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 Prospect Heights during CMS and state inspections, most recent first.
A resident with severe risk for skin impairment and a history of left buttock MASD experienced deterioration of skin integrity when staff failed to consistently monitor, accurately assess, and promptly report changes in the wound. CNAs left an open sacrococcygeal wound uncovered after a dressing fell off and did not notify nursing staff, resulting in exposure to urine. The ADON/WCC later identified a Stage 3 pressure ulcer with significant slough on the sacrococcygeal area but initially applied treatment intended for MASD rather than an open pressure ulcer. The night shift RN was only aware of a healed left buttock MASD, while the day shift RN had been treating an open sacrococcygeal wound without documented timely physician notification, leading to inconsistent wound identification and management contrary to facility policies requiring daily skin monitoring, weekly wound assessment, and immediate MD notification of worsening wounds.
A dependent resident with hemiplegia, dysphagia, GERD, and gastrostomy status, who was NPO and care-planned for assistance with ADLs and oral hygiene every shift and as needed, was observed in bed with a foul mouth odor. A CNA reported having provided oral care but acknowledged the resident’s mouth odor, while the DON stated that CNAs are expected to perform mouth care daily and PRN. Review of the resident’s records and the facility’s ADL policy, which includes hygiene and oral care, showed that the facility did not ensure timely and adequate oral care consistent with the resident’s assessed needs and care plan.
A resident with bilateral pitting edema and multiple comorbidities, including HTN, atrial fibrillation, muscle weakness, and history of falls, was observed with swollen lower extremities, and an RN confirmed pitting edema. Review of the record showed an active physician order to apply ace wraps to both lower extremities twice daily for edema, to be applied in the morning and removed in the evening, but staff did not implement this treatment and the comprehensive care plan did not address edema management with ace wraps. The DON acknowledged the order should have been followed and included in the care plan, and the facility could not provide a specific policy or procedure for edema management or ace wrap application, despite having general policies on physician orders and care planning.
A resident with senile brain degeneration, hemiplegia of the left dominant side, abnormal posture, and documented one-sided ROM impairment in both upper and lower extremities was observed leaning to one side in a recliner without the ordered left hand splint or wheelchair arm trough in place. The care plan and therapy recommendations required a functional hand splint, left arm trough, and related positioning devices while up and during transfers to address impaired mobility and ADL self-care deficits, but nursing staff acknowledged these devices were not applied. The Administrator and DON stated there was no restorative program or contracture-prevention policy, despite existing policies on orthotics, physician orders, and comprehensive care planning that required implementation of such orders.
A resident with a history of multiple falls, fractures, muscle weakness, unsteadiness, and hearing loss was care planned as high risk for falls, with interventions including keeping the call light and personal items within reach and assisting to maintain safety. On two separate observations, the resident was found in a wheelchair with impaired hearing and slurred speech, and the call light placed out of reach, which the DON acknowledged should not occur. The resident had both witnessed and unwitnessed falls, including one event where she slid from her wheelchair while leaning forward to pick up a tissue and another that led to hospital evaluation, yet the root cause analysis for the later fall was simply copied from the earlier incident instead of being newly developed as required by facility policies on post-fall management and fall reduction.
A resident with hemiplegia, dysphagia, GERD, and gastrostomy status, who was NPO and care-planned for oral hygiene and potential pain, was observed with foul oral odor, broken teeth, and heavy buildup, and reported tooth pain. Although the facility had orders for pain assessment every shift using a standardized scale and PRN acetaminophen, and a policy requiring comprehensive pain assessment (including onset, duration, location, severity, and related factors), the resident’s dental pain was not thoroughly assessed or adequately managed in accordance with these requirements.
A resident with hemiplegia, dysphagia, GERD, and gastrostomy status, on an NPO diet and dependent for ADLs, was observed with very dark, broken teeth, yellowish buildup, and foul odor, yet had no documented dental referral or exam despite residing in the facility for several years. The DON reported being unable to locate any dental referral and believed the lack of dental care was related to the resident’s private pay status. This occurred despite a care plan requiring assisted oral care every shift and a facility policy mandating comprehensive oral assessments on admission and at regular intervals, offering dental services on admission, quarterly review of dental needs, and assistance in arranging dental services for identified oral concerns.
Staff failed to follow the facility’s hand hygiene policy during incontinence care for a resident. A CNA removed a soiled brief, cleansed the perineal and sacral areas, and then immediately handled a clean disposable brief without removing gloves and performing hand hygiene in between. This action conflicted with the facility’s written hand hygiene policy, which requires hand hygiene after contact with body fluids and after handling potentially contaminated items. The ADON and DON acknowledged the expectation that hand hygiene should have been performed before handling the clean brief.
A resident at moderate risk for skin breakdown did not receive appropriate pressure ulcer care, as the facility failed to implement an air loss mattress, delayed wound care evaluation, and did not document skin assessments or treatments. The resident developed a stage three pressure sore and moisture-associated skin damage due to these deficiencies.
Failure to Monitor and Manage MASD Leading to Stage 3 Sacrococcygeal Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing monitoring and timely assessment of a resident’s skin condition, resulting in deterioration from a left buttock Moisture Associated Skin Disorder (MASD) to a sacrococcygeal Stage 3 pressure ulcer with slough formation. During observation, CNAs repositioned the resident for wound care, revealing an open sacrococcygeal wound without a dressing, in contact with a urine-soiled disposable brief. One CNA stated that the wound dressing had fallen off earlier that morning during incontinence care and admitted she forgot to notify the RN or the ADON/Wound Care Coordinator. The ADON/WCC confirmed that the open wound should have been covered and that she was unaware of the wound’s deterioration until the surveyor’s observation. The ADON/WCC assessed the wound and described it as a pressure ulcer on the sacrococcygeal area with 80% slough and 20% reddish tissue with serosanguinous drainage, measuring 1.5 cm x 1 cm x 0.1 cm, and acknowledged that it had worsened since the prior week’s wound rounds with the wound care physician. She applied the same treatment ordered for MASD (zinc oxide and xeroform gauze with dry dressing) and later stated that this treatment was not appropriate for an open wound with slough formation, but that she used it until new physician orders could be obtained. The night shift RN reported that she had been treating a left buttock MASD that was now dry and healed, and that she was not aware of any sacrococcygeal pressure ulcer. The day shift RN reported that she had been aware of an open wound between the buttocks in the sacrococcygeal area, described its characteristics, and had been applying zinc oxide, xeroform, and a bordered dressing, but there was no indication that the physician had been notified of this change prior to the survey. Record review showed that the resident had multiple diagnoses including history of falls, fractures, muscle weakness, and unsteadiness, and had a Braden scale assessment indicating severe risk for skin impairment. The care plan documented a pressure ulcer and risk for further skin impairment, with MASD on the left buttock. The most recent wound assessment by the wound care physician prior to the survey described a non-pressure MASD wound on the left buttock that was healing. Facility policies required daily skin monitoring by CNAs, weekly skin checks by licensed nurses, weekly wound documentation with detailed characteristics, daily assessment of dressings, treatment based on wound etiology, and immediate physician notification for wounds with complications or not healing as anticipated. Despite these policies, the resident’s wound progressed and changed location from the left buttock MASD to a sacrococcygeal Stage 3 pressure ulcer without timely recognition, accurate identification, or physician notification, and with inconsistent documentation of wound site and etiology.
Failure to Provide Timely Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely oral care for a dependent resident who required assistance with activities of daily living, including oral hygiene. On 12/9/2025 at 11:05 a.m., the resident (R6) was observed in bed with a foul mouth odor. At 11:10 a.m., a CNA (V16) stated that oral care had been provided for the resident but acknowledged that the resident’s mouth had an odor. At 11:20 a.m., the DON (V2) stated that nursing assistants are expected to perform mouth care daily and as needed. Record review showed that the resident had diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left dominant side, dysphagia (oropharyngeal phase), GERD, and gastrostomy status, with an NPO diet order due to failed speech swallowing. The resident’s care plan, dated 4/17/2024, identified an ADL self-care performance deficit with impaired mobility, impaired cognition, and left-sided hemiplegia, and included an intervention for personal hygiene/oral care specifying assistance by one staff member with grooming and oral hygiene, including oral care every shift and often if needed. The facility’s ADL policy, issued 3/15/2021, requires provision of care and services for hygiene, including oral care, based on comprehensive assessment and resident needs. These observations, interviews, and record reviews demonstrate that despite the resident’s dependence and care plan requirements for oral care every shift and as needed, the facility did not ensure timely and adequate oral hygiene, as evidenced by the resident’s foul mouth odor at the time of surveyor observation.
Failure to Implement Physician Orders and Care Plan for Edema Management
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care according to physician orders and to incorporate that treatment into the resident’s comprehensive care plan. Surveyors observed a resident with swollen bilateral lower extremities; an RN assessed the legs and identified bilateral pitting edema, more prominent in the left lower leg. The resident was described as alert and responsive with periods of confusion, impaired hearing, and slurred speech. Review of the medical record showed the resident had diagnoses including essential hypertension, atrial fibrillation, history of falling, muscle weakness, muscle wasting, unsteadiness on feet, and hearing loss. The active physician order sheet directed staff to apply an ace wrap to the resident’s bilateral lower extremities twice daily for edema, to be applied in the morning and removed in the evening. However, the ace wrap bandages were not applied as ordered, and the comprehensive care plan did not address management of the resident’s edema using ace wrap bandages. When asked, the DON acknowledged that staff should be following the physician’s order and addressing the bilateral lower extremity edema in the care plan. The facility was unable to provide any policy or procedure specific to edema management or the application of ace wrap bandages to the bilateral lower extremities for edema, although it did have general policies on physician orders and care planning.
Failure to Implement Ordered Hand Splint and Arm Trough for Resident With Hemiplegia
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and implement care plan interventions for a resident with limited mobility and hemiplegia affecting the left dominant side. During observation, the resident was seen in a Broda recliner in the activity room leaning to the right side without the ordered left hand splint or wheelchair arm trough in place. After this was shown to the DON, the resident was repositioned upright, but staff confirmed that the left hand splint and wheelchair resting arm were not applied. The resident’s active physician orders required application of a functional hand splint to the left hand, removable only for hygiene, skin checks, and as tolerated, and use of a wheelchair arm trough on the left side while up in the wheelchair on day and evening shifts. The comprehensive care plan documented that the resident had ADL self-care performance deficits related to impaired mobility, generalized weakness, and hemiplegia, with interventions including an AFO on the left lower extremity while up, a left upper extremity sling and hand splint while up and during transfers, and elevation of the left arm in a trough with skin observations during AM/PM care. The MDS assessment showed impairment in functional ROM on one side for both upper and lower extremities, and the OT discharge summary recommended assistance with all ADLs and functional transfers, a left arm trough, and a left resting hand splint to prevent contractures due to limited mobility. The Administrator and DON reported that the facility did not have a restorative program or a policy to prevent contractures for residents with limited mobility, despite existing policies on orthotics, physician orders, and care planning that outlined requirements for orthotic use and implementation of provider orders.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement fall prevention interventions for a resident with a documented history of multiple falls and high fall risk. On two separate observations, the resident was seen sitting in a wheelchair in her room, alert but with impaired hearing and slurred speech, and with the call light placed out of her reach. During both observations, the DON confirmed that the call light should have been accessible and within the resident’s reach for safety. The resident’s care plan interventions specified that staff should assist the resident to meet needs and maintain safety, including keeping the call light and personal effects within easy reach. Record review showed that the resident was admitted with diagnoses including history of falling, displaced trimalleolar fracture of the left lower leg, closed fracture with routine healing, subluxation of the left ankle joint, muscle weakness, muscle wasting, unsteadiness on feet, and hearing loss. The comprehensive care plan identified the resident as being at risk for falls related to history of falls and weakness, and the most recent fall assessment documented that the resident was at high risk for falling. The resident had a witnessed fall on one date, where she slid from her wheelchair while leaning forward to pick up a tissue, and an unwitnessed fall on a later date, after which she was sent to the hospital for evaluation. For the second fall, the root cause analysis was documented as a copy of the previous incident report, rather than a newly developed analysis, despite facility policies requiring identification of underlying causes, review of current interventions, and updating the care plan with new interventions after each fall.
Failure to Thoroughly Assess and Adequately Manage Dental Pain
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess and adequately manage dental pain for a resident with significant medical conditions. On 12/10/2025 at 11:00 a.m., the resident was observed in bed with dark areas in the mouth, a foul oral odor, and broken teeth with yellow to brown buildup. When asked, the resident reported having tooth pain. The resident’s records showed diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left dominant side, dysphagia (oropharyngeal phase), GERD, and gastrostomy status, with an NPO diet due to failed swallowing. The care plan in place included interventions for ADL self-care performance deficits, impaired mobility, impaired cognition, and hemiplegia, with oral care ordered every shift and more often if needed. The resident also had an order for pain management requiring evaluation every shift using a numerical or visual analog pain scale, and a PRN order for acetaminophen 325 mg two tablets via feeding tube every six hours as needed for pain, not to exceed 3000 mg in 24 hours. A care plan dated 4/23/2024 identified potential for pain with an intervention to administer medication per MD order for pain management. Despite these orders and the facility’s pain management policy requiring standardized assessment of pain (including onset, duration, location, severity, alleviating/aggravating factors, possible causes, and associated signs/symptoms using an appropriate pain assessment instrument), the documentation and observations did not demonstrate that the resident’s dental pain was thoroughly assessed in accordance with policy. The DON stated that nurses are expected to assess for pain and reported having assessed the resident for mouth pain and administering acetaminophen; however, the report identifies that pain was not thoroughly assessed and adequately treated for this resident’s tooth pain.
Failure to Provide Required Dental Services and Oral Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide routine and 24-hour emergency dental care for a dependent resident. During an observation, the resident’s teeth were noted to be very dark, broken in places, with a buildup of yellowish film and a foul odor. When the DON was asked about the resident’s last dental referral or exam, the DON stated that she was unable to find any dental referral for the resident and believed that, because the resident was private pay, the resident had not had a dental exam despite having been in the facility for several years. No documentation of prior dental referrals or exams was identified. The resident’s admission record reflects multiple diagnoses, including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left dominant side, dysphagia (oropharyngeal phase), GERD, and gastrostomy status, with an NPO diet order due to failed speech swallowing. The care plan identifies an ADL self-care performance deficit with impaired mobility, impaired cognition, and left-sided hemiplegia, and includes an intervention for oral hygiene requiring assistance with oral care every shift and as often as needed. The facility’s oral assessment and management policy requires a complete oral assessment upon admission, with significant changes, quarterly and annually, and that residents be offered dental services upon admission and reviewed quarterly during care conferences. The policy also states that dental/oral concerns are to be addressed and that the facility will assist with arranging dental services as ordered. Despite these requirements, the resident did not receive needed dental services or documented dental assessments as outlined in the facility’s policy.
Failure to Perform Hand Hygiene Between Incontinence Care and Handling Clean Brief
Penalty
Summary
A deficiency occurred when staff failed to follow the facility’s hand hygiene policy during incontinence care for resident R11. On 12/9/25 at 11:31 AM, CNAs V15 and V16 repositioned R11 to her left side and it was observed that R11 was soiled with urine. V15 removed the soiled disposable adult brief and cleansed the perineal and sacral areas with disposable cleansing wipes. After completing the cleansing, V15 did not remove gloves and did not perform hand hygiene. Immediately after providing incontinence care, V15 handled a clean disposable adult brief and placed it underneath R11 without performing hand hygiene in between. This practice was inconsistent with the facility’s hand hygiene policy, revised 5/8/24, which requires staff to perform hand hygiene after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin, and after handling items potentially contaminated with blood, body fluids, or secretions. When informed of the observation, the ADON (V3) acknowledged that V15 should have performed hand hygiene after incontinence care and before handling the clean brief.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adhere to its pressure injury prevention and wound care management policy for a resident who was at moderate risk for skin breakdown. The resident, who had a history of Alzheimer's disease, anemia, gastrointestinal hemorrhage, hypertension, and heart disease, was readmitted to the facility with a tiny skin opening on the coccyx. Despite the resident's moderate risk for skin breakdown as indicated by the Braden scale, the facility did not implement an air loss mattress, delayed the evaluation by a wound care doctor, and failed to document skin assessments on admission and weekly. The resident's progress notes indicated the presence of open skin areas in the sacral region and right hip, but there was a delay in obtaining physician orders and documenting treatments. Although physician orders were created for wound care, there was no documentation of home health visits or treatments administered from the time of the resident's transfer to the skilled unit until several days later. Additionally, the facility did not conduct a skin assessment upon the resident's transfer to the skilled unit, and there was a lack of documentation for treatment orders or administration of treatment during this period. The facility's Director of Nursing (DON) acknowledged the absence of documentation and the failure to provide an air loss mattress as expected. The wound care doctor confirmed that the resident was not seen on the scheduled date and noted the absence of treatment to prevent infection prior to his visit. The facility's policy required comprehensive assessment and care planning to prevent and manage pressure injuries, but these standards were not met, resulting in a stage three pressure sore and moisture-associated skin damage for the resident.
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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.
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Nursing homes near Prospect Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citadel Of Northbrook, The | 2.4 mi | ★★★★★ | 0 | 0 |
| Bella Terra Wheeling | 2.6 mi | ★★★★★ | 0 | 0 |
| Ascension Nazarethville Place | 2.7 mi | ★★★★★ | 3 | 0 |
| Alden Des Plaines Rehab & Hc | 2.8 mi | ★★★★★ | 4 | 0 |
| Moorings Of Arlington Heights | 3 mi | ★★★★★ | 0 | 0 |
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