Eden Vista Prospect Heights

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing monitoring, assessment to identify worsening of skin impairment and notify the physician for appropriate treatment in a timely manner. This failure resulted in R11's Moisture Associated Skin Disorder (MASD) on left buttocks to progress to sacral/coccyx area stage 3 pressure ulcer with slough formation. This deficiency affects one (R11) of one resident in the sample of 9 reviewed for Wound Care Management.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely oral care for one of three (R6) dependent residents reviewed for oral care in a sample of nine. Findings Include:On 12/9/2025 at 11:05am R6 was observed in bed with a foul mouth odor. On 12/9/2025 at 11:10am V16 (Certified Nursing Assistant-CNA) said I did oral care for R6 her mouth has an odor. On 12/9/2025 at 11:20am V2(Director of Nursing-DON), said I expect the nursing assistants to perform mouth care daily and as needed. [...]

Inspectors wroteBased on observation the facility failed to apply ace wrap bandage to resident's bilateral lower extremities for edema as ordered by physician. The facility also failed to develop plan of care in managing resident's edema. This deficiency affects one (R11) of one resident in the sample of 9 reviewed for Quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician order and implement care plan intervention for resident with limited mobility on left arm. This deficiency affects one (R3) of one resident in the sample of 9 reviewed for Limited mobility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention intervention to resident who has history of multiple falls. This deficiency affects one (R11) of one resident in the sample of 9 reviewed for Fall prevention program.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pain was thoroughly assessed and adequately treated for teeth pain for one of three residents (R6) in a sample of nine reviewed for pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental services were provided for a dependent resident for one of three residents (R6) reviewed for dental services in a sample of nine. Findings Include:On 12/9/2025 at 11:00am this writer observed R6 teeth very dark, broken in places, and a build up of yellowish film and foul odor. On 12/9/2025 at 11:20am this writer asks V2(Director of Nursing-DON) when was R6 last dental referral or exam. On 12/9/2025 at 11:25am V2 said I was unable to find a dental referral for R6, I did call the physician for a referral as soon as possible, I think because she is private pay, she has not had a dental exam she's been here for several years. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene after providing incontinence care and before handling clean disposable brief. This deficiency affects one (R11) of three residents in the sample 9 reviewed for Infection Control Program.

Inspectors wroteBased on interview and record review, the facility failed to follow their pressure injury prevention and wound care management policy for one resident who was at moderate risk for skin breakdown by not implementing an air loss mattress, delay in evaluation by wound care doctor, failing to document skin assessments on admission/weekly, failure to obtain physician orders and document treatments. This affected one of three residents (R1) reviewed for wound care.

Inspectors wroteBased on interview and record review the facility failed to follow the individualized plan of care for safety to ensure a resident remains in common area when awake. This affected one of three (R1) residents reviewed for implementation of care plan interventions.

Inspectors wroteBased on interview and record review the facility failed to supervise and monitor a resident with identified to be an elopement risk, wandering behavior, and poor safety awareness from exitingh the facility without staff knowledge. This affected one of three residents (R1) reviewed for supervsion and elopement risk. This failure resulted in R1 exiting the facility via wheel chair through an exit door without staff knowledge. R1 was eventually found outside past the exit door on the ground after falling from the wheelchair. R1 was sent to the local hospital for evaluation

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions according to resident's plan of care in preventing the development of a pressure ulcer for one (R13) of two residents in the sample of 21 reviewed for pressure ulcers. This failure resulted in R13's intact skin developing moisture associated skin damage on the left buttock which progressed to a Stage 4 pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for fall prevention by not consistently assessing risks for falls, not ensuring fall interventions were implemented, not implementing effective fall interventions for residents experiencing multiple falls, and not providing adequate supervision for high risk fall residents who required increased supervision. This failure applied to two (R122 and R274) of four residents reviewed for falls and resulted in R274 sustaining a left femur fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing and storing food under sanitary conditions by not ensuring food was stored to prevent contamination, not ensuring all dishware, food storage containers, and kitchen equipment were properly cleaned, not ensuring kitchen employees and facility staff practiced appropriate hygiene in the kitchen area, and not performing safe food thawing practices. This failure has the potential to affect all 18 residents who currently reside in the facility and receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that multidose vials and insulin pens are labeled with dates opened; and discontinued medications are disposed of per policy. This failure affected two (R2 and R122) of two residents reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for fall prevention by not comprehensively assessing risks for all falls and not ensuring fall interventions were implemented for a resident who is at high risk of falls. This failure applied to one (R122) of four residents reviewed for falls.