Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
This applies to 3 of 3 residents (R1, R3, R4) reviewed for call light response times in the sample of 4.
The findings include:
1. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple
diagnoses including, diabetes, atrial fibrillation, chronic kidney disease, heart disease, hypertension,
difficulty walking, unsteadiness on the feet, morbid obesity, glaucoma, and dementia.
R3's MDS dated [DATE] shows R3 is cognitively intact, requires setup with eating and oral hygiene,
substantial/maximal assistance with bed mobility, and is dependent on facility staff for all other ADLs. R3 is
always incontinent of bowel and bladder.
R3's care plan entitled, At risk for alteration in skin integrity related to decreased mobility on a wheelchair,
incontinent of bowel and bladder, and history of pressure ulcer initiated on April 19, 2024 shows multiple
interventions revised on April 22, 2024 including, Keep skin clean and dry.
R3's care plan entitled, The resident has an ADL self-care performance deficit r/t (related to) impaired
mobility, weakness. Interventions updated on April 22, 2024 include, Toilet use assist - two staff assistance.
On January 15, 2025 at 9:50 AM, R3 was lying in bed in his room. A strong odor of stool was present in the
room. R3 said his incontinence brief was last changed at 5:00 AM before the night shift went home. R3
said, The last time I was changed was 5:00 AM today. Shortly after being changed, I had a bowel
movement. I know not to press the call light during shift change or when they pass breakfast because no
one will come. Around 7:30 AM or 7:45 AM, when they brought my breakfast tray, I told them that I needed
to be changed. She said she would come back at 8:30 AM to clean me up. As of 9:50 AM, no one has
come, and I have been sitting in poop for many hours. My butt is burning from sitting in poop this long. I
press the call light and when no one comes, I just hold down the button continuously because I think that
sets off an alarm somewhere else showing I really need assistance. When that doesn't work, I just start
screaming out loud for help. They don't like that very much.
During the conversation with R3, R3 pressed the call light to request assistance. No audible call light alarm
could be heard, and the facility does not have illuminated lights over the resident's
(continued on next page)
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 3
Event ID:
146094
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
146094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Burr Ridge
6801 Highgrove Boulevard
Burr Ridge, IL 60527
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
doorways to show which room is calling for help. A scrolling sign was located at the other end of the
hallway, at the nurse's station, showing R3's call light was activated. V9 (LPN-Licensed Practical Nurse)
was passing medications near R3's room. V9 did not stop administering medications to answer R3's call
light. No CNAs were visible in the hallway.
After 10 minutes and 25 seconds, V5 (SS) came to R3's room to ask if he needed help. R3 told V5 he
needed assistance with incontinence care. V5 said she would find a staff member to assist R3. After a total
call light response time of 13 minutes and 26 seconds, V8 (CNA) came to R3's room. R3 said he felt like he
had waited too long to receive incontinence care. V8 said she was assigned to twelve residents and was
busy providing incontinence care to two other residents and had not been able to answer R3's call light or
attend to his need for incontinence care. At 10:09 AM, V8 (CNA) turned R3 to his right side and removed
his incontinence brief. R3 had stool caked on the back of his legs, from his mid-thighs up to his buttocks.
R3's entire buttocks was covered in stool. Stool had also leaked out of the top of R3's incontinence brief
and had spread up R3's lower back. V8 (CNA) had to use multiple disposable wipes, and wiped multiple
times over the same area to remove the stool because the stool was caked to R3's skin and did not wipe off
easily. As V8 (CNA) used disposable wipes to clean stool from R3's legs, buttocks, and lower back, R3
cried out several times and said his skin felt sensitive and was burning. The skin on R3's buttocks was
bright red in the areas where stool had been caked on his skin.
2. On January 15, 2025 at 9:27 AM, R4 was lying in bed in his room. R4 said, I have lived here less than a
month. It takes them a very long time to answer call lights. One time it took over an hour. Forget calling for
help around here. It takes too long for them to come to help. If I could do it myself I would, but obviously
that's why I am here, because I can't do things for myself.
The EMR shows R4 was admitted to the facility on [DATE]. R4 has multiple diagnoses including,
hypotension, acute kidney failure, heart failure, atrial fibrillation, COPD (Chronic Obstructive Pulmonary
Disease), hyponatremia, cognitive communication deficit, difficulty walking, and macular degeneration.
R4's MDS (Minimum Data Set) dated December 29, 2024 shows R4 is cognitively intact, requires setup
assistance with eating, substantial/maximal assistance with oral hygiene, and is dependent on facility staff
for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder.
On January 8, 2025 at 10:32 AM, V5 (SS-Social Services) documented, Main topics discussed: Call
response times: SS contacted [V17] (Daughter of R4) regarding a complaint about call times related to
[R4]. The call light records were reviewed from the 1st to the 8th (January 2025). Average call response
time was approximately 29 minutes. The longest recorded wait time was on the 6th (January 2025) from
7:00 AM to 10:46 AM, likely due to high call volume. Specific concerns: [V17] (Daughter of R4) noted
concerns about two call times exceeding an hour. One confirmed incident was on the 6th (January 2025).
An additional concern for the 5th reported by [V17] (Daughter of R4), though exact timing was unclear.
Follow-up Actions: SS is actively working on resolving the issues and request that [V17] (Daughter of R4)
reach out if she has further questions.
On January 16, 2025 at 9:15 AM, V5 (SS) said, [R4's] family had concerns regarding call lights taking too
long to be answered. I forwarded the concerns to [V2] (DON-Director of Nursing), and she said she would
take care of it and make sure it didn't happen anymore.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146094
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
146094
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eden Vista Burr Ridge
6801 Highgrove Boulevard
Burr Ridge, IL 60527
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
Level of Harm - Minimal harm
or potential for actual harm
3. The EMR shows R1 was admitted to the facility on [DATE] and was discharged to home on January 9,
2025. R1 had multiple diagnoses including, subluxation of C1/C2 cervical vertebrae, chronic osteomyelitis,
displaced fracture of the second cervical vertebra, displaced posterior arch fracture of the first cervical
vertebra, heart failure, rheumatoid arthritis, presence of bilateral artificial hip joints, dysphagia, spinal
stenosis, and adjustment disorder.
Residents Affected - Few
R1's MDS dated [DATE] shows R1 had moderate cognitive impairment and was dependent on facility staff
for all ADLs. R1 was always incontinent of bowel and bladder. R1's MDS continues to show R1 was
admitted to the facility with an unstageable pressure ulcer.
On January 14, 2025 at 1:06 PM, V1 (Administrator) reviewed the call light logs for the entirety of R1's stay
at the facility. V1 said, There were call light response times over 45 minutes. On January 1, 2025 the call
light log shows it took 85 minutes for [R1's] call light to be answered. On January 5, 2025 the call light log
shows it took 55 minutes for [R1's] call light to be answered.
The facility's policy entitled Call Light Use and Response, issued 1/14/19 with revision dated of 5/20/20 and
7/18/23 shows: Purpose: 1. To respond promptly to resident's call for assistance. 2. To assure call system in
proper working order. Procedure: 1. Facility personnel will be aware of call lights. 2. Answer call lights
promptly whether or not the staff person is assigned to the resident or not. 3. Answer call lights in a prompt,
calm, courteous manner; turn off the call light as soon as you enter the room and attend to the resident
needs .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146094
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
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.
FAQ · About this visit
Common questions about this visit
What happened during the January 16, 2025 survey of EDEN VISTA BURR RIDGE?
This was a inspection survey of EDEN VISTA BURR RIDGE on January 16, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EDEN VISTA BURR RIDGE on January 16, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.