Eden Vista Burr Ridge

Inspectors wroteBased on interviews and record review, the facility failed to follow its fall prevention policy and provide adequate supervision for one cognitively impaired resident who was identified as being at high risk for falls. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 having two unwitnessed, avoidable falls occurring on the same day, following the second fall R1 was transported to the hospital, where the resident was diagnosed with a spinal compression fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and safe transport technique and failed to implement care plan interventions to prevent an accident for a resident (R1). The facility failed to follow facility fall prevention policy, failed to develop and implement care plan interventions to prevent recurrent falls, and failed to complete post fall assessment for one of three residents (R2), reviewed for falls. These failures resulted in R1 falling and sustaining a closed head injury, abrasion of the forehead, avulsion of right elbow skin, and a closed nasal bone fracture, and R2 sustaining seven falls within sixteen days, hospitalization, scalp laceration requiring sutures, and a subdural hemorrhage.

Inspectors wroteBased on interview and record review facility failed to initially report a severe injury of unknown origin to the Illinois Department of Public Health (IDPH) no later than two hours after the incident for one resident (R2) of eight residents in the sample. This injury resulted in R2 being hospitalized for scalp laceration requiring sutures, and a subdural hemorrhage.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 4 of 4 residents (R7, R9, R10 and R16) reviewed for ADL (activities of daily living) in the sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide mechanically altered food consistency for residents prescribed the level 6 soft and bite sized diet. This applies to 4 of 4 residents (R1, R16, R19, R30) reviewed for altered consistency diets in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of incontinence care and administration of medication. The facility also failed to ensure that staff would wear complete PPE (personal protective equipment) during provision of care for residents who are on EBP (Enhance Barrier Precaution). This applies to 5 of 12 residents (R2, R3, R7, R10, R18) reviewed for infection control in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a recommended device for contracture management to resident who has contractures. This applies to 2 of 3 residents (R3, R11) reviewed for contractures in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician order and manufacturer's recommendation for medication administration. There were 26 medication opportunities with 2 administration errors resulting to 7.69% medication error rate. This applies to 1 of 2 residents (R10) reviewed for medication administration in the sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean and sanitize kitchen equipment, failed to label/date potentially hazadardous stored food, failed to store cooked meat to prevent cross contamination, and failed to perform hand hygiene per facility policy. This applies to all 22 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care, failed to follow the EBP (Enhanced Barrier Precautions) policy, and clean medical equipment between resident use. This applies to all 22 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide the minimum required servings of fruits/vegetables and grains/breads on their planned menus as per facility policy. This applies to 15 of 15 residents (R1, R3, R7, R10, R11, R14, R15, R16, R18, R20, R127, R128, R129, R130, R176) reviewed for menu planning.

Inspectors wroteBased on interview and record review, the facility failed to give a resident a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) at the end of a resident's Medicare Part A stay. This applies to 1 of 3 residents (R225) reviewed for beneficiary notices in the sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to provide to the resident or resident's representative in writing the facility's bed hold policy when being transfer to the local hospital. This applies to 2 of 3 residents (R4 and R5) reviewed for hospitalizations in the sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with significant weight loss was reviewed by a dietitian upon readmission to the facility from the hospital, failed to provide nutritional interventions to assist in preventing weight loss, and failed to obtain weekly weights as ordered by the physician. This applies to 1 of 1 residents (R3) in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify the placement and patency of a resident's gastrostomy tube (G-tube) before administering medication through it. This applies to 1 of 1 residents (R176) reviewed for gastrostomy tubes in the sample of 12. The Findings Include: R176' Resident Information sheet showed an [AGE] year old male admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Dysphagia following Cerebral Infarction, Encounter for attention to Gastrostomy, and Type 2 Diabetes Mellitus. On January 28, 2025, at 8:36 AM, during medication administration observation, V6 (Nurse) entered R176 room with medications she had prepared outside of the room. V6 then removed the covers from over R176, lifted up his shirt. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify resident specific behaviors to monitor the effectiveness of psychotropic medications. This applies to 3 of 5 residents (R3, R5, and R75) reviewed for unnecessary psychotropic medications in the sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to answer call lights promptly and failed to provide timely incontinence care to a resident. This applies to 3 of 3 residents (R1, R3, R4) reviewed for call light response times in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were present for a resident with recurrent diarrhea and to notify the Physician about the medications, failed to ensure lab testing was completed in a timely manner for the resident, and failed to ensure staff responded to the resident's stool incontinence in a timely manner. These delays in treatment resulted the addition of a third medication, and the resident experiencing increased weakness and skin irritation. This applies to 1 of 4 residents (R14) reviewed for nursing cares in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen in a manner that prevents foodborne illness. This applies to all 26 residents that reside in the long-term care unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents with their ADL (Activities of Daily Living) needs in a timely manner. This applies to 3 of 6 (R173, R18, R7) residents reviewed ADLs in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Dietician recommendation to provide nutritional supplement to a resident with weight loss. This applies to 1 resident (R1) reviewed for weight loss in a sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow disinfection protocol to prevent spread of infection. This applies to 2 residents (R14 and R175) reviewed for infection prevention and control in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to offer and document the provision of the influenza and pneumococcal immunizations to residents admitted to the facility. This applies to 2 of 5 residents (R11, R124) reviewed for influenza and pneumococcal immunizations in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to offer, or document a history or refusal of, the COVID-19 immunizations to residents admitted to the facility. This applies to 2 of 5 residents (R124, R172) reviewed for COVID-19 immunization in a sample of 12.