Eden Vista Prospect Heights

In the surveyor’s words

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

• Actual harm, isolatedF686Dec 12, 2025

  Based on observation, interview, and record review the facility failed to ensure ongoing monitoring, assessment to identify worsening of skin impairment and notify the physician for appropriate treatment in a timely manner. This failure resulted in R11's Moisture Associated Skin Disorder (MASD) on left buttocks to progress to sacral/coccyx area stage 3 pressure ulcer with slough formation. This deficiency affects one (R11) of one resident in the sample of 9 reviewed for Wound Care Management. Findings include: On 12/9/25 at 11:36AM, Observed V15 CNA (Certified Nurse Assistant) and V16 CNA repositioned R11 to her left side for wound care. Observed open wound on sacrococcygeal area without dressing exposed to disposable adult brief soiled with urine. […]

• Actual harm, isolatedF689Sep 11, 2023

  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. […]

• Actual harm, isolatedF686May 18, 2023

  Based on observation, interview, and record review, the facility failed to implement interventions according to resident's plan of care in preventing the development of a pressure ulcer for one (R13) of two residents in the sample of 21 reviewed for pressure ulcers. This failure resulted in R13's intact skin developing moisture associated skin damage on the left buttock which progressed to a Stage 4 pressure ulcer. Findings include: R13 is an [AGE] year-old female, admitted in the facility on 09/30/22 with diagnoses of Pressure Ulcer of Sacral, Stage 4, Neurocognitive Disorder with Lewy Bodies and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. […]

• Actual harm, isolatedF689May 18, 2023

  Based on observation, interview, and record review, the facility failed to follow their policy and procedures for fall prevention by not consistently assessing risks for falls, not ensuring fall interventions were implemented, not implementing effective fall interventions for residents experiencing multiple falls, and not providing adequate supervision for high risk fall residents who required increased supervision. This failure applied to two (R122 and R274) of four residents reviewed for falls and resulted in R274 sustaining a left femur fracture. Findings include: R274 is a [AGE] year-old male who originally admitted on [DATE] and currently resides in the facility. […]

• Actual harm, isolatedF689Feb 7, 2022

  Based on interview, and record review, the facility failed to have effective interventions in place to keep a resident with a history of falls, free from injury after repeated falls. This failure applied to one (R2) of three residents reviewed for falls. This failure resulted in R2 having two major falls with injury while at the facility, resulting in a fractured maxilla and a facial fracture after the second fall. Findings include: R2 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include: Type 2 Diabetes, Repeated Falls, Muscle Weakness (generalized), and Need for Assistance. […]