Eden Vista Burr Ridge

In the surveyor’s words

From the most serious findings on record at Eden Vista Burr Ridge, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 2, 2026

  Based on interviews and record review, the facility failed to follow its fall prevention policy and provide adequate supervision for one cognitively impaired resident who was identified as being at high risk for falls. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 having two unwitnessed, avoidable falls occurring on the same day, following the second fall R1 was transported to the hospital, where the resident was diagnosed with a spinal compression fracture.Findings include:On 6/30/26 at 1:21 PM, V4's RN (registered nurse) stated that R1 had an unwitnessed fall on the hallway floor on the morning of 5/25/26. V4 stated that R1 was confused, at baseline. […]

• Actual harm, isolatedF689May 21, 2026

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and safe transport technique and failed to implement care plan interventions to prevent an accident for a resident (R1). The facility failed to follow facility fall prevention policy, failed to develop and implement care plan interventions to prevent recurrent falls, and failed to complete post fall assessment for one of three residents (R2), reviewed for falls. These failures resulted in R1 falling and sustaining a closed head injury, abrasion of the forehead, avulsion of right elbow skin, and a closed nasal bone fracture, and R2 sustaining seven falls within sixteen days, hospitalization, scalp laceration requiring sutures, and a subdural hemorrhage. […]

• Actual harm, isolatedF684Apr 19, 2024

  Based on observation, interview, and record review, the facility failed to ensure that medications were present for a resident with recurrent diarrhea and to notify the Physician about the medications, failed to ensure lab testing was completed in a timely manner for the resident, and failed to ensure staff responded to the resident's stool incontinence in a timely manner. These delays in treatment resulted the addition of a third medication, and the resident experiencing increased weakness and skin irritation. This applies to 1 of 4 residents (R14) reviewed for nursing cares in a sample of 26. Findings include: R14 was admitted to the facility on [DATE]. R 14 has diagnoses that includes congestive heart failure, muscle weakness, and enterocolitis due to clostridium difficile. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2025

  Based on observation, interview and record review, the facility failed to clean and sanitize kitchen equipment, failed to label/date potentially hazadardous stored food, failed to store cooked meat to prevent cross contamination, and failed to perform hand hygiene per facility policy. This applies to all 22 residents residing in the facility. The findings include: Facility Long-Term Care Facility Application for Medicare and Medicaid, dated January 27, 2025, shows the facility census was 22 residents. […]

• No harm, potential for more than minimal, widespreadF880Jan 30, 2025

  Based on observation, interview, and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care, failed to follow the EBP (Enhanced Barrier Precautions) policy, and clean medical equipment between resident use. This applies to all 22 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 27, 2025, showed the facility census was 22 residents. […]