Cycle 1
Health 2024-09-20 · Fire 2024-09-20
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lisle, IL
Brookdale Plaza Lisle SNF
5-star overall rating with 4-star inspections with $18,249 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1800 Robin Lane, Lisle, IL
(630) 353-5519
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2004-02-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.51
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.39
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.01
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.43
CMS adjusted RN staffing hours
Adjusted total hours
4.16
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,592
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.79% · Performance 24.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.86
Baseline 6.00% · Performance 7.28% · Measure score 1.86 · Achievement 1.86 · Improvement 0
Total nurse turnover
5.65
Baseline 41.30% · Performance 40.58% · Measure score 5.65 · Achievement 5.65 · Improvement 0
Adjusted total nurse staffing
5.41
Baseline 5.25 hours · Performance 4.62 hours · Measure score 5.41 · Achievement 5.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.2% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 199 · Observed rate 5.03% · Lower 95% interval 5.68% |
| Discharge to community | 67.94% |
50.57%
17.4 pts better
|
Better than the National Rate · Eligible stays 178 · Observed rate 60.67% · Lower 95% interval 61.16% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 114 · Denominator 115 |
| Falls with major injury | 1.74% |
0.77%
1 pts worse
|
Numerator 2 · Denominator 115 |
| Discharge self-care score | 55.07% |
53.69%
1.4 pts better
|
Numerator 38 · Denominator 69 |
| Discharge mobility score | 39.13% |
50.94%
11.8 pts worse
|
Numerator 27 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 3.48% |
2.29%
1.2 pts worse
|
Numerator 4 · Denominator 115 · Adjusted rate 3.14% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 7.89% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 14.29% |
8.2%
6.1 pts better
|
Numerator 15 · Denominator 105 |
| Staff flu vaccination coverage | 43.92% |
42%
1.9 pts better
|
Numerator 65 · Denominator 148 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 36 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 68 · Denominator 68 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 15% |
25.2%
10.2 pts worse
|
Numerator 9 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
89.6%
5.9 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 96.7% · Q3 97.4% · Q4 94.9% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.3%
0.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.3% · Q3 2.6% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
50.3%
49.5 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
6.5%
2.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.6% · Q4 7.7% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.0% |
18.5%
17.5 pts better
|
19.6%
18.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.6% |
22.8%
20.2 pts better
|
16.7%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 37.1% |
17.2%
19.9 pts worse
|
16.3%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
15.0%
4.5 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 9.1% · Q3 11.1% · Q4 7.7% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.7%
1.4 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.4% · Q3 2.7% · Q4 2.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
21.3%
10.2 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 25.4% · Q3 19.7% · Q4 43.7% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.2%
0.1 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.3% · Q3 6.1% · Q4 4.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
68.8%
24.3 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 90.4% · Q3 94.9% · Q4 94.1% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
14.0%
2 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 12.0% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.3%
0.5 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 4.2% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.2% |
63.0%
26.2 pts better
|
79.7%
9.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
26.2%
1.4 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 28.0% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-30 · Fire 2022-11-30
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-10
E · Potential for more than minimal harm
2023-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-03
F · Potential for more than minimal harm
2022-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
F · Potential for more than minimal harm
2024-09-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-20
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-04
E · Potential for more than minimal harm
2023-10-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-10-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-31
E · Potential for more than minimal harm
2023-10-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-31
G · Actual harm
2023-09-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-25
G · Actual harm
2023-06-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-28
G · Actual harm
2023-04-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-04-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-04-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-30
E · Potential for more than minimal harm
2022-11-30
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-31
Penalties and ownership
What sits behind the stars
$10,059
2023-09-14
Fine
Fine · fine $10,059
Fine
$8,190
2023-06-14
Fine
Fine · fine $8,190
Fine
Ownership
Brookdale Living Communities Inc.
5% Or Greater Direct Ownership Interest · Organization
Brookdale Senior Living Inc
5% Or Greater Indirect Ownership Interest · Organization
Bowman, Kevin
Operational/Managerial Control · Individual
Bowman, Kevin
Corporate Officer · Individual
Guajardo, Francisco
Operational/Managerial Control · Individual
Hussain, Jawwad
Operational/Managerial Control · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
La Marre, Kevin
Corporate Officer · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Munoz, Anna
Corporate Officer · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
Stephenitch, Ryan
Operational/Managerial Control · Individual
White, Chadwick
Operational/Managerial Control · Individual
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#3
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