Eden Vista Prospect Heights

Based 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. An admission record dated 12/10/2025 indicates that R6 has an diagnosis of Hemiplegia and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, dysphagia, oropharyngeal phase, GERD, and gastrostomy status, a order summary report dated 12/10/2025 that indicates NPO diet for failed speech swallowing dated 7/17/2023, a care plan dated 4/17/2024 with a focus of ADL self-care performance deficit impaired mobility, impaired cognition, hemiplegia left side a interventions for personal hygiene/oral care assist-one with grooming, oral hygiene-oral care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: On 12/9/25 at 11:26AM, Observed R11 with swollen bilateral lower extremities with V17 RN (Registered Nurse). V17 assessed R11's bilateral lower extremities for pitting edema. V17 said that she has bilateral pitting edema but more prominent on left lower leg. R11 is alert and responsive with periods of confusion. She has impaired hearing and slurred speech. On 12/9/25 at 3:05PM, Reviewed R11's medical records with V2 DON (Director of Nursing). R11 is admitted on [DATE] with diagnosis listed in part but not limited to Essential hypertension, Atrial Fibrillation, History of falling, Muscle weakness, Muscle wasting, Unsteadiness on feet and hearing loss. Active Physician order sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: On 12/9/25 at 11:15AM, Observed R3 in Broda (Recliner chair) in the activity room leaning to right side off the recliner chair in front of V14 Activity Aide. No hand splint or wheelchair resting hand splint applied. Showed observation to V2 Director of Nursing (DON). V2 repositioned R3 in upright position. R3 is re-admitted on [DATE] with diagnosis listed in part but not limited to Senile degeneration of brain, Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Abnormal posture. Active physician orders indicated Apply functional hand splint to left hand, may remove for hygiene, skin checks and as per patient's tolerance. Wheelchair arm through the left side to facilitate proper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: On 12/9/25 at 11:06AM, Observed R11 sitting in wheelchair in her room. She is alert with impaired hearing and slurred speech. The call light is away from her, unable to reach. Showed observation to V2 DON (Director of Nursing). V2 said that call light should be accessible and placed within resident reach for safety.On 12/9/25 at 3:05PM, Reviewed R11's medical records with V2 DON. R11 is admitted on [DATE] with diagnosis listed in part but not limited to History of falling, displaced Tri malleolar fracture of left lower leg, Closed fracture with routine healing, Subluxation of left ankle joint, Muscle weakness, Muscle wasting, Unsteadiness on feet and hearing loss. Care plan intervention indicated: Assist resident to meet needs and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings include:On 12/10/2025 at 11:00am R6 was observed in bed with dark areas, a foul odor to mouth and broken teeth with yellow to brown build up. R6 was asked did she have pain to her teeth R6 said pain.On 12/10/2025 at 11:25am V2(Director of Nursing-DON) said I expect all nurses to assess for pain, I did assess R6 for mouth pain and R6 did confirm that she was in pain which I administered acetaminophen 625mg two tabs and called the physician for an assessment for dental ASAP and notified the power of attorney-POA.An admission record dated 12/10/2025 indicates that R6 has an diagnosis of Hemiplegia and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, dysphagia, oropharyngeal phase, GERD, and gastrostomy status, an order summary report dated 12/10/2025 that indicates NPO diet for failed speech swallowing dated 7/17/2023, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. An admission record dated 12/10/2025 indicates that R6 has an diagnosis of Hemiplegia and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, dysphagia, oropharyngeal phase, GERD, and gastrostomy status, an order summary report dated 12/10/2025 that indicates NPO diet for failed speech swallowing dated 7/17/2023, a care plan dated 4/17/2024 with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings include: On 12/9/25 at 11:31AM, Observed V15 CNA (Certified Nurse Assistant) and V16 CNA repositioned R11 to her left side. Observed R11 soiled with urine. V15 removed the soiled disposable adult brief. She cleansed the perinium and sacral area with disposable cleansing wipes. V15 did not remove and perform hand hygiene. V15 took clean disposable adult brief and placed underneath R11. Informed V15, V16 and V3 ADON (Assistant Director for Nursing) of observation made regarding failure to perform hand hygiene after providing incontinence care and before handling clean adult brief. V3 said that V15 should perform hand hygiene after incontinence care and before handling clean brief. On 12/9/25 at 12:01PM, Informed V2 Director of Nursing (DON) of above observation and concern. Requested for hand hygiene…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R1 was readmitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, anemia, gastrointestinal hemorrhage, hypertension, and heart disease. R13's Braden scale dated 2/13/25 documents moderate risk for skin breakdown. R1's admission screener dated 1/30/25 document under skin coccyx tiny skin opening. R1's progress note dated 1/31/25 documents: Readmit from skilled unit. Seen by V5 (MD),orders verified and noted. Skin check done. With skin discoloration [greenish ] in back of right hand, with brownish skin discoloration in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: R1 face sheet denotes R1 has diagnosis of vascular dementia, unsteady on feet, history of falling, difficulty walking. R1 MDS dated 6.4.2023 section C denotes in-part attempt to conduct brief interview 0 is noted for No- resident rarely /never understood. Section C0700 denotes staff assessed R1 to have short term memory problems, and long-term memory problems. Cognitive skills for daily decision making- 2 are denoted for moderately impaired. 1 is denoted for yes there is evidence of acute change in mental status. One is denoted for inattention (behavior continuously present, does not fluctuate). One is denoted for disorganized thinking (behavior continuously present, does not fluctuate). Section E for behavior denotes Wandering- 3 (behavior of this type occurs daily). One is denoted that wandering places…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 Findings include: R1 face sheet denotes R1 has diagnosis of vascular dementia, unsteady on feet, history of falling, difficulty walking. R1 MDS dated 6.4.2023 section C denotes in-part attempt to conduct brief interview 0 is noted for No- resident rarely /never understood. Section C0700 denotes staff assessed R1 to have short term memory problems, and long-term memory problems. Cognitive skills for daily decision making- 2 are denoted for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: On 05/15/23 from 09:50 AM - 10:05AM, observed a whole turkey thawing in a sink under sitting water. V12 (Dietary Manager) stated the turkey should be thawed under running water. Observed ice machine scoop stored in the ice machine in contact with ice. V12 stated the ice machine originally came with an internal storage piece for the scoop, however, the scoop is usually stored outside the ice machine in a holder. Observed V12 and V13 (Cook/Mentor) with their hairnets not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Per facility matrix dated [DATE], current census is 18 residents. On [DATE] at 10:36 AM during inspection of medication room and medication carts, the following were observed: Three multidose vials of Tubersol, opened and undated as to its first use were observed stored in the refrigerator in the medication room. V6 (Registered Nurse, RN) was asked if the vials should be dated when opened. V6 stated, We're supposed to label it with date opened, expiry date and our initials. Inside medication cart number 2, R2's and R122's Insulin Glargine pens were observed opened and used but not dated. V6 verbalized, We have to date the insulin pens when opened, because it is only good for 30 days from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R122 is an [AGE] year-old female with diagnoses history including Dementia, Alzheimer's, Restlessness and Agitation, Bipolar Disorder, Anxiety Disorder, Difficulty in Walking, Unsteadiness on Feet, Need for Assistance with Personal Care, and Chronic Congestive Heart Failure who was admitted to the facility 03/16/23. The facility's fall log from 11/15/22 to 05/15/23 documents R122 had 15 unwitnessed falls from 03/28/23 - 05/15/23. There were no post fall/fall risk assessments completed for R122's falls occurring 03/26/23, 03/28/23, 03/31/23, 04/05/23, and 04/08/23. R122's medical records did not include progress notes or incident reports for 10 of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.