Inspection visit
Inspection
35 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 35 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, interview and record review the facility failed to provide privacy by not closing the
privacy curtains and room door during activity of daily living (ADL) care for one of four residents (R26)
reviewed for dignity in a sample of 15.
Findings include:
On 8/17/2022 at 10:30am R26 was observed in bed yelling for assistance, V14 (Registered Nurses-RN)
walked into the room and assisted R26 with her clothes and onto her wheelchair then took her into the
washroom without closing the privacy curtain or the room door.
On 8/17/2022 at 10:40am V14 was asked should she have provided privacy for R26, V14 said yes, I should
have closed the privacy curtain and the room door.
On 8/17/2022 at 1:45pm V2(Director of Nursing-DON) said I expect all staff to provide privacy for residents.
R26's Care-Plan dated 7/30/2022 indicates R26 needs Actual/Risk and Potential for complications with
Deficits with Activity of Daily Living, related to impaired mobility.
Facility Policy: May 2020
Dignity Quality of Life General
Policy
In full recognition of his or her individuality, the facility promotes care for residents in a manner and in an
environment that maintains or enhances each resident's dignity and respect.
This includes staff:
Respecting private space and property
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 18
Event ID:
145852
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure privacy curtains were
available for one of four residents reviewed for privacy, in a sample of 15.
Residents Affected - Few
Findings include:
On 8/17/2022 at 10:50am R23 was observed in bed and V14 (Registered Nurse-RN) was administering
wound care without a privacy curtain to close. R23 has a roommate that was present at the time of the
observation (R26).
On 8/17/2022 at 10:55am V14 said she doesn't have a privacy curtain; she should have one.
On 8/17/2022 at 11:10am V16 (Maintenance Director) said it should be privacy curtains in all the residents'
room that have a roommate.
On 8/17/2022 at 11:12am V2(Director of Nursing-RN) said all residents that have a roommate should have
a privacy curtain.
On 8/19/2022 at 10:33am A care plan dated 7/19/2022 indicates that R23 needs assistance with activity of
daily living care.
Facility Policy- Revised May 2020
Policy
Resident's rooms are designed and equipped for adequate nursing care, comfort, and privacy of residents.
-Bedrooms are designed or equipped to assure full visual privacy for each resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 2 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on observation, interview, and record review, the facility failed to update and implement the fall and
care plan for two (R11, R14) of two residents in a sample of 15 reviewed for care plan revision and
implementation.
Findings include:
1. On 08/16/22 at 11:25AM during observation, R14's bed was observed with regular mattress on the bed
frame.
On 08/18/22 at 11:40AM, V2 (Director of Nursing) said that R14 should have a winged mattress on.
A post fall review for R14 dated 05/28/22 indicated a new fall prevention intervention to be implemented as
a result of the assessment was a winged mattress. Current care plan printed indicates safety/falls
intervention of winged mattress.
On 08/16/22 at 11:40AM, R11's order summary report dated 08/16/22 indicated admission date of 03/01/22
and diagnoses of age-related osteoporosis, unsteadiness on feet and repeated falls. Incident progress note
dated 03/26/22 indicated that at 10:55AM on 03/26/22 CNA alerted nurse that R11 was on the floor in her
room. It also stated that R11 stated she tried to get up by herself to go to the bathroom and slid off her bed
onto the floor.
On 08/17/22 at 9:29AM, V2 stated that after a fall, full body assessment should be done, an incident report
and post fall review investigation should be completed, and the care plan should be updated. She also said
that there was no post fall review done for the fall incident of R11 on 03/26/22 and the care plan was not
updated.
Facility policy:
Policy Title: Accidents/Falls - HDGR
Revision Date: May 2020
Definitions:
The definition of a fall extends to include the following factors:
- When a resident is found on the floor, a fall is considered to have occurred
Procedure:
10. The resident's individualized care plan is to be updated with any changes or new interventions post
fall/incident/accident, communicated to appropriate staff, and implemented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 3 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to shave facial hair of a resident who is
dependent with personal hygiene and grooming. This deficiency affects one ( R19) of three residents in the
sample of 15 reviewed for Activity of Daily Living (ADL).
Residents Affected - Few
Findings include:
On 8/16/22 at 10:15am, Observed R19 with facial hair on her chin and cheek area.
On 8/16/22 at 10:38am, V7 CNA (Certified Nurse Assistant) said that she is the CNA assigned for R19 and
she needs total care with her ADLs.
On 8/17/22 at 10:25am, Observed R19 still with facial hair on her chin and cheek area. V7 said she is the
CNA assigned for R19. She said she did not shave the facial hair of R19 because she is a hospice resident.
V7 said that the hospice CNA came yesterday but she did not do it. The hospice CNA should shave the
facial hair of R19.
Informed and showed observation to V14 RN (Registered Nurse) that R19 was observed for 2 days
(yesterday and today) with facial hair. V14 said that part of morning care and daily personal hygiene and
grooming performed by CNA to resident is to shave facial hair.
On 8/17/22 at 10:47am, V2 DON and V3 MDS/ Care Plan Coordinator said that shaving resident facial hair
is done by CNA during shower/bed bath or as needed when performing personal hygiene and grooming as
part of daily ADLs.
Review R19's medical records indicated that she has diagnosis to include Cerebral Atherosclerosis,
Traumatic Subdural Hemorrhage. R19 care plan indicates that she has self care deficit due to
medical/physical status- impaired mobility, weakness.
Facility's policy on Activity of Daily Living (ADL) indicates:
A resident who is unable to carry out activities of daily living receives the necessary services to maintain
good nutrition, grooming and personal hygiene.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 4 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to provide treatment and care in
accordance with physician orders. The facility also failed to identify and assess the resident's skin
impairment and obtain appropriate treatment order from the physician. This deficiency affects all three (R1,
R19 and R26) residents in the sample of 15 reviewed for Quality of Care.
Residents Affected - Few
Findings include:
1. On 8/16/22 at 10:38am, Observed R19 right arm dressing soiled with blood. Showed observation to both
V7 CNA (Certified Nurse Assistant) and V8 CNA who are providing incontinence care to R19. Both said
that V10 RN is the assigned nurse for R19.
On 8/16/22 at 2:24pm, Observed R19 right arm dressing is undone, and loose. Right elbow open wound is
exposed with dried blood. V10 said that V7 CNA did not tell her that R19's right arm dressing was soiled
with blood this morning. V10 RN (Registered Nurse) cut the bandage dressing on R19's with scissors. R19
removed the non-adherent dressing on left upper arm. No dressing covering the right elbow wound. V10
cleansed the wound on right upper arm and right elbow with wound cleanser. V10 applied 4x4 gauze to
both wound on upper arm and elbow, then wrapped with bandage dressing.
Review wound treatment of R19 to right upper arm and elbow with V10 RN. R19 has treatment order of
Mepelix (Foam dressing) for right upper arm, But no order for right elbow. Informed V10 that she applied
4x4 gauze dressing to right upper arm and wrapped it with bandage. V10 apologize and said that she
should apply the Mepilex dressing and follow the physician order. V10 said that the CNA did not inform her
this morning that R19's right arm is soiled with blood.
On 8/17/22 at 10:25am Observed R19's right arm dressing is undone and loose. R elbow wound is
exposed. Observed V14 RN performed right upper arm and right elbow wound care to R19. V14 said that
right arm wound is from skin tear. When V7 and V14 repositioned R19 to her right side, observed huge
purple blister at the back of right calf. Both V7 and V14 said that this is new. V14 said that there are no
treatment orders for right elbow wound and purple blister on right calf. V14 said that changes in resident
skin condition should be called to physician for treatment order.
On 8/18/22 at 10:47am, V2 DON (Director of Nursing) said that CNA who observed changes in skin
condition or dressing soiled or wound dressing undone should report to the nurse. The nurse will then
assess and call the physician for treatment order.
Review R19's medical records indicated that she has diagnosis to include Cerebral Atherosclerosis,
Traumatic Subdural Hemorrhage. R19 is a hospice resident. R19's care plan indicates that she has
self-care deficit due to medical/physical status- impaired mobility, weakness. She has actual skin
impairment due to current medical/physical status.
2. On 8/16/22 at 10:30am, R1 is up in wheelchair in the dining room with group activity. She is not wearing
compression stocking.
Review R1's medical records indicates that she has diagnosis of Congestive Heart Failure, Hypertension.
She has order of compression stockings for edema apply in AM (morning), off at HS (bedtime).
On 8/16/22 at 3:16pm Observed R1 lying in bed still with not wearing compression stocking.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 5 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
On 8/16/22 at 3:19pm Asked V12 Agency CNA and V11 RN if R1 is using compression stocking. Both said
they did not know because it usually applied in the morning shift.
On 8/17/22 at 9:18am Informed V2 DON of observation made yesterday for R1 and R19. V2 said that they
should follow and implement physician order.
Residents Affected - Few
Facility's policy on Implementing Physician order indicates: to ensure physician orders are implemented.
This policy applies to nurse, therapists, medication aides and any other individuals who provide care,
treatment or other services for the center and or its patients.
Plan:
1. Physician/provider orders will be implemented as written.
5. Physician/Provider orders received will be implemented by persons with qualifications to administer the
specific order.
Facility's policy on Notification to physician/Family/Resident representative of change in resident health
status indicates:
The facility will consult the resident's physician, nurse practitioner or physician assistant and notify the
resident representative or an interested family member when there is:
*Acute illness or a significant change in the resident's physical. Mental or psychosocial status (deterioration
in health, mental or psychosocial status in either life threatening conditions or clinical complications).
*Need to alter treatment significantly (need to discontinue or change an existing form of treatment due to
adverse consequences or to commence a new form of treatment)
Facility's policy on Pressure injury/Skin integrity/Wound management indicates: A system is in place for the
prevention, identification, treatment and documentation of pressure injuries and non-pressure wounds. A
resident with pressure ulcer will received treatment and services consistent with professional standards of
practice to promote healing and prevent infection and prevent new pressure injuries from developing.
Procedure:
C. Routine/ongoing documentation:
i. Daily and or routine ongoing documentation should be conducted by the licensed nurse related to the
resident's skin condition and the resident's response to the care and treatment of the skin. This includes
non-pressure wounds as well.
3. On 8/17/2022 at 11:20am R26 was observed with a dressing on her right hand and a dressing on her left
buttocks. V14 (Registered Nurse-RN) said I don't have an order for the right hand or the left buttocks I will
notify the physician now.
On 8/18/2022 at 10:30am V2 (Director of Nursing-DON) said if a resident has any type of dressing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 6 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
applied then it should be a physician order.
Level of Harm - Minimal harm
or potential for actual harm
On 8/18/2022 at 12:00pm A Physician order dated 8/17/2022 indicates an order for Right back of hand
cleanse area with normal saline apply bacitracin cover with dry dressing every night shift for skin tear. A
Physician order dated for 8/17/2022 for Left buttocks moisture associated skin damage apply mupirocin
Ointment 2 % topically every night shift. A care- plan dated 8/8/2022 for skin integrity, intervention to
Observe skin in AM/PM care and with toileting for redness, rashes, open areas, pian, swelling, and report
them to team leader and weekly skin check.
Residents Affected - Few
Facility Policy: Revision September 2011, October 2016, November 2016
Pressure Injury/Skin Integrity/Wound Management-HDGR
Policy
A system is in place for the prevention, identification, treatment, and documentation of pressure injuries and
non-pressure wounds.
Procedure
1.
Wound Assessment
b. Weekly:
I. A weekly skin check will be conducted and documented for at risk residents.
3. Treatment/Management
a. Residents with risk for or who have a loss of skin integrity will receive the appropriate treatment/services,
and residents who are determined to ne at risk for or who have loss of skin integrity will receive the
appropriate treatment/services which may include.
x. Assessment/care to prevent infections: and or
b. All interventions and treatments should be evaluated for efficacy and modified/changed as needed.
4. Documentation
a. Assessment:
I. Assessment information should identify specific factors that might increase the risk of pressure injury
development or affect healing of a pressure injury such as.
8. Incontinence
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 7 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to follow manufacturer recommendation
in usage of low air loss mattress to enhance wound healing. The facility also failed to identify and assess
the resident's skin impairment and obtain appropriate treatment order from the physician. This deficiency
affects two (R1 and R19) of three residents in the sample of 15 reviewed for Wound care management.
Residents Affected - Few
Findings include:
1. On 8/16/22 at 10:38am, Observed R19 lying in low air loss mattress with fitted sheet, disposable pads
and cloth pads over the mattress. R19 wears disposable brief. V7 CNA (Certified Nurse Assistant) and V8
CNA said that there should be only fitted sheet and disposable pads not cloth pad. Observed black
discoloration on left heel and non-blanchable redness on right heel.
On 8/17/22 at 10:25am V14 RN said that she is the nurse for R19. She is not aware that R19 has black
discoloration on her left heel and non-blanchable redness on her right heel. V7 CNA said that she forgot to
inform V10 RN yesterday ( 8/16/22) when she observed left heel black discoloration and right
non-blanchable redness on right heel while providing incontinence care with R19 observed by surveyor on
8/16/22.
V7 CNA and V14 RN repositioned R19 to her right side. Observed huge purple blister at the back of right
calf. Both V7 and V14 said that this is new. Observed foam dressing on sacral area. V14 said that last
Friday (8/12/22) when she did wound care to R19 she has MASD (moisture associated skin disorder) but
today the wound worsens and progress to Stage 3 with slough formation and dark discoloration on wound
bed.
V14 RN said that there are no treatment orders for black discoloration on left heel, non-blanchable redness
on right heel and purple blister on right calf. V14 said that changes in resident skin condition should be
called to physician for treatment order.
Review R19's medical records indicated that she has diagnosis to include Cerebral Atherosclerosis,
Traumatic Subdural Hemorrhage. R19 is a hospice resident. R19's care plan indicates that she has
self-care deficit due to medical/physical status- impaired mobility, weakness. She has actual skin
impairment due to current medical/physical status. Care plan intervention indicated usage of low air loss
mattress.
Review R19's Wound care physician wound report dated 8/5/22 indicates that she has unstageable (due to
necrosis) sacrum Pressure ulcer full thickness, duration - 3 days ago, measures 1.6x1.2x0.1cm, moderate
serous exudate, 15% necrotic, 25% slough and 60% granulation. Other diagnosis Moisture Associated
Dermatitis.
On 8/17/22 at 9:18am, Informed observation to V2 DON (Director of Nursing), she said that resident on low
air loss mattress should only flat sheet over the mattress.
On 8/18/22 at 10:47am, V2 DON (Director of Nursing) said that CNA who observed changes in skin
condition or dressing soiled or wound dressing undone should report to the nurse. The nurse will then
assess and call the physician for treatment order.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 8 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
2. On 8/16/22 at 3:19pm, Observed R1 lying in low air loss mattress with fitted sheet, folded linen/sheet and
cloth pad. R1 wearing disposable adult brief. Showed observation to V11 RN. V11 said that ideally it should
only be flat sheet over the mattress. Observed V11 performed wound care to R1 to left buttocks. V11 said
that R11 has pressure ulcer that became infected.
Review R1's medical records indicated that she has diagnosis of Congestive Heart Failure, Rheumatic
disorders of valve, Dementia. Wound care physician report dated 8/12/22 indicated Left upper buttocks,
etiology- infection, measures 1x1.3x1.1 cm, moderate serous exudate, 5% slough and 95% granulation.
Low air loss manufacturer recommendation given by V2 DON indicated:
Special consideration: Make sure you don't place unnecessary equipment between the patient's skin and
the surface which would block the beneficial effects of the mattress.
Facility's policy on Pressure injury/Skin integrity/Wound management indicates: A system is in place for the
prevention, identification, treatment and documentation of pressure injuries and non-pressure wounds. A
resident with pressure ulcer will received treatment and services consistent with professional standards of
practice to promote healing and prevent infection and prevent new pressure injuries from developing.
Procedure:
C. Routine/ongoing documentation:
i. Daily and or routine ongoing documentation should be conducted by the licensed nurse related to the
resident's skin condition and the resident's response to the care and treatment of the skin. This includes
non-pressure wounds as well.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 9 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview and record review the facility failed to implement fall care plan
interventions to residents who are high risk of falls. The facility also failed to follow its policy in investigation
of a fall incident occurrence. This deficiency affects two (R1 and R11) of three residents in the sample of 15
residents reviewed for Fall prevention management.
Findings include:
On 8/16/22 at 2:30pm, Observed R1 lying in bed, with 2 floor mats folded and placed at the corner of her
room. Floormats were not placed on bilateral sides of the bed.
On 8/16/22 at 3:16pm, V11RN (Registered Nurse) said that R1 is on fall precautions due to her risk of
falling. Informed V11 of observation made. V11 said that floor mats should be on both side of R1's bed
when she is lying on bed.
Review R1's medical records indicated she has diagnosis of Macular Degeneration, History of Falling,
Abnormality of Gait, Dementia, Unsteadiness on feet. R1's care plan indicates she is at risk for fall due to
current medical/physical status-poor safety awareness, unsteady gait and balance. R1 has multiple falls
incident at the facility. R1 fell on 2/14/22, 2/24/22, 5/8/22, 5/29 and 5/30/22. Most recent fall assessment
done on 5/30/22 indicated that she is at high risk for fall. Fall intervention indicates fall mat on the floor near
to bed- standard on both sides.
On 8/17/22 at 10:47am V2 DON (Director of Nursing) said that floor mat should be on the floor when the
resident is in bed as indicated in care plan.
Facility's policy on Accidents/Falls indicates: The facility strives safety, dignity and overall quality of life for its
resident by providing an environment that is free from any hazards for which the facility has control and
providing appropriate supervision and interventions to prevent avoidable accidents.
2. On 08/17/22 at 9:29AM, V2 stated that after a fall, full body assessment should be done, an incident
report and post fall review investigation should be completed, and care plan should be updated. She also
said that there was no post fall review done for the fall incident of R11 on 03/26/22.
R11's order summary report dated 08/16/22 indicated admission date of 03/01/22 and diagnoses of
age-related osteoporosis, unsteadiness on feet and repeated falls. Incident progress note dated 03/26/22
indicated that at 10:55AM on 03/26/22 CNA alerted nurse that R11 was on the floor in her room. It also
stated that R11 stated she tried to get up by herself to go to the bathroom and slid off her bed onto the
floor.
Facility policies:
Policy Title: Accidents/Falls - HDGR
Revision Date: May 2020
Definitions:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 10 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
The definition of a fall extends to include the following factors:
Level of Harm - Minimal harm
or potential for actual harm
When a resident is found on the floor, a fall is considered to have occurred
Procedure:
Residents Affected - Few
7.Each incident/accident or fall must be investigated and/or assessed to determine the cause of the
episode to prevent any further injury.
9. A post fall assessment will be conducted following any fall episode within 24 hours post fall.
10. The resident's individualized care plan is to be updated with any changes or new interventions post
fall/incident/accident, communicated to appropriate staff, and implemented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 11 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, interview, and record review, the facility failed to dispose expired medications of R8,
R11 and R19 from low side medication cart. This observation was made in one of one medication carts
observed for expired medications.
Findings include:
On 08/16/22 at 10:40AM during observation, low side medication cart was observed with the following:
1.
R19's Travoprost 0.004% indicating an open date of 7/9/22. Label reads Discard 28 days after first use.
2.
R8's Systane lubricant eye drops indicated open date 7/23/22 with expiration date of 5/2022
3.
R11's Magnesium oxide 400mg tab with expiration date 7/31/22
4.
R11's Omeprazole DR 20mg capsule with expiration date 7/31/22
On 08/16/2022 at 11:15AM, V10 (Registered Nurse) observed with surveyor the expiration dates of the
above-mentioned medications. She said that all medications should be checked for expiration and be
removed from the cart and placed in the bin inside the medication room for disposal.
On 08/16/2022 at 11:23AM, V2 (Director of Nursing) said that there should not be any expired medications
in the carts. She added that all nurses are expected to check the carts for expired medications and remove
them for disposal.
Facility policies:
Policy Title: 5.3 Storage and Expiration Dating of Medications, Biologicals
Revision Date: 01/01/2022
Procedure:
4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2)
have been retained longer than recommended by manufacturer or supplier guidelines; . are stored separate
from other medications until destroyed or returned to the pharmacy or supplier.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 12 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Policy Title: 8.2 Disposal/Destruction of Expired or Discontinued Medication
Level of Harm - Minimal harm
or potential for actual harm
Revision Date: 01/01/2022
Procedure:
Residents Affected - Few
4. Facility should place all discontinued or outdated medications in a designated, secure location which is
solely for discontinued medications .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 13 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
Based on observation, interview and record review the facility failed to communicate and collaborate with
hospice services regarding changes in resident's skin condition. The hospice services failed to provide
facility the documentation to promote communication between facility and hospice service to coordinate
resident care. This deficiency affects one (R19) of three residents in the sample of 15 reviewed for Hospice
services.
Findings include:
On 8/16/22 at 10:38am Observed R19 lying in bed in her room, with O2 via NC at 2LPM. R19 is on low air
loss mattress with floor mat on the right side of the bed.
On 8/16/22 at 11:10am, V9 Medical Record said that resident who is on hospice care usually have a binder
with all documents from hospice including- admission notes, consent, plan of care and discipline notes. V9
searched for the binder at the nursing station's cabinet but unable to find it. V9 looked for the R19's paper
chart but found have the 1-page admission assessment from hospice care service signed by hospice staff.
Surveyor called V2 DON (Director of Nursing).
V2 DON said that usually the V6 Social Worker (SW) is the one responsible for hospice documents. V2 said
that they don't have social service in the building but she's calling V6 to come in. V2 said that V6 only works
interim. V2 said she does not know what hospice information should be available in the facility. Surveyor
called V1 Administrator.
On 8/16/22 at 11:25am, V1 Administrator said that there should be a binder for the hospice service records
or in R19's chart such as consent for admission, care plan of care, frequency of visits, IDT visit notes.
Informed V1 that no hospice records available in resident 's paper chart and e-chart. R21 was admitted to
Journey care hospice on 7/12/22. V1 searched the cabinets in the nursing station and asked the DON to
search for the hospice documents for R19. Both V1 and V2 could not find it. V1 called V3 Care plan
Coordinator to help look for R19's hospice documents. Both V1 and V3 again searched the cabinets and
R21's chart in the nursing station. Both still cannot find it. V2 said that she will call the hospice service.
Discussed concern with V1 Administrator and V2 DON regarding concern of hospice service provision of
information to promote communication between facility and hospice service in coordinating and
collaborating R19's medical needs and care.
V6 Social Worker did not come to the facility and unable to interview.
On 8/17/22 at 10:47am, Follow with V2 DON and V3 Care Plan coordinator for R19's hospice records. V3
showed faxed copies from hospice services of R19's hospice records dated 8/17/22 at 9:34am. Documents
included Physician certification of terminal illness, physician justification of hospice services, Medication
report, Episode summary report and Plan of care. No Interdisciplinary team (IDT) calendar of visits and
notes included. Asked V3 for hospice nurses and CNAs visit and notes from admission date of 7/12/22. V3
said she will call again the hospice service to fax the IDT visit notes.
No hospice nurses and CNA visits notes provided to surveyor.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 14 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
On 8/16/22 at 10:38am, Observed R19 with black discoloration/necrotic on left heel and non-blanchable
redness on right heel.
On 8/16/22 at 2:24pm, Observed V10 RN performed wound care on right arm- right upper arm and right
elbow. No treatment order for wound on right elbow.
Residents Affected - Few
On 8/17/22 at 10:25am Observed V14 RN and V7 CNA performed wound care on sacral area. Observed
huge purple blister at the right calf. Both V7 and V14 said that this is new. V14 said that last Friday (8/12/22)
when she did wound care to R19 she has MASD (moisture associated skin disorder) but today the wound
worsens and progress to Stage 3 with slough formation and dark discoloration on wound bed. V14 RN and
V10 RN said that she is not aware that R19 has black discoloration/necrotic on her left heel and
non-blanchable redness on her right heel. V14 said that there is no treatment order for wound on right
elbow, black discoloration/necrotic on left heel ,non-blanchable redness on right heel and purple blister on
right calf.
Informed V2 DON of above wound care observation. V2 said that any changes in resident condition should
be notified to hospice services.
Requested to interview with hospice service personnel in charge of R19. Unable to interview hospice
personnel.
On 8/19/22 at 11:01am Follow up with V15 Nurse consultant, requested interview with hospice nurse in
charge of R19. She said she will try again. V15 said failed to provide informational records for R19 as
indicated in their contract.
Review R19's medical records indicated that she has diagnosis to include Cerebral Atherosclerosis,
Traumatic Subdural Hemorrhage. R19 is admitted to hospice care on 7/12/22.
Facility's contract with Hospice service provider indicates:
Responsibility of facility:
e. Coordination of care.
f. Notification of change in condition. The facility shall immediately inform hospice of any changes in the
condition of hospice patient.
Responsibility of Hospice:
e. Provision of information. Hospice shall promote open and frequent communication with facility and shall
provide facility with sufficient information so that the provision of facility services under this agreement is in
accordance with each hospice patient's hospice plan of care, assessments, treatment planning and care
coordination.
i. Hospice plan of care, medications and orders- the most recent hospice plan of care, medication
information and physician orders specific to each hospice patient residing at facility.
ii Election form-Hospice election form and any advance directives
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 15 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
(X3) DATE SURVEY
COMPLETED
A. Building
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
iii Certifications- Physician certification and recertifications of terminal illness.
Level of Harm - Minimal harm
or potential for actual harm
iv. Contact information-Names and contact information for hospice personnel involved in providing hospice
services
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 16 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to implement appropriate hand
hygiene, disinfecting of medical equipment and implementing proper perineal care for female resident. This
deficiency affects all three (R1, R19 and R21) residents in the sample of 15 reviewed for infection control
during resident care and wound care.
Residents Affected - Few
Findings include:
On 8/16/22 at 10:45am, V7 CNA (Certified Nurse Assistant) and V8 CNA performed incontinence care to
R19. V7 removed the fecal matter from R19's rectal area with wipes. V7 removed her right-hand glove and
applied new glove without performing hand and hygiene. She applied barrier cream and removed righthand glove and applied new glove without performing hand hygiene.
Informed V7 CNA of above observation made. V7 said that she forgot to wash her hand after removed her
glove. V7 said hand washing is done before putting on gloves and after removing it.
On 8/16/22 at 11:08am, V2 DON (Director of Nursing) said that hand hygiene, hand washing or hand
sanitizer, is done before and after donning gloves.
On 8/16/22 at 2:24pm, V10 RN (Registered Nurse) placed all the prepared wound dressing in plastic tray.
V10 placed the plastic tray on R19's bedside tray table. V10 cut the bandage dressing on R19's right arm
with scissors. V10 cleansed the wound on left upper arm and left elbow with wound cleanser. V10 did not
change gloves. V10 applied 4x4 gauze to both upper arm and elbow, then wrapped with bandage dressing.
V10 use same gloves for the entire wound dressing. V7 placed back the plastic tray on top of the treatment
cart without disinfecting it. V7 placed back the scissors and wound cleanser bottle inside the treatment cart
without disinfecting it. V7 also return remaining gauze dressing inside the treatment cart.
On 8/16/22 at 2:55pm, V10 RN placed all the dressing supplies for wound care on right heel on plastic tray.
V10 placed the plastic tray on R21's chair. V10 cleansed the right heel wound with minimal serous drainage
with NSS. V10 did not change gloves after cleaning. V10 applied calcium alginate covered with foam
dressing. She used same gloves for the entire wound care. V10 placed the plastic tray on top on the
treatment cart without disinfecting it. V10 returned all the remaining gauze dressing inside the treatment
cart.
Informed V10 RN of wound observation made on 2 residents. V10 said that she forgot to change gloves
after removing the dressing and cleansing wound. V10 said she should don new gloves when applying
clean dressing. V10 said she forgot to disinfect plastic tray and scissors after each resident use.
On 8/16/22 at 3:19pm, V12 Agency CNA and V11 RN provided incontinence care with R1. V11 said that R1
is soiled with urine. V12 provided incontinence care by wiping R1's rectal area to urethral area. V12 did not
change gloves after cleaning. V12 applied clean disposable brief and dressed R1. V12 used the same
gloves for the entire incontinence care.
Informed V12 Agency CNA of above observation during incontinence care. V12 said that he should wipe
from front to back when cleaning perineal of R1 during incontinence care. V12 added that he forgot to
change his gloves. V12 said he should change gloves after wiping and before applying clean disposable
brief.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 17 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145852
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Prospect Heights
700 East Euclid Avenue
Prospect Heights, IL 60070
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 8/16/22 at 3:41am, V11 RN said that V12 Agency CNA should wipe from front to back instead of back to
front when providing incontinence care to R1. V12 should also change glove after wiping peri care and
before applying clean disposable brief.
On 8/17/22 at 9:18am, V2 DON said that plastic tray and scissors should be disinfected after each resident
use. Hand hygiene should be performed after in contact with body fluids such as during incontinence care
and wound care. V2 said that when providing incontinence care to female resident it should be wipe from
front to back (from urethra to rectal area).
Facility's policy on Hand washing/hygiene indicates: This facility considers hand hygiene the primary means
to prevent the spread of infections.
Procedures:
2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of
infections to other personnel, residents and visitors.
5. Employees must wash their hands for at least 20 seconds using antimicrobial or non antimicrobial soap
and water under the following conditions:
b. When hands are visibly soiled (Hand washing with soap and water)
c. Before and after direct resident contact
h. Before and after assisting a resident with personal care.
k. Before and after changing a dressing.
u. After removing gloves or aprons
Facility's policy on Perineal care indicates: Resident will be provided with perineal care to promote
adequate skin integrity to ensure clean, dry skin and to control odor.
Procedures:
10. For female, spread labia. Clean with warm soap and water. Wash from urethral area toward rectum and
then aspect of thighs.
Facility's policy on cleaning resident equipment/medical device indicates: This policy applies to all
employees, applicants, contract staff, students, trainees, volunteers, non-employed licensed practitioners
and any other individual who provide care, treatment or other services for the community.
Plan
B. Blood pressure cuffs, stethoscopes and medical devices will be wiped down by the nursing staff using an
EPA ( Environmental protection agency) approved disinfectant.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145852
If continuation sheet
Page 18 of 18
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Back to topCitations
35 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F761 - Labeling of Drugs and Biologicals
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.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0133GeneralS&S Fpotential for harm
Install a two-hour-resistant firewall separation.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0781GeneralS&S Epotential for harm
Have restrictions on the use of portable space heaters.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F926 - Establish policies, in accordance with applicable Federal, State, and
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
FAQ · About this visit
Common questions about this visit
What happened during the August 19, 2022 survey of EDEN VISTA PROSPECT HEIGHTS?
This was a inspection survey of EDEN VISTA PROSPECT HEIGHTS on August 19, 2022. The surveyor cited 35 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EDEN VISTA PROSPECT HEIGHTS on August 19, 2022?
Yes, 35 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.