Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eden Vista Burr Ridge during CMS and state inspections, most recent first.
The facility failed to provide safe wheelchair transport and adequate supervision for one resident with high fall risk and cognitive impairment, resulting in a fall with a closed head injury, nasal fracture, forehead abrasion, and right elbow skin avulsion. Staff observed the resident being moved without proper leg/footrests, and a CNA stated the resident was unstable and fell while being pushed in the wheelchair. The facility also failed to follow its fall prevention policy for another resident with dementia and repeated falls, with no effective new interventions, missing post-fall assessments, and incomplete documentation after multiple unwitnessed falls, including one that led to hospitalization, a scalp laceration, and a subdural hemorrhage.
Failure to Timely Report Severe Injury of Unknown Origin: A resident was found with blood on the bed, an unwitnessed head laceration, and later hospitalized with a subdural hemorrhage and scalp laceration requiring staples. The RN documented the injury and transfer to the ER, but the initial report of severe injury of unknown origin was not sent to IDPH within the required 2 hours; the DON and Administrator stated they believed the initial report was due within 24 hours.
Multiple residents who were cognitively impaired and care planned as needing total assistance with ADLs were repeatedly observed with unkempt facial hair, uneven and jagged fingernails with dark debris underneath, and soiled clothing. Despite documented care plans calling for staff assistance with dressing, personal hygiene, and grooming to maintain a well-groomed appearance, residents remained with overgrown facial hair, dirty nails, and stained garments over multiple observations. Several residents verbally expressed that they relied on staff and wanted their facial hair shaved, fingernails cleaned and trimmed, and clothing changed, while nursing leadership acknowledged that providing nail care, dressing assistance, and removal of unwanted facial hair is part of routine nursing care for residents requiring help.
The facility failed to provide ordered IDDSI Level 6 soft & bite-sized mechanically altered diets for four residents with conditions such as dementia, dysphagia, COPD, CHF, malnutrition, and GERD. Despite physician orders and a policy requiring foods to be fork-mashable, cut into small pieces, with soaked bread and no mixed consistencies, residents were repeatedly served regular-texture meals. Observations showed large pieces of pork roast, whole firm vegetables, whole scalloped potatoes, bratwurst with skin, large salad components, and large fresh fruit pieces in liquid, while prescribed items such as slurry bread and strawberry shortcake slurry were not prepared or served. The Culinary Director confirmed that mechanically altered foods were not prepared for these meals and acknowledged that the food sizes and textures did not meet Level 6 soft & bite-sized standards.
Staff failed to follow infection control policies for hand hygiene, glove use, and Enhanced Barrier Precautions (EBP) during medication administration and incontinence/toileting care for multiple residents. A nurse handled and opened capsule medications with bare hands after touching environmental surfaces and without hand hygiene before mixing them into food for a resident. CNAs providing incontinence and toileting care to several residents, including one on EBP for a leg wound, did not wear complete PPE as required, used the same soiled gloves to perform both contaminated and clean tasks such as cleaning perineal areas, applying barrier cream and clean briefs, adjusting clothing, repositioning residents, and touching bed controls, and frequently failed to perform hand hygiene after glove removal or before moving from dirty to clean activities.
Surveyors found that staff failed to implement ordered contracture management and positioning interventions for two residents with significant contractures and functional limitations. One resident with hemiplegia and a left-hand contracture had a care plan and therapy documentation for use of a resting hand splint, but over multiple observations the hand remained tightly clenched with no splint, palm protector, or substitute device in place, and only a thin dressing was used on the palm. Another resident with dementia, functional quadriplegia, and contractures was repeatedly observed in bed with contracted upper and lower extremities and adducted legs rubbing together, without the recommended wedge or pillow between the knees, despite care plan and therapy notes calling for positioning and pillow placement for comfort and skin protection.
A resident with multiple chronic conditions, including hypothyroidism and dysphagia, received Levothyroxine and delayed-release Aspirin in a manner inconsistent with physician orders and manufacturer guidelines, contributing to a medication error rate above 5%. A nurse administered the Levothyroxine and Aspirin mid-morning after the resident had already eaten, and crushed both medications, converting the delayed-release Aspirin to an immediate-release form, despite orders specifying Levothyroxine as a time-sensitive dose to be given early in the morning on an empty stomach. Staff interviews confirmed that Levothyroxine (Synthroid) is expected to be given before breakfast on an empty stomach, and that nurses are expected to follow pharmacy recommendations and physician orders, which did not occur in this instance.
The facility failed to maintain sanitation and food safety standards, affecting all 22 residents. Observations revealed dirty kitchen equipment, improperly stored and unlabeled food, and inadequate hand hygiene by a food service worker. These actions violated the facility's policies on food safety, dishwashing, and sanitation.
The facility failed to adhere to its Water Management Plan for Legionella, with inadequate eyewash station checks and no chlorine testing. An LPN did not follow Enhanced Barrier Precautions or hand hygiene protocols during medication administration, failing to sanitize equipment between residents and not wearing a gown for a resident on EBP. These actions violated the facility's policies on infection control.
The facility did not meet the nutritional needs of its residents by failing to provide the required servings of fruits/vegetables and grains/breads as per their policy. This affected 15 residents on Regular and/or No Added Salt diets. The menus, reviewed by a corporate dietitian, lacked the necessary servings on multiple days across four weeks, despite guidelines specifying the required daily servings.
A facility failed to provide a SNF-ABN to a resident at the end of their Medicare Part A stay. The resident's Medicare coverage ended, but they remained in the facility without receiving the required notice. A social services staff member admitted to not providing the SNF-ABN due to unawareness of the resident's continued stay. The facility lacked documentation to show the notice was given.
The facility failed to provide written notification of its bed hold policy to residents or their representatives during hospital transfers, as required by federal law. This deficiency was identified in two residents, who were transferred to the hospital multiple times without proper documentation or communication of the bed hold policy. The facility's policy requires written notice at the time of transfer, but this was not adhered to, resulting in incomplete and improperly handled documentation.
A resident with significant weight loss was not reviewed by a dietitian upon readmission from the hospital, and the facility failed to provide necessary nutritional interventions or obtain weekly weights as ordered. The resident, with a history of severe malnutrition and other medical conditions, experienced a 14% weight loss. Nutritional supplements were not reordered, and the dietitian was not informed of the resident's condition until late January.
A resident's G-tube placement and patency were not verified before medication administration, contrary to facility policy. The nurse administered medication without aspirating for residuals or flushing the tube, as required. The regional nurse consultant confirmed the expectation to follow these procedures.
The facility failed to identify and monitor resident-specific behaviors to assess the effectiveness of psychotropic medications for three residents. Generic behavior lists were used instead of individualized symptoms, and behavior monitoring was vague and inconsistent. This deficiency was evident in residents with diagnoses of psychosis, anxiety, dementia, and depression, whose care plans lacked specific behavior assessments and monitoring documentation.
The facility failed to adhere to its policy of promptly responding to call lights and providing timely incontinence care, affecting three residents. One resident with multiple health issues was left in soiled briefs for hours, causing skin irritation. Another resident and their family reported long wait times for assistance, with records showing delays exceeding an hour. A third resident experienced similar delays, with call light response times reaching up to 85 minutes. These deficiencies indicate a systemic issue with the facility's call light response system.
The facility failed to ensure medications were present and administered for a resident with recurrent diarrhea, did not notify the physician about the missing medications, and did not complete lab testing or respond to stool incontinence in a timely manner. These delays resulted in the addition of a third medication and the resident experiencing increased weakness and skin irritation.
The facility failed to maintain kitchen hygiene and proper food storage, affecting all 26 residents. Observations included uncovered facial hair, improperly stored and expired food items, inadequate sanitization practices, and lack of proper hair coverings for staff. Facility policies on food storage, personal cleanliness, and sanitization were not followed.
The facility failed to assist residents with their ADL needs in a timely manner. One resident waited 30 minutes for staff to answer her call light and was left on the toilet, another reported waits as long as two hours, and a third resident's call light was unanswered for over two hours. The facility's policy states that call lights should be answered promptly, but staff reported difficulties in completing tasks and responding to call lights due to workload and lack of assistance from nurses.
A resident with severe protein-calorie malnutrition and significant weight loss did not receive the recommended nutritional supplements due to a delay in entering the Dietician's orders. Despite the facility's policy to act on such recommendations within 24 hours, the supplements were not provided, and the resident's care plan was not updated accordingly.
The facility failed to follow proper infection control protocols, including the use of appropriate disinfecting wipes for CDIFF and single-use port protector caps for a PICC line. Staff did not adhere to hand hygiene guidelines, leading to deficiencies in care and increased risk of infection for residents.
The facility failed to offer and document influenza and pneumococcal immunizations for two residents. Both residents' records lacked documentation of vaccine consent or refusal, and the admission checklist was missing from the EMR and paper chart. Interviews with the ADON and DON confirmed the lapse in following the facility's vaccination policies.
The facility failed to offer or document the COVID-19 immunizations for two residents upon their admission. Both residents' records lacked documentation regarding the administration or refusal of the COVID-19 vaccine, and the facility's policy on vaccine education and documentation was not followed.
Unsafe wheelchair transport and repeated fall-management failures
Penalty
Summary
The facility failed to provide adequate supervision and safe transport technique for a resident with high fall risk and cognitive impairment, and failed to implement the resident’s care plan interventions during wheelchair transport. The resident had diagnoses including polyneuropathy and generalized anxiety disorder, was assessed as high risk for falls, required partial/moderate assistance for transport, used a wheelchair, and had moderately advanced cognitive impairment. The care plan directed staff to use wheelchair leg rests when the resident was not propelling herself and to store the leg rests on the back of the wheelchair when she was propelling herself. During observation, the Administrator was seen pushing the resident in a wheelchair without a leg/footrest, with the resident’s feet dangling and dragging on the floor. The Administrator told the resident twice to raise her legs, but the resident was barely able to do so. A CNA later stated that while pushing the resident from the dining room to the activity room, both of the resident’s feet were on only one leg rest, the resident was not steady, her shoulder went close to her knees, and then she fell to the floor. The CNA stated she could have monitored the resident more closely and also stated she had training on mechanical lift transfers but not on moving a resident in a wheelchair. The resident’s hospital record documented injuries from the fall including a closed nasal bone fracture, avulsion of skin of the right elbow, abrasion of the forehead, and closed head injury. The facility also failed to follow its fall prevention policy, failed to develop and implement effective interventions for recurrent falls, and failed to complete required post-fall assessments for another resident with repeated falls. This resident had dementia, a history of TIA/CVA, a pubic fracture, UTI, moderate cognitive impairment, and was assessed as high risk for falls on admission. The resident fell seven times within sixteen days, with incidents involving attempts to get to the bathroom, being found on the floor, and one fall resulting in hospitalization and a scalp laceration requiring sutures and a subdural hemorrhage. Facility staff stated there was no fall prevention coordinator, that fall discussions were not documented, and that post-fall assessments were not completed every eight hours for seventy-two hours after each fall. Review of the record showed missing post-fall assessments after several of the falls and missing or incomplete documentation for some incidents, including one fall not listed on the facility’s fall summary report.
Failure to Timely Report Severe Injury of Unknown Origin
Penalty
Summary
The facility failed to initially report a severe injury of unknown origin to the Illinois Department of Public Health within the required two hours after the incident for one resident. On 4/19/2026 at 5:00 AM, the RN documented in the risk management/incident report that the nurse was informed by a CNA that the resident had blood on the bed. Upon assessment, a small laceration was noted to the right top of the resident’s head, the resident could not recall what happened, and the incident was unwitnessed. The resident was transferred to the hospital for a head injury. Later that morning, the nurse documented in the EHR that the resident was found with dried blood on linens and the floor near the bed, with a 1-inch laceration to the right top of the head and complaints of pain to the right hip and sacral area. The physician ordered transfer to the emergency room, and the DON was made aware. The resident was admitted to the hospital with a diagnosis of subdural hemorrhage and a laceration to the right top of the head requiring five staples. The initial report of severe injury of unknown origin was not emailed to IDPH until 8:50 AM on 4/20/2026, and the DON and Administrator stated the initial report was believed to be due within 24 hours.
Failure to Provide Needed Assistance With Personal Hygiene and Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide needed assistance with personal hygiene and grooming for multiple residents who were care planned as dependent on staff for ADLs. One resident with severe cognitive impairment and diagnoses including unspecified dementia required total assistance with upper body dressing and personal hygiene per the admission MDS and care plan. On two consecutive days, this resident was observed in the dining room with long curling facial hair above the lips, uneven and jagged fingernails with chipped nail polish and dark substances underneath, and a soiled shirt with white stains and food debris. The resident stated she needed staff assistance and wanted her facial hair removed, fingernails cleaned and trimmed, and her shirt changed, despite an active care plan that included interventions for assistance with dressing and personal hygiene to maintain a well-groomed appearance. Another resident with diagnoses including diabetes with chronic kidney disease, glaucoma, and rheumatoid arthritis, and who was moderately cognitively impaired, was assessed on the MDS as requiring total assistance with personal hygiene. This resident was observed in bed on two separate days with long facial hair above the lips and on the chin, and long, jagged fingernails with black substances underneath. The resident reported needing staff assistance for facial hair removal and nail care and expressed a desire to have facial hair shaved and fingernails trimmed and cleaned. The DON was present during one observation and acknowledged the resident needed staff assistance with nail care and shaving, despite the resident’s active care plan identifying an ADL self-care performance deficit and interventions for assistance with personal hygiene. A third resident with unspecified Alzheimer’s disease and unspecified dementia, assessed as severely cognitively impaired and totally dependent on staff for upper body dressing and personal hygiene, was observed in the dining room wearing a shirt with food debris and having uneven, mostly jagged fingernails with black substances under some nails. The following day, the resident’s fingernails remained uneven and jagged with dark material under some nails, and the ADON acknowledged that nail care was needed. This resident’s care plan documented an ADL self-care performance deficit with a goal of a well-groomed appearance and interventions for assistance with dressing and personal hygiene/grooming. A fourth resident, a 91-year-old with dementia, diabetes, and muscle wasting, whose MDS showed a need for assistance with grooming and hygiene, was repeatedly observed over several days with unkempt, overgrown facial hair and jagged, uneven, dirty fingernails with black/brown substance underneath. This resident verbally stated a desire to have fingernails clipped and facial hair shaved. The DON later stated it is part of nursing care and services to assist all residents needing help with nail care, dressing, and removal of unwanted facial hair to maintain personal hygiene and grooming, yet these needs were not met for the observed residents.
Failure to Provide Ordered IDDSI Level 6 Soft & Bite-Sized Diets
Penalty
Summary
The deficiency involves the facility’s failure to provide IDDSI Level 6 soft and bite-sized mechanically altered diets as ordered for four residents. Facility diet reports and physician orders showed that these residents were prescribed a regular diet with Level 6 Soft & Bite Sized texture and Level 0 thin liquids. Speech therapy recommendations for one resident specified a mechanical soft/thin diet with small bites, slow rate, and diet advancement only with speech therapy involvement. Despite these orders and the facility’s own policy defining Level 6 soft and bite-sized foods as items that can be mashed with a fork, cut into pieces no larger than 1.5 cm x 1.5 cm, with bread soaked and no regular dry bread or mixed consistencies, the meals prepared and served did not meet these requirements. On multiple observed meals, residents on Level 6 diets were served food in regular texture and size rather than mechanically altered form. At a lunch observation, two residents on Level 6 diets received pork roast in large cut pieces, whole California medley vegetables with large, firm pieces of cauliflower, broccoli, and carrot slices, and whole scalloped potatoes, identical to regular diet meals. They were not served the prescribed strawberry shortcake slurry dessert listed on the Level 6 menu. At a dinner observation, one resident on a Level 6 diet was served bratwurst sausage with the skin on, cut into large slices, along with a salad containing large pieces of lettuce, tomato, and cucumber with skin, and large slices of peaches, half strawberries, and chunks of melon in liquid, instead of the specified soft and bite-sized preparations and bread slurry. The Culinary Director acknowledged during observation that the bratwurst pieces and salad components were too large for a soft and bite-sized diet and confirmed that for this diet, food pieces should be no larger than the tines of a fork. The Culinary Director also stated that the slurry bun, defined as bread softened in milk, was not prepared or served. Additionally, during an initial kitchen observation, the Culinary Director identified one resident on a puree diet and four residents on mechanically altered diets, yet there was no mechanically altered food prepared for the lunch meal, despite the Level 6 menu specifying roast beef and roasted vegetables in small bite-sized pieces without skin, a slurry bread roll with margarine, and crustless cherry pie. These observations, interviews, and record reviews demonstrate that the facility did not prepare or serve meals in accordance with the ordered Level 6 soft and bite-sized diet and its own IDDSI-based policy for four residents.
Failure to Follow Hand Hygiene, Glove Use, and EBP PPE Requirements During Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies regarding hand hygiene, glove use, and use of PPE, including Enhanced Barrier Precautions (EBP), for multiple residents. A nurse administering medications to one resident handled capsule medications with bare hands after touching various objects and surfaces, without performing hand hygiene, and then opened the capsules and mixed their contents into applesauce for the resident to ingest. Another nurse later stated that staff are supposed to sanitize their hands before opening capsules and avoid touching anything prior to handling medications to prevent contamination. For a resident on EBP due to a leg wound requiring wound care, two CNAs provided incontinence care after the resident had a bowel movement and was wet with urine. They wore gloves but did not don complete PPE as required for residents on EBP. One CNA used double gloves to clean the perineal area, then removed only the outer gloves and, with the remaining gloves still on, applied barrier cream and a new incontinence brief. After removing the second pair of gloves, the CNA assisted the resident to dress without performing hand hygiene. The DON later stated that staff must wear complete PPE when providing direct care to residents on EBP to prevent potential spread of infection or cross contamination. Additional deficiencies were observed during incontinence and toileting care for other residents. One CNA assisted a resident to the toilet, cleaned the perineum, removed a soiled brief, applied a clean brief, pulled up the resident’s pants, and assisted the resident back to a wheelchair while wearing the same soiled gloves and without hand hygiene between dirty and clean tasks. The same CNA, when providing incontinence care to another resident, cleaned the perineum, applied a new brief, repositioned the resident, and straightened bed linens while wearing the same soiled gloves, then removed PPE and left the room without hand hygiene. Another CNA, assisted by a second CNA, cleaned a resident’s anal and perineal areas while wearing gloves, then, using the same soiled gloves, applied a clean brief, pulled up the resident’s pants, and touched the bed control. This CNA later acknowledged not removing the soiled gloves or performing hand hygiene before proceeding to clean tasks, contrary to the facility’s hand hygiene and PPE policies, which require glove removal and hand hygiene after contaminated tasks and before moving to clean tasks.
Failure to Implement Contracture Management and Positioning Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide and apply recommended devices for contracture management and positioning to residents with known contractures, as outlined in their care plans and therapy recommendations. One resident, a 78-year-old under hospice care with hemiplegia and a left-hand contracture, had a care plan intervention specifying application of a left-hand splint on for 12 hours and off for 12 hours. A therapy form documented that a resting hand splint had been provided but was missing. Across multiple observations over several days, the resident was repeatedly seen in bed with the left arm and hand contracted and the hand tightly clenched, with fingers digging into the palm. There was no resting hand splint, palm protector, carrot splint, or rolled towel in use or present in the room. A CNA reported that the resident used to have a carrot splint and was using only a thin dressing on the palm to protect the skin from fingernails. Another resident, a 73-year-old with dementia, functional quadriplegia, and contractures of the upper and lower extremities, had therapy documentation indicating contractures and a need for cuing to relax limbs and pillow placement to increase comfort and decrease skin breakdown. This resident’s care plan identified contracture, quadriplegia, and chronic pain syndrome, with interventions including non-pharmacological pain mechanisms such as comfortable positioning. During multiple observations over several days, the resident was seen resting in bed with contracted hands, wrists, and bilateral lower extremities. The lower extremities were contracted and adducted, with the skin of the legs touching and rubbing together, and there was no wedge pillow or other pillow placed between the knees, despite the documented need for such positioning support.
Improper Administration of Time-Sensitive and Delayed-Release Medications
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and manufacturer recommendations, resulting in a medication error rate of 7.69% (2 errors out of 26 opportunities) during a medication pass observation. A 92-year-old resident with dementia, dysphagia, hypertension, tachycardia, and hypothyroidism had physician orders for Levothyroxine Sodium 50 mcg to be given once daily as a time-sensitive medication at 6 AM (earliest 5 AM) and Aspirin 81 mg delayed-release once daily for VTE. On December 29, 2025, at 10:23 AM, a nurse administered multiple medications to this resident, including Levothyroxine and Aspirin, after the resident had already eaten breakfast, and crushed both medications, which converted the Aspirin delayed-release tablet into an immediate-release dose. The manufacturer’s recommendation for Levothyroxine specified administration on an empty stomach, 30 minutes to 1 hour before breakfast with a full glass of water, and staff interviews confirmed the expectation that Synthroid (Levothyroxine) should be given early in the morning on an empty stomach to ensure optimal absorption, but this was not followed in the observed administration. The administrator stated that nurses are expected to relay pharmacy recommendations to the physician and follow physician instructions and orders, and another nurse confirmed that Synthroid is normally given at 6 AM before breakfast on an empty stomach to increase effectiveness, indicating that the observed practice for this resident deviated from both the physician’s time-sensitive order and the manufacturer’s administration guidelines.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen, affecting all 22 residents. During an inspection, it was observed that the area behind and between large cooking equipment was covered in food splatters, dust, and loose particles. Equipment hoses, cords, and back panels were also found to be dirty. Additionally, a package of hot dogs was stored in the walk-in cooler without a label or date, and was placed above raw Swiss steak, which had leaked blood into the pan. Cooked bratwurst was initially stored below the raw meat, posing a risk of cross-contamination. The facility's food service manager admitted that staff relied on memory to determine food discard dates, which is not in compliance with the facility's policy requiring labeling and dating of stored food. Furthermore, a food service worker was observed serving food and handling various items without performing proper hand hygiene. After serving food and coffee to a resident, the worker removed her gloves and put on new ones without washing her hands. She continued to handle food and clean surfaces with the same gloves, violating the facility's hand washing policy. The facility's policies on food safety, dishwashing, and sanitation were not adhered to, as evidenced by the lack of proper hand hygiene and the improper storage and labeling of food items.
Failure to Follow Water Management and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to its Water Management Plan for Legionella, as evidenced by the maintenance director's inadequate weekly checks of the eyewash stations and the failure to perform required chlorine testing. The maintenance director demonstrated a check of the eyewash station that lasted only one to two seconds, contrary to the plan's requirement for a three-minute flush. Additionally, the hot water temperatures recorded were consistently below the control limits set by the facility's plan, and there was no documentation of biannual legionella testing for 2023 or 2024. The maintenance director admitted to not having chlorine testing kits and not sending legionella samples to the laboratory since August 2023. The facility also failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols during medication administration. An LPN was observed not performing hand hygiene before and after entering a resident's room, not wearing a gown for a resident on EBP, and not sanitizing a blood pressure cuff between uses on different residents. The LPN handled medications and resident care activities without changing gloves or performing hand hygiene, despite the facility's policies requiring these actions to prevent infection transmission. The facility's policies on hand hygiene, isolation precautions, and cleaning of resident care equipment were not followed, as demonstrated by the LPN's actions. The LPN acknowledged the failure to perform hand hygiene and sanitize equipment between resident uses, which are critical steps in preventing the spread of infections. The regional nurse consultant confirmed the importance of these practices, emphasizing the need for hand hygiene before and after resident care and the use of PPE for residents on EBP.
Facility Fails to Meet Nutritional Standards in Menu Planning
Penalty
Summary
The facility failed to meet the nutritional needs of its residents by not providing the minimum required servings of fruits/vegetables and grains/breads as per their own policy. This deficiency was identified through interviews and record reviews, affecting 15 residents who were on Regular and/or No Added Salt diets. The facility's menus, which were supposed to be reviewed by a corporate dietitian, did not include the required servings of fruits/vegetables on multiple days across four weeks. Specifically, the menus lacked at least 5 servings of fruits/vegetables on several days each week and failed to provide at least 6 servings of grains/breads on various days. The Food Service Manager, identified as V9, confirmed that the menus were reviewed by the corporate dietitian but was unable to identify the missing servings when reviewing the menus. The facility's Menu Planning Guide, dated November 2023, specifies that the Regular/No Added Salt menus should include foods that meet or exceed the Dietary Reference Intakes for older adults, including 5 or more servings of vegetables and fruits and 6 or more servings of grains daily. Despite this guideline, the facility's menus did not comply with these nutritional standards, leading to the deficiency.
Failure to Provide SNF-ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) to a resident, identified as R225, at the end of their Medicare Part A stay. R225's Medicare Part A Skilled Services began on October 10, 2024, and the last covered day was November 14, 2024. However, the facility did not issue the SNF ABN form to R225, who remained in the facility until November 19, 2024, when they were discharged to a local hospital. On January 28, 2025, a social services staff member, V18, acknowledged that R225 did not receive the SNF ABN form because V18 was unaware that R225 would remain in the facility after the last covered day. V18 also stated that the SNF ABN should be provided two days before the last covered day to allow the resident or their representative time to appeal if desired. The facility lacked documentation to show that R225 received the SNF ABN form before the end of their Medicare Part A coverage.
Failure to Provide Written Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives during hospital transfers, as required by federal law. This deficiency was identified in two residents, R4 and R5, out of a sample of 12. R5, who had severe cognitive impairment and multiple health issues, was transferred to the hospital multiple times from August 2024 to January 2025. However, the facility did not document any discussion of the bed hold policy with R5 or her representative during these transfers. The BEDHOLD AGREEMENT-TRANSFER NOTICE forms provided by the facility were either incomplete or incorrectly dated, indicating a lack of proper communication and documentation. R4, a female resident, was transferred to the hospital on January 11, 2025, due to symptoms of congestion and a chest x-ray showing possible atelectasis, pneumonia, or edema. The Bed Hold Agreement form in R4's electronic medical record was uploaded on January 2, 2025, but was unsigned and undated. It was later presented to the surveyor with a handwritten date of January 11, 2025, and an electronic signature from the social services representative, V18, but lacked details such as the hospital to which R4 was discharged. V18 admitted to not discussing the bed hold policy with residents or their representatives at the time of discharge, nor providing them with a copy of the form. The facility's policy, dated October 12, 2021, requires that written notice of the bed hold policy be provided to residents and their representatives at the time of transfer for hospitalization or therapeutic leave. Despite this policy, the facility failed to comply, as evidenced by the incomplete and improperly handled documentation for R4 and R5. This lack of adherence to policy and federal requirements resulted in the identified deficiency during the survey.
Failure to Provide Adequate Nutritional Care for Resident
Penalty
Summary
The facility failed to ensure a resident with significant weight loss was reviewed by a dietitian upon readmission from the hospital, did not provide necessary nutritional interventions, and did not obtain weekly weights as ordered by the physician. The resident, who had a history of severe protein-calorie malnutrition and other complex medical conditions, experienced a 14% weight loss over a short period. Despite having a physician's order for weekly weights, the facility did not consistently obtain these measurements, missing several weeks in January 2025. Additionally, the resident's nutritional supplements were not reordered upon readmission from the hospital in December 2024, and the dietitian was not informed of the resident's condition until late January 2025. The resident required assistance with feeding and had difficulty swallowing, yet the facility did not make a timely referral to the dietitian. The dietitian confirmed that they were not notified of the resident's hospitalizations and readmissions, which contributed to the oversight in nutritional care. The physician acknowledged that the lack of nutritional supplements may have contributed to the resident's weight loss.
Failure to Verify G-tube Placement Before Medication Administration
Penalty
Summary
The facility failed to verify the placement and patency of a resident's gastrostomy tube (G-tube) before administering medication. This deficiency was observed during a medication administration for a male resident with a history of hemiplegia, hemiparesis, dysphagia following cerebral infarction, and type 2 diabetes mellitus. The nurse, identified as V6, administered medication through the resident's G-tube without aspirating to check for residual gastrointestinal fluid or flushing the catheter, which are necessary steps to ensure the tube's proper placement and patency. The facility's policy on administering medications through a feeding tube requires staff to verify the placement of the feeding tube by checking for residuals and flushing the tube with water. However, during the observation, these steps were not followed by the nurse. The regional nurse consultant, V3, confirmed that the staff is expected to check for proper placement and patency of the G-tube before use, as outlined in the facility's policy. This oversight in following the established procedure led to the deficiency noted in the report.
Failure to Monitor Resident-Specific Behaviors for Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to identify resident-specific behaviors to monitor the effectiveness of psychotropic medications for three residents. The documentation survey report revealed that residents were being monitored for a generic list of behaviors rather than individualized symptoms. This lack of specificity in behavior monitoring was evident in the cases of three residents who were reviewed for unnecessary psychotropic medications. One resident, admitted with diagnoses including unspecified psychosis, anxiety, and dementia with behaviors, had a care plan that did not specify target behaviors for monitoring. Despite being on antidepressant and antipsychotic medications, the behavior monitoring was vague and not resident-specific, with several shifts lacking any behavior monitoring documentation. Another resident, diagnosed with depression, had no assessment to determine specific behaviors indicative of depression, and their care plan lacked resident-specific behaviors to monitor the effectiveness of the prescribed antidepressant. A third resident, also diagnosed with depression, had a care plan that included monitoring for signs and symptoms of depression, but the behavior tracking records did not align with the symptoms listed in the care plan. The facility's policy required assessments to identify specific behaviors and document the resident's response to non-pharmacological interventions, but this was not adhered to, leading to the deficiency.
Failure to Respond Promptly to Call Lights and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to follow its policy to answer call lights promptly and provide timely incontinence care to residents, affecting three out of four residents reviewed. One resident, R3, who has multiple diagnoses including diabetes, heart disease, and dementia, was found in bed with a strong odor of stool in the room. R3 reported that his incontinence brief had not been changed since 5:00 AM, despite having a bowel movement shortly after. He expressed frustration with the call light system, stating that pressing the call light during shift changes or meal times was ineffective. When R3 pressed the call light during an interview, it took over 13 minutes for staff to respond, during which time R3 was found with stool caked on his skin, causing discomfort and redness. Another resident, R4, who has conditions such as heart failure and COPD, also reported long wait times for call light responses. R4's family had previously raised concerns about call light response times, with records showing an average response time of 29 minutes and some instances exceeding an hour. Despite these concerns being forwarded to the Director of Nursing, the issue persisted, indicating a systemic problem with call light response times in the facility. A third resident, R1, who was discharged home, had a history of multiple diagnoses including spinal injuries and heart failure. During R1's stay, call light logs revealed response times exceeding 45 minutes on several occasions, with one instance taking 85 minutes. The facility's policy, which mandates prompt response to call lights, was not adhered to, contributing to the deficiencies observed. The lack of timely response to call lights and incontinence care highlights a significant lapse in the facility's adherence to its own policies, impacting the quality of care provided to residents.
Failure to Administer Medications and Respond to Incontinence
Penalty
Summary
The facility failed to ensure that medications were present for a resident with recurrent diarrhea and did not notify the physician about the missing medications. Additionally, the facility did not complete lab testing in a timely manner and failed to respond promptly to the resident's stool incontinence. These delays in treatment resulted in the addition of a third medication and the resident experiencing increased weakness and skin irritation. The resident, who has diagnoses including congestive heart failure, muscle weakness, and enterocolitis due to Clostridium difficile, was admitted to the facility and required staff assistance for mobility using a walker. The care plan indicated a risk for further skin breakdown due to decreased mobility. On the day of the survey, the resident's call light had been unanswered for over an hour, and the resident's family member reported that the resident had been having diarrhea for five days. Despite orders for fidaxomicin and metronidazole, the medications had not been administered, and the physician was not notified about the delay. The resident's condition worsened, leading to the addition of Vancomycin. The surveyor observed the resident calling for assistance and found the resident's buttocks excoriated and covered in stool. The Director of Nursing confirmed that the medications were not administered as ordered and that there was no documentation of the physician being notified about the delay.
Failure to Maintain Kitchen Hygiene and Food Storage Standards
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting all 26 residents in the long-term care unit. During a kitchen tour, it was observed that the cook/kitchen supervisor had uncovered facial hair, and various food items were improperly stored. The ice cream cooler had an open and uncovered container of mint chocolate chip ice cream. In the dry storage area, several blue bags containing raisins, craisins, chocolate chips, and vermicelli were not labeled or dated. Additionally, two dented cans of peaches were found, which the kitchen supervisor acknowledged should not be used due to potential contamination. The walk-in cooler contained sour cream, coleslaw, and salad dressings that were either not in their original containers or expired. The walk-in freezer had unlabeled and undated bags of chicken tenders, chicken breast chunk fritters, and seasoned potato wedges. The reach-in cooler had cinnamon apple sauce without any dates. The sanitizer for the three-compartment sink was not within the safe range, and the meat slicer was found with crusts and debris particles. The flour and oatmeal bins were past their use-by dates, and the vents over the cooking area were dusty. Logs for testing the three-compartment sink or sanitization buckets were not maintained. Staff members were also observed without proper hair coverings, and personal food items were found in the nourishment refrigerator, which is against facility policy. The facility's policies on food storage, personal cleanliness, and sanitization were not followed. The food storage chart indicated specific durations for the freshness of various food items, which were not adhered to. The facility's policy on personal cleanliness required all dietary staff and anyone entering the kitchen to wear approved hair restraints, which was not consistently practiced. The sanitization and cleaning schedule policy mandated that all refrigerated and prepared foods be covered, labeled, and dated, which was also not followed. The facility's failure to comply with these policies and maintain proper kitchen hygiene and food storage practices poses a risk of foodborne illness to the residents.
Failure to Assist Residents with ADLs in a Timely Manner
Penalty
Summary
The facility failed to assist residents with their Activities of Daily Living (ADL) needs in a timely manner. Resident R173 was observed sitting on the side of the bed in a t-shirt and disposable underpants, stating that it took staff about 30 minutes to answer her call light and that she was left on the toilet waiting for staff to return. The surveyor observed nursing staff at the nursing station and two nursing staff walking by R173's room without addressing the call light. It took 26 minutes for non-nursing staff to respond to R173's call light. R173's MDS dated 4/8/24 shows moderate cognitive impairment and requires partial/moderate staff assistance with most ADLs. R173's care plan dated 4/3/24 shows an ADL self-care performance deficit related to back pain. Resident R18 reported that staff are slow to respond to call lights on the second and third shifts, with waits as long as two hours. R18 has had to get up in his wheelchair to find staff assistance. R18's MDS dated 4/1/24 shows he is cognitively intact and requires substantial/maximal staff assistance with ADLs. R18's care plan dated 3/27/24 includes an ADL self-care performance deficit related to impaired mobility and multiple fractures. Resident R7's call light was unanswered for two hours and 26 minutes. R7's MDS dated 4/6/24 shows moderate cognitive impairment and requires substantial staff assistance with ADLs. R7's care plan dated 3/26/24 shows an ADL self-care deficit and a risk for falls related to Parkinson's Disease and Lewy body dementia. The facility's policy states that call lights should be answered promptly, but staff reported difficulties in completing tasks and responding to call lights due to workload and lack of assistance from nurses.
Failure to Follow Dietician's Nutritional Supplement Recommendation
Penalty
Summary
The facility failed to follow the Dietician's recommendation to provide a nutritional supplement to a resident (R1) who experienced significant weight loss. R1, a [AGE] year old female with severe protein-calorie malnutrition, congestive heart failure, and a need for assistance with personal care, lost 15.4 lbs (13.9%) in one month. Despite the Dietician's recommendation on 4/9/24 to provide nutritional supplements and Prostat to support weight and wound healing, these orders were not entered into the resident's POS as of 4/18/24. Observations and interviews confirmed that R1 did not receive the recommended supplements, and no supplements were found at her bedside. The Dietician stated that recommendations are typically entered within 72 hours, but this did not occur in R1's case, leading to a delay in care. The Director of Nursing (DON) acknowledged that the Dietician's recommendations are usually carried out within 24 hours but was unaware of the delay in this instance. The DON could not find the email from the Dietician with the recommendations and admitted that the supplements were not ordered. The facility's policy requires cooperation between nursing staff and the Dietician to monitor and intervene in cases of significant weight changes, but this protocol was not followed, resulting in the resident not receiving the necessary nutritional support in a timely manner.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to follow proper disinfection protocols to prevent the spread of infection, specifically Clostridium Difficile (CDIFF). One resident, diagnosed with CDIFF, was placed under strict contact isolation. However, a registered nurse (RN) did not use the appropriate bleach wipes to disinfect equipment used in the resident's room. Instead, the RN used purple top Sani-cloth wipes, which are not effective against CDIFF. Additionally, the RN did not wash her hands with soap and water after handling the resident's equipment, as required by the facility's policy. The Director of Nursing (DON) confirmed that the facility did not have the necessary bleach wipes in stock, and other staff members corroborated that the purple top wipes were ineffective against CDIFF. The facility's policy and manufacturer guidelines clearly state that bleach wipes should be used and that handwashing with soap and water is essential after caring for residents with CDIFF. Another deficiency was observed with a resident who had a peripherally inserted central catheter (PICC) line. The RN reused a green disinfecting port protector cap after flushing the PICC line, contrary to standard practice and manufacturer guidelines, which state that these caps are single-use only. The DON and other staff members confirmed that reusing the port protector cap could lead to central line contamination or infection. The resident's care plan indicated a risk for infection and required aseptic and sterile techniques, which were not followed in this instance. The facility's failure to adhere to proper infection control protocols, including the use of appropriate disinfecting wipes and single-use port protector caps, as well as the failure to perform proper hand hygiene, led to deficiencies in the care provided to residents. These actions and inactions directly violated the facility's policies and manufacturer guidelines, putting residents at risk for infection and other complications.
Failure to Document and Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and document the provision of influenza and pneumococcal immunizations to residents admitted to the facility. This deficiency was identified during an infection control task where the electronic records of two residents, R11 and R124, were reviewed and found to be incomplete. R11, who was admitted with multiple diagnoses including rhabdomyolysis, pleural effusion, congestive heart failure, and chronic obstructive pulmonary disease, had no documentation of influenza vaccine consent or refusal. Similarly, R124, admitted with diagnoses such as trochanteric fracture of the right femur, acute myocarditis, and chronic obstructive pulmonary disease, also had no documentation of influenza and pneumococcal vaccine consent or refusal. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's process for determining vaccine history should take up to a week, and that influenza vaccines are offered to residents upon admission. However, the immunization history for R124 was not completed, and the admission checklist for both R11 and R124 was missing from the electronic medical record (EMR) and paper chart. The facility's policies on seasonal influenza and pneumococcal vaccinations require screening of vaccine history and documentation of consents or refusals in the EMR, which was not adhered to in these cases.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to offer or document the COVID-19 immunizations for two residents, R124 and R172, upon their admission. Both residents' electronic records lacked documentation regarding the administration or refusal of the COVID-19 vaccine. R124 was admitted with multiple diagnoses including a trochanteric fracture of the right femur, acute myocarditis, and chronic obstructive pulmonary disease, among others. Similarly, R172 was admitted with diagnoses such as cardiomyopathy, atrial fibrillation, and chronic respiratory failure. The immunization reports for both residents did not address the COVID-19 vaccines, and there was no documentation of consent or refusal for the immunizations in their records. Interviews with the facility's ADON and DON revealed that the facility's policy required staff to ask new admissions about their vaccine status and offer the vaccine if there was no evidence of prior administration. The ADON stated that the process of determining vaccine history should take up to a week, and the DON confirmed that if a resident refused the vaccine, a signed document should be uploaded into the EMR. However, for both R124 and R172, the immunization history was not completed, and the admission checklist documenting this was missing from both the EMR and paper charts. The facility's COVID-19 Vaccine policy mandated offering the vaccine and documenting education and administration or refusal, which was not followed in these cases.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,929 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Burr Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chateau Nrsg & Rehab Center | 0.4 mi | ★★★★★ | 2 | 0 |
| Briar Place Nursing | 2 mi | ★★★★★ | 25 | 0 |
| Bria Of Westmont | 2.3 mi | ★★★★★ | 14 | 0 |
| Burgess Square Healthcare Ctr | 2.6 mi | ★★★★★ | 10 | 0 |
| Oak Trace | 3.2 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.