Health inspection·February 26, 2025

F 0686 2/13/25. R1's medical record did not document any skin or wound assessment until 2/18/25. Level of Harm - Minimal harm or potential for actual harm R1's wound evaluation dated 2/18/25 documents: pressure stage 3 to coccyx measuring length 2.57 centimeters (CM) x 0.96 cm width x 0.3 CM depth. Present on admission. R1's wound evaluation dated 2/19/25 documents MASD_ incontinence associated dermatitis to left gluteus measuring 3.66 CM length x 2.52CM width x 0.2 cm depth. Inhouse acquired. Residents Affected - Few R1's physician orders do not document any wound or treatment orders when transferred to skilled unit on 2/13/25. R1's medication and treatment record do not document any treatments to R1 on 2/13/25 until 2/18/25. R1's physician order dated 2/18/25 with start date of 2/19/25. Coccyx cleanse with normal saline. Pat dry. Apply Medi honey and cover with bordered dressing every day. Discontinued 2/19/25. R1's physician order dated 2/14/25: Wound consult On 2/25/25 at 3:38PM, V2(DON) said skin assessment are done weekly by staff. On memory care if there was a wound reported it would be referred to home health for treatment. V2 said a referral was sent to home health but unsure what happened. V2 was requested to provide documentation of referral but none provided during the survey. V2 said home health did not evaluate R1's wounds and he was moved to skilled unit for treatment and therapy. V2 said staff should conduct a skin assessment when moving to another unit and was unable to find or locate any documentation of R1's skin assessment on 2/13/25. V2 said residents should have a treatment in place and documented in the medical record. V2 was unable to find, present or locate any documentation of treatment orders or administration of treatment for R1 from 2/13/25 through 2/18/25. V2 said R1 was expected to have an air loss mattress when he moved to skilled because of the wounds. V2 was unable to recall if he was provided an air loss mattress. On 2/26/25 at 9:35AM, V2(DON) said R1 was not seen by wound doctor on 2/14/25. V2 said regular wound doctor was not here and a replacement doctor was sent but did not see all the residents, including R1. On 2/26/25 253pm V6 (wound care MD) said he saw R1 on 2/19/25 for initial visit. V6 said he was unsure why R1 was not seen on 2/14/24. R1 was on group one mattress which is a pressure relieving mattress not an air loss mattress. V6 said he put in orders for air loss mattress after visiting due to wound being a stage three pressure sore. V6 said he would have expected some treatment to be in place for wounds to prevent infection prior to visit. V6 said staff can call him with any concerns or new wounds and does not recall any calls or concerns related to R1. On 2/26/25 at 1:03PM, V5(MD) said she would expect an order for any treatment for a open wound and all orders to be followed as ordered. Initial wound evaluation by V6(wound MD) dated 2/19/25 documents support surface group 1. Under wounds stage three pressure sore measuring 2.5 centimeters (CM) length x 3.5 CM width x 0.1cm depth. Under recommendations air loss mattress. Wound two moisture associated skin damage measuring 5.5 CM length x 4.5 CM width x o.1cm depth R1's mattress delivery order submitted 2/19/25 and delivered stat on 2/19/25. R1's physician order dated 2/18/25: may use air loss mattress. Please verify it's in good working condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145852 If continuation sheet Page 2 of 3 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 02/26/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Facility pressure injury prevention and wound care management policy revised 3/4/24 documents: the purpose of the policy is to provide healthcare staff with the standards of care and the processes to be followed by all residents. To identify factors that places the resident at risk for development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds, to promote systematic approach and monitoring process for the care of residents with existing wounds and those who are at risk for skin breakdown, to promote healing of existing pressure injuries and wounds. It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, with comprehensive assessment and plan of care. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Skin impairments including pressure injuries should be assessed and documented weekly. Event ID: Facility ID: 145852 If continuation sheet Page 3 of 3