, and no assessments were found to self-administer medications. On July 24, 2025 at 1:01 PM, V42 (LPN/Licensed Practical Nurse) said for residents to self-administer medications, they need an order to self-medicate from the doctor. V42 said the doctor would be notified and an assessment needed to be completed. On July 25, 2025 at 1:16 PM, V13 (LPN) said she did not have any residents who were allowed to self-administer medications. V13 said when passing medications, they should stand and wait for the resident to take their medications before leaving the room. V13 said if a resident wanted to self-medicate, they would need to notify the doctor and do a self-administration consent. 3. On July 22, 2025, at 10:02 AM, R2 was lying in bed, sleeping. R2’s nightstand had 1 bottle of Nystatin (Antifungal) powder and 1 medicine cup with white cream swirled with clear ointment. At 11:30 AM, R2’s nightstand still had both the powder and cream mixture on it. R2’s face sheet showed she was admitted to the facility with diagnoses including diabetes mellitus, cirrhosis of liver, bipolar disorder, major depressive disorder, hypertension, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R2’s MDS dated [DATE], showed R2 has severe cognitive impairment. POS dated July 24, 2025, showed orders for Clotrimazole Cream 1% (Antifungal cram) Apply to affected area/s topically as need for skin condition, dated July 17, 2025, and Antifungal powder to breast/abdominal folds twice daily as needed for moisture/fungal rash, dated May 14, 2024. R2’s care plan dated May 24, 2024, showed R2 has impaired thought process secondary to bipolar disorder as well as signs and symptoms of depression and mood distress. R2’s did not have any care plans which demonstrated safe self-medication administration. R2’s EMR (Electronic Medical Record) was reviewed, which did not show R96 was assessed to safely self-administer medications. 4. On July 22, 2025, at 10:37 AM, R25 was lying in bed, watching television. R25’s bedside table had 2 bottles of Nystatin powder, 2 tubes of Recti Care (hemorrhoidal ointment), and 1 tube of Lidocaine ointment 5%. Per R25, she applies the Lidocaine ointment over her left arm AV (arteriovenous) fistula before dialysis and whenever she feels pain on that site. Per R25, she applies it whenever she needs pain relief and is not sure if there is a maximum daily dose. R25’s face sheet showed she was admitted to the facility with diagnoses including chronic kidney disease, dependence on renal dialysis, diabetes mellitus, pleural effusion, gout, lymphedema, osteoarthritis, and insomnia. R25’s MDS dated [DATE], showed R25 is cognitively intact. R25’s POS also showed orders for Antifungal powder to breast/abdominal folds twice daily as needed for moisture/fungal rash (dated July 17, 2025); Lidocaine External Cream 4% Apply to AV fistula topically one time a day for pain (dated July 9, 2025); and Preparation H External Cream 1% (Hydrocortisone Rectal) Apply to rectum topically at bedtime (dated July 23, 2025) and every 6 hours as needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 2 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (dated August 6, 2024) for hemorrhoids. R27’s POS did not show any orders for R25 to self-administer medications or to keep the medications at bedside. R25’s current care plan with completion date of June 6, 2025, does not show that R25 was assessed as safe to self-administer medication. R25s EMR was reviewed, and no assessments were found to self-administer medications. On July 23, 2025, at 2:00 PM V24 (LPN/Wound Care Coordinator) said that the only type of topical medication or cream that may be kept at the bedside is a moisture barrier. All other topical agents should be stored a locked treatment cart. The facility’s Self Administration of Medication Program dated April 2025 showed the facility will allow the resident to self-administer drugs if the interdisciplinary team (IDT) has determined that this practice is safe. Nurse will complete a Self-administration of Medication Assessment. Once the resident has been deemed safe by the IDT an order will be obtained from the resident’s physician or physician extender listing the medication(s) that may be self-administered, where the medication will be stored, who will be responsible for documentation, and the location of administration. Appropriate documentation of the above determinations will be documented in the resident’s care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 3 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review the facility failed to provide maintenance services for a safe, comfortable and homelike environment. This applies to 1 of 1 (R48) resident reviewed for safe home like environment, in a sample of 30Findings include:On 07/22/2025 at 10:37 AM the molding of R48's cardiac table, stationed next to R48's bed, was broken and hanging downwards. R48 stated it had been broken for more than two weeks, that he had asked them to repair it and it was not done yet. On 7/23/25 at 2:15 PM the molding of R48's over bed table was still broken and hanging to the floor. R48 stated he had told multiple nursing staff about it.On 7/24/25 at 1:10 PM the molding around R48's cardiac table next to R48's bed was still broken and hanging downwards. On 7/24/25 at 1:10 PM, V5 (RN-Registered Nurse) stated, resident could scrape his skin due to the broken over-bed table.On 7/24/25 at 1:30 PM V29 (Maintenance Director) stated, he did not know about the broken table and that nobody had informed him about it. V29 stated, it could be a cause for potential injury to R48. V29 stated, he doesn't have a log of the work orders. Usually, the staff either call him or text him when an item need to be repaired and he fixes it. Facility policy on maintenance services dated 5/25/25 showed maintenance department is responsible for maintaining the equipment in a safe and operable manner. Event ID: Facility ID: 146093 If continuation sheet Page 4 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Based on interview and record review, the facility failed to facilitate non-discriminatory discharge planning that meets the resident's preferences by allowing the resident to remain in the facility and paying privately for a bed.This applies to 1 resident (R5) reviewed for discharge planning in a sample of 30 residents.Findings include:On 7/22/25 at 11:53 AM, R5 and V31 (R5's Son-in Law) said they are concerned because they want R5 to be able to remain in the facility, but they were told R5 is going to be transferred to another facility on 7/29/25 when her Medicare days run out. V31 said they had a meeting with the facility staff and told the staff they want to remain in the facility after the 29th as private pay, but the staff said they will not have a room for R5 after 7/29/25.V1's (Administrator) progress note dated 7/10/25 at 9:12AM states V2 (DON/Director of Nursing) and V1 met with R5's POA (Power of Attorney) and son to discuss discharge planning. Progress note states R5's 100th day is on 7/29/25 and V1 explained to POA that at this time the facility does not have long term care bed availability. V28's (Social Service Director's) Progress Note dated 7/7/25 at 1:49 PM states a Care Plan meeting was held with R5, R5's son, and R5's daughter and Social Services went over a discharge plan. V28's progress note states R5's discharge date is 7/29/25, her 100th Medicare day and this note also states R5 would like to pay for a little bit.On 7/24/25 at 12:34 PM V28 (Social Service Director) said R5's discharge plan is to be discharged on 7/30/25 to an undetermined facility. V28 said she knows R5 wants to stay in the facility as private pay, but it has been explained to R5 and her family that the facility does not have a long term bed right now. V28 said she knows they do not have a long term bed because V1 (Administrator) told V28 there is no long term bed available for a private pay resident. V28 said she does not know how bed availability is determined, but V1 has the final say. V28 said R5 was accepted at another facility, but R5's daughter said she is uncertain if she wants her mom to go to that facility because R5 might need dialysis and she doesn't know if R5's primary physician goes to that facility like he does this facility.On 7/24/25 at 1:54 PM, V1 (Administrator) said the facility has 140 certified beds for Medicaid/Private Pay residents. V1 said based on that 140 certified bed allowance and the facility census of 130 residents, they do have a bed available for R5. V1 said R5 and her family were told there was no bed available because V1 was told by the facility's CFO (Chief Financial Officer) to only accept 82 long term care residents. V1 said the only long term care residents that she has accepted since she started at the facility in May 2025 have been Hospice or Respite. V1 was asked if the facility is licensed and certified for 140 Medicaid/Private Pay beds, why would the CFO tell her to only accept 82 residents and V1 replied, It is for profit. V1 said the facility does have the bed available for R5 to stay in the facility after 7/29/25 based on their certification status, but they told R5 and her family they did not have a bed for her. V1 said when the facility is accepting residents into their beds, V1 and V30 (Admissions Director) reference an email dated 3/13/2020 sent by the Bureau of Long Term Care Chief. This email states, Dear Administrator, The Department of Public Health notified my office of an increase in the Medicaid distinct part unit effective October 1, 2019. Of the 197 licensed beds, 140 of these beds are certified in the Medicaid program. On 7/24/25 at 2:57 PM, V30 (Admissions Director) said she does not know how many beds the facility has for Private Pay or Medicaid residents. V30 said all Long-Term Care admissions need to be approved by V1. V30 then provided surveyor a document showing all beds that were available on 7/22/25 and are still available to accept a Medicaid or Private Pay resident. V30 said there are 29 available Medicaid/Private Pay beds.R5's Care Plan initiated on 6/19/25 states the resident has a psychosocial well-being problem related to recent admission. Interventions include increase communication between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 5 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 0627 Level of Harm - Minimal harm or potential for actual harm resident/family/caregivers about care and living environment: Explain all. changes, rules, options and provide opportunities for the resident and family to participate in care.The facility provided brochure titled, Residents' Rights for People in Long-term Care Facilities dated 4/24 states, You have the right to keep living in your facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 6 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to review and revise resident care plans to reflect significant incidents/changes in condition. This applies to 2 of 2 residents (R25 and R36) reviewed for care plans in a sample of 30. The findings include: 1. R25’s face sheet showed he was admitted to the facility with diagnoses including chronic kidney disease, diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, gout, dependence of renal dialysis, lymphedema, osteoarthritis, and hypertension. R25 had a fall incident on June 13, 2025 at 4:15 AM per V45’s (LPN/Licensed Practical Nurse) “Post Fall Observation” assessment form. V45’s progress noted dated June 13,2025, states she saw R25 “tipped back against the wall with her legs in the air and her head tilted to the right against the wall.” Per V45, “leaving her (R25) on the floor was not an option due to the Hoyer lift being stuck under the geri-chair.” V45’s “Post-Fall Observation” assessment form dated June 13, 2025, states that resident sustained a fall in her room and was sent to the ER for evaluation. R25’s fall care plan accessed on July 23,2025 still states resident is “at risk” for falls due to weakness and impaired mobility and does not reflect resident’s actual fall incident on June 13, 2025. On June 24, 2025, 5:20 PM, V2 (Director of Nursing) stated that R25’s incident is not considered a fall, so it was not investigated or reported as such. 2. R36’s face sheet showed she was admitted to the facility with diagnoses including dementia and a history of falling. R36’s MDS (Minimum Data Set) dated July 2, 2025 showed R36 had severe cognitive impairment and used a wheelchair for mobility. R36’s care plan dated January 17, 2025 showed the resident is an elopement risk [due to] [diagnosis] dementia, cognitive deficit and wandering behavior with interventions including Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? R36’s care plan dated July 24, 2025 (during the survey) showed R36 had the potential for injury [marked by] wandering and exit seeking behavior dementia [with] decreased focus and safety awareness with interventions including hourly visual checks and record, monitor for [signs and symptoms] elopement: increased agitation, hanging around exits, increased pacing and stated desire to leave, redirect [resident] as needed- utilize activities as therapeutic distraction, and respond promptly to all door alarms. The care plan dated December 30, 2021 also showed [R36] is at risk for falls due to decreased mobility, weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 7 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete R36’s care plan did not show any updates regarding R36’s fall on July 21, 2025 and interventions to prevent falls. Facility’s policy titled, “Fall Prevention and Management” dated June 2025, states the facility’s fall response includes updating residents’ care plans including the development of fall interventions plan based on results of the fall assessment as well as investigation of all circumstances and related resident outcomes. Multi-disciplinary discussion regarding such interventions is expected to adjust the care plan as needed. Event ID: Facility ID: 146093 If continuation sheet Page 8 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 Based on observation interview and record review the facility failed to provide incontinence care for a dependent resident.This applies to 1 of 9 residents (R11) reviewed for ADL (Activities of Daily Living) in a sample of 30 .Findings include:On 07/24/2025 at 12:29 PM, a head-to-toe skin check for R11 was conducted with V40 RN (Registered Nurse). V40 RN stated R11 sacral area was a little red due to frequent stooling related a chronic infection. V40 stated to minimize the irritation R11 is cleaned frequently, and barrier cream is applied. Before V40 started the skin assessment R11 requested butt cream be applied. When V40 RN pulled R11 blanket and top sheet back, her undergarment was saturated and soaked through to her bottom sheet. R11 had stool up through her vagina and her buttocks were reddened. No barrier cream was noted on R11.On 07/24/2025 at 12:44 PM, V41 CNA (Certified Nursing Assistant) assigned to R11 stated her work shift started at 06:00 AM. V41 stated the last time she provided incontinence care to R11 was between 08:00 and 08:30 AM. V41 stated she saw R11 at 10:00 AM to pick up her meal tray but did not provide incontinence care.On 07/24/2025 at 2:45 PM, V2 (Director of Nursing) stated R11 is incontinent and should be visually checked for incontinence every two hours and R11 is not a reliable historian. On 07/24/2025 at 3:24 PM, V32 (Wound Nurse) stated she had just left R11. R11 told her not to mess with her cream. V32 stated she had to show R11 she had a bowel movement because she did not know she had gone.R11 was admitted to the facility with diagnoses that includes cerebral infarction, aphasia, dysphagia, pressure ulcer, hypertension, and anxiety disorder. R11's MDS (Minimum Date Set) dated 6/9/25 shows she is cognitively impaired and completely dependent on staff for incontinent care and at risk for developing pressure ulcers / injuries. R11 physician orders includes house stock moisture barrier, and the CNA may apply it and leave it at bedside. R11's care plan includes an impairment to skin integrity and potential for further impairment to skin integrity. Interventions includes use of house stock barrier cream. R11 has bladder incontinence due to impaired mobility. Interventions include change disposable brief upon rising, after meals, before bed and as needed. Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episode.The facility policy Activities of Daily Living dated April 2025 states, 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. If a resident with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 9 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 ensure a resident's equipment and environment were free from accident hazards, and failed to ensure a resident with known wandering habits was supervised to prevent a fall. This failure resulted in the emergent transfer to the hospital for 2 residents due to fall incidents. This applies to 2 of 2 residents (R25 and R36) reviewed for accidents and supervision in a sample of 30. The findings include: 1. R25’s face sheet showed he was admitted to the facility with diagnoses including chronic kidney disease, diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, gout, dependence of renal dialysis, lymphedema, osteoarthritis, and hypertension. R25’s MDS (Minimum Data Set) dated May 5, 2025, shows R25 is cognitively intact, non-ambulatory, and requires total assist with transfers with 2 staff members via Hoyer lift. R25’s latest fall risk assessment (prior to fall on June 13,2025) dated January 25, 2024, states R25 has a history of multiple falls and is in the high-risk category for falls. On July 22, 2025, at 10:02 AM, R25 said on June 13, 2025, she was in her room at around 4:00 AM, about to be wheeled downstairs to dialysis. After being transferred to her dialysis chair/ “geri-chair” (geriatric chair), staff stepped away from her to get something when R25 felt the backrest of her chair falling backwards and then felt the chair “give out” from underneath her. R25 said she hit her right temporal area and right shoulder on the wall. Per R25, she was in pain from being “wedged between the dialysis chair and the wall.” R25 stated nursing staff used the Hoyer lift to get her up from the floor and she felt intense neck pain during the transfer since her head was not supported by the mechanical lift sling. R25 said 911 paramedics arrived after she staff assisted her up to transfer her to the ER (Emergency Room) for evaluation. V45 LPN (Licensed Practical Nurse) completed R25's Post Fall Observation assessment form at 4:15 AM on June 13, 2025. V45’s progress noted dated June 13,2025, states she saw R25 “tipped back against the wall with her legs in the air and her head tilted to the right against the wall.” Per V45, “leaving her (R25) on the floor was not an option due to the [full-body mechanical life] lift being stuck under the geri-chair.” R25’s June 13, 2025 “Post-Fall Observation” assessment form showed that resident sustained a fall in her room and was sent to the ER for evaluation. R25’s “After Visit Summary” from states that resident had a fall resulting in closed head injury, strain of neck muscle, and contusion of right shoulder. On June 24, 2025, 5:20 PM, V2 (Director of Nursing) stated that she did not investigate or report R25's fall. A Grievance/Concern Form written by V2, dated 6/13/25, showed that R25's “dialysis chair malfunctioned while R25 was being transferred from bed to dialysis chair. Facility’s policy titled, “Fall Prevention and Management” dated June 2025, states it is the duty of the facility to ensure and maintain a safe environment for residents to reduce the risk of falls, including those resulting in harm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 10 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 2. On July 23, 2025 at 2:27 PM, V43 (Firefighter) said the fire department was dispatched for a call regarding a person who had fallen. V43 said when they arrived at the facility, there was a staff member waiting at the elevator to lead the team to the emergency egress stairwell on the second floor. V43 said the emergency egress stairwell was behind an alarmed emergency door that would need to be pushed and held for 10 to 15 seconds to open the door. V43 said the resident was lying on the floor on the top of the stairs and her wheelchair was at the base of a flight of stairs below. V43 said when they had arrived, the emergency door was propped open, and the alarm was sounding. V43 said the facility staff had reported to him they had last seen her 15 to 20 minutes prior. On July 23, 2025 at 12:52 PM, V5 (RN/Registered Nurse) said she was R36’s nurse when R36 had a fall on July 21, 2025. V5 was working on the second floor, which was the floor R36 resided on for long term care. V5 said she was working the 2 to 10 PM shift and was in another patient’s room when she heard the door alarm sounding off. V5 said she told V4 (CNA/Certified Nurse Assistant) to make sure the resident she was working with was ok and went to the alarming door and saw R36 outside the emergency exit door on the floor. V5 said it was around 7:10 PM. V5 said R36’s body was facing the wall, and her feet were facing the door. V5 said she could not remember where the wheelchair was. V5 said R36 complained of pain to her hips and her head was on the floor. V5 said R36 was not oriented and was confused. V5 said R36 was able to get around in the wheelchair. V5 said she had last seen R36 was in the TV room speaking to V4. V5 said residents that wander were placed at the nurse’s station and in the TV room and a CNA was always watching them as they could not be left unattended. V5 said the wandering residents need to be redirected. On July 23, 2025 at 1:26 PM, V4 (CNA) said he worked on July 21, 2025 until 10 PM. V4 said he had just finished his shift supervising the TV room when he saw the flashing light above the nurse’s station. V4 said he was not sure if the light was from the door or a resident pulling the call light out of the wall. V4 said V5 came to him at the nurse’s station and told him to check on the resident she had been working with and V5 went to address the flashing light. V4 said after he checked on the resident, he went to the stairwell where V4 was attending to R36, who had fallen. V4 said he had last seen R36 before 7 PM when she had come to the TV room asking for the exit. V4 said R36 told him she was looking for the police and asking about her dad. V4 said R36 wandered a lot and went into other residents’ rooms. V4 said R36 was by the nurse’s station, asking the other nurses if she could get out. V4 said they keep the residents in the TV room to keep an eye on them. V4 said if residents were out of their room, they should be in the TV room. V4 said if a wandering resident leaves the TV room, they should be redirected and put back in the TV room. R36’s face sheet showed she was admitted to the facility with diagnoses including dementia and a history of falling. R36’s MDS (Minimum Data Set) dated July 2, 2025 showed R36 had severe cognitive impairment and used a wheelchair for mobility. R36’s care plan dated January 17, 2025 showed the resident is an elopement risk [due to] [diagnosis] dementia, cognitive deficit and wandering behavior with interventions including Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? The care plan dated December 30, 2021 also showed [R36] is at risk for falls due to decreased mobility, weakness. R36’s Progress Note showed the following: A late entry progress note written by V5 (RN) dated July 21, 2025 showed “Staff responded to the door alarm; resident was observed by staff on her left side on the floor next to the exit door. Resident is alert, on her baseline stating, 'get me up.' Able to move extremities but complain of a little pain to her left hip, otherwise no pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 11 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 to the rest of her body. No visible injury noted. Resident was observed by staff wheelchair her wheelchair by the nurses’ station about 10 mins ago. Head to toe assessment without visible injury. ROM (Range of Motion) within baseline, no internal external rotation, no shortening. 911 was called to transfer resident to the ER (Emergency Room). MD (Medical Doctor) and family made aware of incident and transfer.” Residents Affected - Few R36’s Elopement Risk assessment dated [DATE] showed R36 was At Risk for Elopement. The facility’s Wandering and Elopements Policy dated April 2025 showed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If an employee observes a resident leaving the premises, he/she should 1. Attempt to prevent the resident from leaving in a courteous manner; 2. Get help from other staff members in the immediate vicinity, if necessary; and 3. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 12 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to safely maintain and reconcile controlled medication counting logs for residents receiving narcotics.This applies to 2 out of 3 residents (R11 and R34) reviewed for narcotics in a sample of 30.Findings include:1. On 7/23/2025 at 10:40 AM, R11's Tramadol 50 mg (milligrams) medication punch card was observed with no tablets available. R11's Controlled Substances Proof of Use sheet for Tramadol showed R11 had 1 tablet remaining for use. R11's Pregabalin 75 mg medication punch cards were observed with 30 capsules available. R11's Controlled Substance Proof of Use sheet for Pregabalin showed R11 had 31 capsules remaining for use. The Pregabalin punch cards showed #5, #8, #14, and #16 medication punch slots were torn with loose capsules inside, not secured. V3 (Assistant Director of Nursing/ADON) was present during the observations and said she was not sure why the medication logs were inaccurate. V3 said controlled medications had to be logged when removed and if not properly secured they had to be reconciled and discarded appropriately. R11's Order Summary Report dated 7/23/2025 showed active orders for Tramadol HCI Oral Tablet 50 MG and Pregabalin Oral Capsule 75 MG.2. On 7/23/2025 at 10:50 AM, R34's Tramadol 50 mg medication punch card was observed with 1 tablet available. R34's Controlled Substance Proof of Use sheet for Tramadol showed R34 had 2 tablets remaining for use. V3 remained present for R34's observation. On 7/23/2025 at 10:45 AM, V12 (Registered Nurse/RN) said she had administered R11 and R34's scheduled controlled medications as ordered at 8 AM on 7/23/2025. V12 said she did not log R11 and R34's removed narcotics. R34's Order Summary Report dated 7/23/2025 showed an active order for Tramadol HCI Oral Tablet 50 MG.On 7/24/2025 at 1:30 PM, V2 (Director of Nursing/DON) said nurses were expected to ensure proper storage, disposition, and logging of controlled medications to prevent discrepancies and maintain accurate counts.The facility's policy titled Controlled Substances dated 04/2025 said 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.14. Policies and procedures for monitoring controlled medications to prevent loss, diversion, or accidental exposure. Event ID: Facility ID: 146093 If continuation sheet Page 13 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 safely store medications.This applies to 10 out of 10 residents (R136, R153, R154, R155, R156, R126, R127, R138, R66, and R52) reviewed for medication storage in a sample of 30.Findings include:1. On 7/23/2025 at 10:20 AM, the facility's first floor medication room fridge and a medication cart that housed R136's and R152's medications was checked for medication storage with V3 (Assistant Director of Nursing/ADON). R136 and R153's opened Ozempic pens were stored in the fridge. The pens were not labeled with opened-on dates, and the weekly pre-scheduled dates for dosage administrations had been left blank. R154's opened Lispro pen was also stored in the fridge without an opened-on date. R136 and R154's opened Albuterol inhalers were stored in the medication cart and did not include their opened-on dates. R136's Order Summary Report dated 7/23/2025 showed orders for Ozempic subcutaneous solution pen-Injector and Albuterol inhaler.2. R153's Order Summary Report dated 7/23/2025 showed an order for Ozempic subcutaneous solution pen-Injector.3. R154's Order Summary Report dated 7/23/2025 showed orders for Lispro Insulin solution pen-injector and Albuterol inhaler.4. On 7/23/2025 at 10:50 AM, the facility's second floor medication room was checked for medication storage with V13 (Licensed Practical Nurse/LPN). R155 and R156's Naloxone Nasal Liquid sprays were stored directly underneath the sink. V13 said R155 and R156 were discharged and was unsure why the medications were not disposed of appropriately. R155's admission Record sheet dated 7/24/2025 showed a discharge date of 5/29/2025.5. R156's admission Record sheet dated 7/24/2025 showed a discharge date of 5/22/2025.6. On 7/23/2025 at 11:00 AM, the medication cart that housed R52's and R126's medications was checked with V14 (RN). R52's Fluticasone nasal spray and R126's Albuterol inhaler medications were opened and undated. V14 said multi-use medications including nasal sprays, inhalers, and eyedrops should be labeled when open for medication administration safety. R52's Order Summary Report dated 7/23/2025 showed an order for Fluticasone nasal spray.7. R126's Order Summary Report dated 7/23/2025 showed an order for Albuterol inhaler.8. On 7/23/2025 at 11:10 AM, the medication cart that housed R66's medications was checked with V15 (LPN). R66's opened Fluticasone nasal spray was undated. R66's Order Summary Report dated 7/23/2025 showed an order for Fluticasone nasal spray. 9. On 7/23/2025 at 11:20 AM, the medication cart that housed R138's and R127's medications was checked with V16 (LPN). R138's Systane eyedrop bottle and Fluticasone nasal spray were opened and undated. R127's opened Latanoprost eyedrop bottle was also undated. R138's Order Summary Report dated 7/23/2025 showed orders for Systane eyedrops and Fluticasone nasal spray.10. R127's Order Summary Report dated 7/23/2025 showed an order for Latanoprost eye drops.On 7/24/2025 at 1:30 PM, V2 (Director of Nursing/DON) said multi-use medications had to be labeled when opened and stored appropriately to ensure safe medication administration. The facility's policy titled Storage of Medications dated 04/2025 said The facility stores all drugs and biologicals in safe, secure, and orderly manner. Event ID: Facility ID: 146093 If continuation sheet Page 14 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevent foodborne illness.This applies to 128 residents receiving dietary services.Findings include:On 07/22/2025 at 3:01 PM, V1 Administrator confirmed 128 residents were receiving food services from the dietary department.On 07/22/2025 at 09:02 AM, the kitchen tour began with V32 (Dietary Manager).V32 stated the dishwasher disinfects by temperature. The goal is 180 degrees F (Fahrenheit). The staff are to look at the gauge and the test strip to assure the temperature reach 180 degrees F.V35 (Dishwasher) ran a load of dishes to test the dishwasher temperature. V35 stated the wash temperature should reach 180 degrees to disinfect the dishes. V35 placed a temperature sensitive test strip that read 160-degree F / 71 degree C (Celsius) on a plate. The wash cycle gauge maximum temperature reached 148 degrees F. The rinse tank gauge maximum temperature was 156 degrees F. The temperature sensitive test strip did not change black which would indicate the 160-degree temperature had been reached. Two stacks of dishes that had yellow and brown specks and particles on them. V35 Dishwasher stated the dishes were just taken of the dishwasher and were ready for use. The dry storage contained a 102 oz (Ounce) can of diced tomatoes that was dented. A 106 oz can of apple sauce was dented.The walk-in cooler contained a one-gallon container of mustard with on opened on or use by date and a manufacture date of 10/7/24. A large bin labeled employee food was present. The bin contained a watermelon cut in half without a label, two bags of corn tortillas with no visible date, and a personal food container with unidentifiable food had no label or dates.V33 (Kitchen Supervisor) provided test strips to test the red sanitization bucket and the three compartment sink. The test strip was pulled from a zipper bag that was affixed to the wall with other various strips that were not in their original packaging. One test strip that did have packaging taped to the wall was dated 12/1/2022. V33 stated the label taped to the wall was for the test strips that were used for testing the sanitizer level. V33 was requested to provide the original product packaging. V33 brought out a small plastic container that would have held the strips and it had no informational packaging insert. V33 stated the label affixed to the wall went with the test strips they were using to test the red sanitization buckets and the three compartment sink. V34 (Dietary Aid) stated he used the test strips from the zippered bag affixed to the wall to test the three-compartment sanitization sink.A deep freezer identified by V32 as activities freezer contained two unlabeled bags of shredded yellow cheese, a box containing of 3 pastries with no dates, and a small package of [NAME] cheese with a manufacturer's date of 4/24/24 that was open to air. A 32 oz (ounce) package of pepper jack cheese without an opened on or use by date was also present. A small package of pepper jack cheese was open to air and had no opened on or use by date. A whole pie with the plastic wrap falling off without a label to identify contents or dates was also present.A silver kitchen cabinet contained a pink purse, a green purse, a bottle of water, an umbrella, a book, two black jackets, and a 24-count box of turmeric tea bags that expired on 03/2024.On 07/24/2025 at 1:27 PM, V32 (Dietary Manager) stated no separate logs were maintained for the red sanitizing buckets because the buckets are filled from the same dispenser that fills the three-compartment sink. V32 stated dented cans should be separated from stock so they are not used. The food could become contaminated and cause the residents to become sick. All foods should have an opened on and use by date so they can assure it is safe for residents to eat. If outdated food is served to residents, they could become sick. Employee's personal items should not be stored in the kitchen prep area because there could be a cross contamination of the food. Employee food items should not be stored in the kitchen because of the risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 15 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 cross contamination. The test strips for sanitization should be stored in the original container to verify the strips and the expiration date. The dishwasher disinfects by temperature and the wash temperature should reach 160 degrees and the final rinse should reach 180 degrees F to properly disinfect the dishes. Our policy says it is ok for us to use the 160 degrees F test strip. V32 stated she did not know why the test strip did not turn black to indicate the desired temperature was reached. Staff should look at the gauge and test strip to assure the desired disinfecting temperature was reached. V32 stated she was not familiar with the test strips that were used and should have known those test strips were being used.The facility policy Machine Washing and Sanitizing dated 2021 states dishwashing machines using hot water for sanitizing may be used if the temperature of the wash waster is no less than that specified by the manufacturer, which may vary from 150 degrees F to 165 degrees F, depending on the type of machine, and the final rinse temperature is no less than 180 degrees F. The final rinse temperature is tested with a paper thermometer. The paper thermometer turns color when it registers 160-degree F which sanitizes the plates, tableware, utensils etc. (160 degrees F on the dish or utensil surface reflects 180 degrees F at the manifold where the temperature of the dishwashing machine final rinse is measure.)The facility policy Sanitation Buckets / wiping Cloths Food Contact Surfaces and Equipment Too Large To Immerse In The Sink dated 2021 states using the appropriate test strips, the strength of the sanitizing solution will be tested each time the sanitization buckets are changed.The facility policy Labeling and Dating Foods dated 2021 states to decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened and the date by which the item should be discarded.The facility policy Storage of Frozen Foods dated 2021 states if food is taken out of its original container the food is tightly wrapped and labeled with the item name and the use by date. Frozen foods can deteriorate in quality the longer they are stored. Therefore, frozen foods are best if used within three months. Frozen food is discarded after three months. Opened products that have not been properly sealed and dated are discarded.The facility policy Personal Hygiene dated 2021 states keep spare clothes and other personal item away from food preparation and food storage areas.The facility policy Storage of Dry Goods / Foods dated 2021 states dented cans are stored in a designated area and returned to vendors. Event ID: Facility ID: 146093 If continuation sheet Page 16 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 implement transmission-based precautions for a resident with an acute GI (gastrointestinal infection). The facility also failed to follow contact and enhanced-barrier precautions and hand-hygiene when providing resident care.This applies to 5 out of 5 residents (R152, R117, R41, R104, and R8) reviewed for infection control in a sample of 30. Residents Affected - Some The findings include: 1. On [DATE] at 1:30 PM, V36 (Physician) was assessing R152 in her room. R152’s room did not have any posted transmission-based precautions sign. V36 was not wearing any PPE (Personal Protective Equipment). At 1:35 PM, R152 said she had ongoing diarrhea that started on [DATE]. R152 said her stool was collected to check for C. diff (Clostridium difficile is an acute contagious GI infection) and the results were pending. R152 said she was not placed on transmission-based precautions for her suspected GI infection and staff was continuing to provide her care. On [DATE] at 1:15 PM, R152 was in her room. R152’s room had a contact precautions sign instructing everyone to don PPE, including gloves and gown, prior to entering. The sign said for everyone to clean their hands before entering and when leaving the room with ABHR (alcohol-base hand rub). On [DATE] at 2:15 PM, V2 (Director of Nursing/DON) said R152 should have been immediately placed on contact precautions on [DATE] when her GI symptoms were identified for the safety of everyone. V2 said R152’s stool sample resulted positive for C. diff on [DATE]. V2 continued to say anyone entering a resident’s room with a C. diff infection were required to perform strict hand-hygiene with soap and water not ABHR to ensure the infection could not be spread to others. V2 said she would change R152’s posted transmission-base contact sign to the correct sign of “Contact Enteric Precautions.” V2 said she expected all staff and visitors to adhere to the indicated transmission-based precautions when entering residents’ rooms. R152's stool result dated [DATE] showed positive results for “C difficile GDH Ag and Toxin A.” R152’s care plan dated [DATE] said she required “strict contact isolation rt (+) C diff” initiated on [DATE]. 2. [DATE] at 1:00 PM, R117 was in his room. V39 CNA (Certified Nurse Assistant) entered the room to remove his meal tray. V39 did not don any PPE. R117’s door had a contact precautions sign instructing everyone to wear a gown and gloves prior to entering the room. V39 said she did not believe she had to adhere to the indicated contact precautions instructions when entering a resident’s room. R117’s Order Summary Report dated [DATE] showed an order for “Contact isolation for VRE of wound” initiated on [DATE]. 3. On [DATE] at 2:40 PM, V6 (CNA) and V10 LPN (Licensed Practical Nurse) provided perineal care to R41. R41 was on EBP (Enhanced Barrier Precautions) for having a gastrostomy tube and a urinary catheter. V6 and V10 wore gloves but did not wear gowns. V6 removed the soiled disposable brief while V10 held R41 onto her right side. Neither V6 nor V10 cleansed the perineal area of R41. Neither staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 17 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 member performed hand hygiene or changed gloves. Together they applied a new disposable brief on R41, repositioned her, and tidied up her bed linen while wearing the same soiled gloves. V6 removed his gloves, did not perform hand hygiene, and left the room carrying soiled linen that was not contained. On [DATE] at 1:30 PM V7 (LPN) checked the placement of the GT (gastrostomy tube) for R41. V7 wore gloves but did not wear a gown. On [DATE] at 1:40 PM, V7 and V9 (CNA) turned R41 to observe the back of the resident. Both wore gloves but did not wear a gown for the procedure. Record review for R41 showed R41 was admitted on [DATE] with diagnoses to include neuromuscular dysfunction of bladder, dysphagia, right side hemiplegia and protein-calorie malnutrition. R41’s treatment orders included Enhanced Barrier Precautions related to gastrostomy tube and indwelling urinary catheter; All must clean their hands before entering and leaving the room; Staff must wear PPE (Personal Protective Equipment) during High Contact Resident Care Activities. 4. On [DATE] at 1:10 PM V8 (CNA) pulled R104 up in bed with resident’s cooperation. R104 was on EBP for having a urinary catheter and a perma-cath. V8 wore gloves, but no gown. V8 helped R104 to sit up in Fowler’s position. V8 set up the lunch tray in front of him on the over-bed table. V8 removed her gloves, did not perform hand hygiene and left the room to handle lunch trays from other rooms. Record review for R104 showed he was admitted to facility on [DATE] with diagnoses of neuromuscular bladder, cerebral palsy, renal dialysis and gastroenteropathy. R104’s treatment orders included EBP related to urinary catheter and Perma catheter. Care-plan dated [DATE] documented EBP related to urinary catheter and Perma catheter. On [DATE] at 2:55 PM V6 (CNA) stated he should have washed his hands before leaving the room and should have worn a gown as R41 was on EBP. V6 also stated he should have taken the linen out of R41's room in a plastic bag as per facility policy. On [DATE] at 1:30 PM, V5 RN (Registered Nurse) stated a gown and gloves need to be worn when caring for a resident on EBP. 5. R8 was admitted to the facility with diagnoses including hemiplegia and hemiparesis, dementia, and thyrotoxicosis. R8’s POS (Physician Order Sheet) dated [DATE] showed an order for EBP: related to history of VRE (Vancomycin-Resistant enterococci) in the urine. Everyone must clean their hands before entering and leaving the room. Providers and staff must wear PPE during High Contact Resident Care Activities with a start date of [DATE]. On [DATE] at 11:10 AM during initial tour, R8’s room did not have any isolation signage or PPE bin outside her room or near the vicinity of her room. On [DATE] at 4:08 PM, V4 (CNA) was in R8’s room providing incontinence care. V4 did not have a gown on while providing incontinence care for R8. V4 applied the new incontinence brief onto R8 and then rearranged her blankets to cover her back up. On [DATE] at 2:09 PM, V25 (LPN) said R8 was supposed to be on EBP for the wounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 18 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 The facility’s policy titled Transmission-Based Precautions dated 06/2025 said “Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.” Facility policy on Enhanced Barrier Precautions dated [DATE] showed EBP involves the use of gowns and gloves during high contact resident care activities for residents with indwelling medical devices to prevent spread of MDROs (Multi Drug Resistant Organisms) in the facility. Facility policy on Hand Washing/Hand Hygiene dated [DATE] showed hand hygiene must be performed before and after handling an invasive device, before moving from a contaminated body site to a clean body site during resident care, after removing gloves, and before and after entering isolation precaution settings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 19 of 20 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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 its antibiotic stewardship program to monitor residents receiving antibiotics.This applies to 4 out of 4 residents (R152, R75, R117, and R136) reviewed for antibiotic use in a sample of 30. The findings include:1. On 7/23/2025 at 1:00 PM, V13 (Infection Preventionist/IP Nurse) said the facility's antibiotic stewardship program was to ensure safe antibiotic use. V13 said inappropriate use could result in antibiotic overuse and resistance. V13 said she was responsible for completing antibiotic review forms in the residents' EMRs (Electronical Medical Records) when admitted with or prescribed antibiotics. V13 said the facility determined appropriate antibiotic use based on the McGeer Criteria and if determined inappropriate the prescribing provider was notified to ensure safe use.V13 reviewed R152, R75, R117, and R136's EMRs and said they received antibiotics as prescribed. V13 said their antibiotic review forms were not completed to determine if they met the McGeer Criteria for appropriate use. On 7/23/2025 at 3:45 PM, V2 (Director of Nursing/DON) said she expected antibiotic surveillance to be completed for all residents receiving antibiotics per facility policy to ensure safe antibiotic use. V2 said she also reviewed R152, R75, R117, and R136's EMRs and they did not have their antibiotic review forms initiated.R152's Order Summary Report dated 7/24/2025 showed an order for Vancomycin oral suspension for Clostridium difficile infection (gastrointestinal infection) started on 7/23/2025.2. R75's Order Summary Report dated 7/24/2025 showed an order for Cefepime intravenous solution for a urinary tract infection started on 7/16/2025.3. R117's Order Summary Report dated 7/24/2025 showed an order for Cefepime intravenous solution for osteomyelitis started on 7/09/2025.4. R136's Order Summary Report dated 7/24/2025 showed and order for Cefdinir oral capsule for a urinary tract infection started on 7/11/2025. The facility's policy titled Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcome dated 11/23/2021 said Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146093 If continuation sheet Page 20 of 20