Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookdale Plaza Lisle Snf during CMS and state inspections, most recent first.
Kitchen sanitation and food storage were not maintained in accordance with professional standards. Surveyors observed an out-of-range sanitizer bucket, dish machine rinse temperatures below the stated disinfecting level, dented cans, open and unlabeled food items, spoiled produce, unsecured CO2 cylinders, dirty textiles near dry storage, and dirty uncovered equipment such as mixers and a meat slicer. Facility logs also showed sanitizer and dish machine temperatures that did not match the facility’s stated acceptable ranges.
Unsafe Storage of Chemicals and Unsecured CO2 Cylinders: Unsecured CO2 cylinders were observed in the kitchen area, with no holder or rack, and a 32-ounce bottle of charcoal lighter fluid was stored in a cabinet outside dry storage. A dryer was also found with dirty textiles inside, a lint trap filled with red lint, and Maintenance stated lint buildup is a fire hazard. The Chef, Administrator, and DOP acknowledged the storage and safety concerns, and the facility policy required chemicals and toxic materials to be stored away from food prep and food storage areas.
A resident with severe cognitive impairment received ABH Gel even though the hospice PRN order had not been renewed in the EMR. Another resident with chronic edema and venous ulcers did not receive compression wraps as ordered to both lower extremities, and a third resident who was always incontinent was found with two soaked briefs, urine odor, and new groin redness with fluid-filled blisters while also having an order for topical treatment for fungal rash.
Failure to reconcile controlled substances: A RN found a discrepancy in an ABH Gel count for one resident, with fewer syringes on hand than the controlled substance record indicated after a dose was removed but not signed off. Two discharged residents also had controlled meds left in the locked narcotic drawer with pink proof-of-use forms instead of being counted in the narcotic binder, and the RN said they were not being included in shift-change narcotic counts because the residents had been discharged.
A resident with severe cognitive impairment and on blood thinners was transferred by a single CNA using a mechanical lift, despite facility policy requiring two staff for such transfers. The resident was subsequently found with extensive bruising on the right side of the body, and interviews confirmed that proper transfer protocols were not followed, leading to injury.
The facility failed to maintain proper food safety and hygiene standards in the kitchen, affecting all residents receiving oral nutrition. Staff did not consistently wear hair restraints, and food items were improperly stored, with several being unlabeled, undated, or expired. Prepared salads were stored too close to a handwashing sink, risking cross-contamination. The facility's policies on food storage, labeling, and hair restraints were not adequately followed, contributing to these deficiencies.
The facility failed to provide necessary assistance with ADLs, including showers and nail care, for four residents. Two residents did not receive scheduled showers despite needing assistance, and their care plans did not address this need. Additionally, two other residents were observed with unkempt nails, indicating a lack of personal hygiene care. The DON acknowledged the importance of maintaining nail hygiene to prevent infections and injuries.
A long-term care facility failed to follow infection control protocols, including improper hand hygiene and PPE use. Staff were observed neglecting to change gloves or use hand sanitizer during resident care, and PPE was not used in isolation rooms. Additionally, catheter drainage bags were improperly placed on the floor, increasing contamination risks.
The facility failed to implement an antimicrobial stewardship program, affecting all residents reviewed for antibiotic use. The Assistant Director of Nursing admitted that while infections were logged, antibiotic use was not monitored. Residents received antibiotics for various conditions, with some orders lacking stop dates, highlighting a systemic issue in the facility's approach to antibiotic stewardship.
The facility failed to maintain privacy for two residents, one with a C. diff infection and another with a Foley catheter. A sign detailing the infection was posted outside the first resident's room in a high-traffic area, violating privacy protocols. The second resident's urinary catheter bag was visible at the nurses' station, contrary to care plan requirements for privacy bags. The DON acknowledged these breaches in privacy.
A facility failed to properly transfer a resident using a mechanical lift, resulting in the resident being flung to the floor. The CNA ignored the resident's transfer requirements, leading to the incident. Additionally, a used disposable razor was improperly left on a resident's dresser, posing a safety hazard, despite the presence of a sharps container in the bathroom.
The facility failed to obtain physician orders for over-the-counter medications and improperly allowed medications to be stored in resident rooms. One resident had Clobetasol Gel on the bedside table without prior authorization, and another resident had a topical analgesic cream without a physician order. The facility's policy requires medications to be stored in secured locations, which was not followed.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The kitchen failed to maintain food storage, sanitation, and equipment conditions in a manner that prevents food borne illness for all 49 residents receiving dietary services. During the kitchen tour, surveyors observed three red sanitization buckets in use, and one bucket tested at 1130 PPM even though the facility’s test strips and manufacturer instructions listed the acceptable range as 272 to 700 PPM. The dishwasher was also observed in use, and the digital disk thermometer reading was 159.9 degrees Fahrenheit while staff stated the machine disinfects by temperature and that the rinse cycle should reach 180 degrees Fahrenheit. Staff further stated the dishwasher temperatures had not matched earlier and the supervisor was not notified. Surveyors observed multiple food storage and sanitation problems in the dry storage, walk-in cooler, walk-in freezer, reach-in cooler, and ice cream cooler. Dry storage contained dented cans of black beans, several open bags of dry goods exposed to air, and ten capped carbon dioxide cylinders not secured in any restraint or holder. Outside the dry storage area, a washer and dryer unit contained dirty textiles, the dryer lint trap was filled with red lint, and the dryer contained a bag of textiles. The walk-in cooler floor was dirty and had onion skins and blueberries scattered on it, and it contained multiple unlabeled or undated items, food stored open to air, produce with spoilage, and prepared foods with dates that were expired or incomplete. The walk-in freezer and reach-in cooler also contained unlabeled, undated, or open-to-air food items, including meats, cheese, ravioli, and chicken salad. Additional observations included six open 3-gallon containers of ice cream stored open to air, two mixers that were dirty and uncovered, and a meat slicer that was dirty and uncovered. Staff stated dented cans should not be used because they can become tainted with botulism, that food items should be labeled with contents and dates, and that spoiled food should be thrown out. The facility’s own policies stated dented cans must be marked and set aside, prepared items must be labeled with the item name, date and time prepared, and discard/use-by date, and high temperature dish machines must have a rinse water temperature of 180 degrees Fahrenheit. The logs provided by the facility showed sanitizer testing documented at 200 PPM and dish machine rinse temperatures documented at 170 degrees Fahrenheit, which did not match the stated acceptable ranges.
Unsafe Storage of Chemicals and Unsecured CO2 Cylinders
Penalty
Summary
The facility failed to safely store hazardous chemicals and carbon dioxide cylinders in the kitchen area and failed to maintain a clothes dryer in a safe manner. During a kitchen tour, ten new and capped carbon dioxide cylinders were observed unsecured and not restrained in a holder. The Chef stated the cylinders were for the soda machine and that the facility did not have any information on how to store them. The Administrator later stated that carbon dioxide canisters should be in a rack or secured because they are under pressure, and that the restraint protects the valves so the tanks do not explode. Outside the dry storage area, a washer/dryer unit was observed with the wash tub filled with dirty textiles, the dryer lint trap filled with red lint, and a bag of textiles inside the dryer. Maintenance stated the dryer should be cleared of lint and kept clean, and that lint buildup is a fire hazard. A 32-ounce bottle of charcoal lighter fluid was also observed in a storage cabinet outside the kitchen dry storage. The Director of Operations stated there was no carbon dioxide detector in dry storage and that lighter fluid is flammable and should not be stored in the kitchen area. The facility policy stated chemical and toxic materials must be stored appropriately away from food preparation and food storage areas.
Failure to follow medication, treatment, and perineal care orders
Penalty
Summary
The facility failed to renew an as needed hospice order before administering ABH Gel to a resident with severe cognitive impairment and anxiety. R7 was observed in a geriatric chair at the nurse’s station, anxious and fidgeting despite staff redirection. The RN stated that R7’s ABH Gel had been given at 3 PM even though the EMR did not have an active renewal order, and the DON stated medications should only be administered with a physician’s order and that hospice should have been contacted to reactivate the order. R7’s EMR showed the ABH Gel order had to be renewed before 12/11/2025, yet the medication was still administered on 12/11/2025, 12/14/2025, and 12/16/2025. The facility also failed to apply compression wraps as ordered for a resident with chronic edema and venous ulcers. R1 was observed with compression wraps loosely wrapped around his ankles, and later the LPN changed a left medial leg venous wound dressing but applied a compression wrap only to the right lower extremity and placed a regular white sock on the left foot. Later that day and the next morning, R1 was observed wheeling himself on the unit without compression wraps to either leg. R1’s order required compression wraps to both lower extremities every morning and removal before bedtime, and his wound management summary and care plan both directed continued use of compression wraps for bilateral lower extremities. The facility also failed to ensure a resident with incontinence and a fungal rash was kept clean and dry. R34, who was dependent on staff for toileting and personal hygiene and was always incontinent of urine and bowel, was found wearing two heavily soaked incontinent briefs with a strong urine odor. After the briefs were removed, her left groin was red and had two fluid-filled blisters. Staff documented the new skin issue and the DON stated that only one incontinent brief should be applied because two briefs can lead to increased skin issues and infection risk. R34 also had an order for Nystatin-Triamcinolone cream to the groin and affected area for fungal rash.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to reconcile controlled substances for 3 of 3 residents reviewed for narcotics. During review of the medication cart narcotic drawer, R7 had six ABH Gel droplet syringes available even though the Individual Controlled Substance Record sheet showed seven syringes should have been available. The RN stated a dose had been administered at 3 PM but had not been signed off on the record sheet when it was removed for administration. The record sheet also showed the last administered dose was at 12 AM and still indicated seven syringes should have been present. Controlled medications for two discharged residents remained in the locked narcotic drawer with their pink controlled substance proof-of-use forms wrapped with a rubber band instead of being in the narcotic count binder. R47’s medication cards for Lacosamide 100 mg and Zolpidem Tartrate 5 mg were found this way, and the RN stated the medications were not being counted during shift change medication reconciliation because the resident had been discharged. R59’s Tramadol 50 mg card was also found with its proof-of-use form in the narcotic drawer, and the RN gave the same explanation. The EMR showed R47 was discharged on 12/09/2025 and R59 on 12/13/2025. The facility policy stated controlled substances stored in medication carts and emergency supplies, including those waiting to be destroyed, should be routinely reconciled.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including congestive heart failure, dementia, osteoporosis, and use of blood thinning medication, was transferred using a mechanical lift by a single CNA, contrary to facility policy requiring two staff for such transfers. The resident was later found to have extensive bruising on the right ribs, hip, knee, and ankle, with measurements indicating significant subcutaneous bleeding. The CNA involved admitted to transferring the resident alone and suggested that the lift arm may have pressed against the resident's rib area during the process. The CNA also failed to promptly report the skin changes to nursing staff. Interviews with other CNAs and RNs confirmed that mechanical lift transfers are to be performed by two persons for safety. The resident's physician noted that the pattern of bruising was consistent with an impact against a hard surface, and a CT scan confirmed a subcutaneous bleed without evidence of spontaneous internal bleeding. Facility leadership acknowledged that the incident was avoidable and that the resident likely experienced an impact during the unsupervised transfer.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards in the kitchen, affecting all residents who receive oral nutrition. During a kitchen tour, it was observed that staff members, including the Associate Director of Dining Services and other kitchen personnel, did not consistently wear hair restraints, which is a violation of the facility's policy. Additionally, food items were improperly stored, with several items being unlabeled, undated, or expired. For instance, an opened bag of feta cheese was found to be expired, and various other food items such as whipped topping, hot dogs, guacamole, and tortillas were either undated or past their expiration dates. Furthermore, prepared salads were stored too close to a handwashing sink, posing a risk of cross-contamination. The facility's policies on food storage, labeling, and hair restraints were not adequately followed, as evidenced by the presence of expired and improperly sealed food items in both the walk-in cooler and dry storage areas. The Associate Director of Dining Services acknowledged the importance of labeling and dating food items, keeping food away from handwashing sinks, and ensuring all staff wear hair restraints to prevent contamination. However, it was noted that the facility lacked specific policies regarding the removal of expired foods and the resealing of opened food items, contributing to the observed deficiencies.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who required help, specifically in providing showers and nail care. Four residents were identified as not receiving adequate care. One resident, admitted with conditions including Covid-19 and mild cognitive impairment, was cognitively intact and required substantial assistance for bathing and dressing. Despite multiple requests, this resident did not receive a shower since admission. Another resident with moderate cognitive impairment and various health issues also did not receive showers as scheduled, despite being documented to need assistance. Both residents' care plans failed to address their need for showering, and electronic records confirmed the absence of shower documentation. Additionally, two other residents were observed with long, dirty, and jagged nails, indicating a lack of personal hygiene care. One resident, with intact cognitive functions, required assistance with personal hygiene but did not receive help with nail care despite requests. Another resident, dependent on staff for personal hygiene and with moderately impaired cognitive functions, also did not receive nail care. The Director of Nursing acknowledged the expectation for staff to check and maintain nail hygiene during showers and hygiene care, as untrimmed nails could lead to infections and injuries. The facility's policy emphasized the need for appropriate support and assistance with hygiene for residents unable to perform ADLs independently.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control precautions, as evidenced by multiple observations of staff neglecting hand hygiene and personal protective equipment (PPE) protocols. For instance, two CNAs were observed providing perineal care to a resident without changing soiled gloves or using hand sanitizer, even after handling contaminated materials and touching various surfaces. This lack of hand hygiene continued as they transferred the resident to a recliner, further compromising infection control standards. In another instance, a resident's family member was found in a room without PPE, despite the resident being on COVID-19 isolation. A CNA entered the same room without gloves, handled various items, and only used hand sanitizer upon leaving. This was contrary to the facility's policy, which mandates PPE for anyone entering a COVID-19 isolation room. Additionally, a resident with an indwelling catheter had their drainage bag placed on the floor, which is against the facility's urinary catheter care policy due to contamination risks. Further deficiencies were noted with a resident diagnosed with C. difficile, where staff failed to wear appropriate PPE despite the resident being on contact isolation. The isolation sign was removed prematurely, leading to staff entering the room without gowns. Another resident on enhanced barrier precautions for a urinary catheter and pressure ulcer was not provided care with the required PPE, and their catheter drainage bag was also found on the floor. These repeated lapses in infection control practices highlight significant deficiencies in the facility's adherence to established protocols.
Failure to Implement Antimicrobial Stewardship Program
Penalty
Summary
The facility failed to implement an antimicrobial stewardship program, which is essential for monitoring antibiotic use and preventing antibiotic resistance. During a review of the facility's Infection Control Program, the Assistant Director of Nursing and Infection Preventionist admitted that while infections were logged, antibiotic use was not being monitored. This oversight affected all eight residents reviewed for antibiotic use in a sample of 23, indicating a systemic issue in the facility's approach to antibiotic stewardship. The deficiency was highlighted through specific examples of residents receiving antibiotics without proper monitoring or protocols in place. For instance, one resident was prescribed Ciprofloxacin for a urinary tract infection, while another was given Methenamine Hippurate without a stop date. Other residents were prescribed various antibiotics for conditions such as diverticulitis, shingles, and enterocolitis due to Clostridium Difficile, with some orders lacking appropriate stop dates. The Director of Nursing acknowledged the importance of minimizing unnecessary antibiotic use to prevent resistance, yet the facility's mission statement on antimicrobial stewardship was not being effectively implemented.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain privacy for two residents, one with a contagious gastrointestinal infection and another with a Foley catheter. The first resident, who had a Clostridium difficile (C. diff) infection, was in a room with a partially open door, and a sign detailing the progression of a C. diff infection was posted outside the door. This room was located in a high-traffic area across from the nurses' station, where multiple visitors, staff members, and other residents could see the sign. The resident's care plan included an intervention to promote dignity by ensuring privacy, but this was not adhered to. The second resident was observed sitting in a geriatric wheelchair at the nurses' station, with a urinary catheter bag hanging visibly from the wheelchair. The catheter drainage bag was not inside a privacy bag, making the urine visible to others in the area. The resident's care plan required the use of privacy bags for the catheter at all times, but this was not followed. The Director of Nursing acknowledged that the infection sign should not have been posted and that urinary catheter bags should be covered to maintain privacy.
Improper Transfer and Razor Disposal in LTC Facility
Penalty
Summary
The facility failed to ensure proper transfer procedures for a resident, leading to an accident. A resident with intact cognitive functions, who requires a mechanical lift and assistance from two staff members for transfers, was improperly transferred by a CNA. Despite the resident's reminder about the need for a mechanical lift, the CNA attempted to physically lift the resident from the bed to a wheelchair, resulting in the resident being flung to the floor. The Director of Nursing confirmed that the CNA was aware of the resident's transfer requirements but chose to proceed without the necessary equipment, contrary to the facility's policy on supporting activities of daily living. Additionally, the facility failed to properly dispose of a sharp disposable razor, posing a potential hazard. A used disposable razor was found on a resident's bedside dresser, despite the presence of a sharps container in the bathroom. The resident, who requires partial to moderate assistance with personal hygiene, was not able to shave himself, and the staff was responsible for his grooming. The RN acknowledged that the razor should not have been left in the room and should have been discarded or stored safely. The Director of Nursing stated that disposable razors should be disposed of in sharps containers to prevent cross-contamination and safety risks, although the facility lacked a specific policy for razor disposal.
Medication Storage and Physician Order Deficiency
Penalty
Summary
The facility failed to obtain physician orders for over-the-counter medications and allowed medications to be stored in resident rooms without proper authorization. This deficiency was observed in two residents. For the first resident, three tubes of Clobetasol Propionate Gel 0.05% were found on the bedside table. The resident reported that the gel was applied by staff after every brief change due to irritation from diarrhea. However, the order to keep the medication at the bedside was only received during the survey, indicating a lack of prior authorization for bedside storage. For the second resident, a tube of generic Ultra Strength Topical Analgesic Cream was found on the bedside dresser. The resident used the cream for back pain but did not have a physician order for its use or storage in the room. The facility's Director of Nursing confirmed that a physician order is required for medications to be stored in resident rooms to ensure safety. The facility's Medication Storage policy mandates that medications be stored in designated, secured locations, which was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thrive Of Lisle | 1.4 mi | ★★★★★ | 1 | 0 |
| Arista Healthcare | 3.6 mi | ★★★★★ | 0 | 0 |
| Alden Estates Of Naperville | 3.7 mi | ★★★★★ | 6 | 0 |
| Pearl Of Naperville, The | 3.8 mi | ★★★★★ | 10 | 0 |
| The Pearl Of Downers Grove | 4.4 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.