Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 2 | 0 |
| Pearl Of Naperville, The | 3.8 mi | — | 1 | 0 |
| The Pearl Of Downers Grove | 4.4 mi | — | 2 | 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 August 2026) and official state health department websites.