Cycle 1
Health 2025-01-30 · Fire 2025-01-30
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Burr Ridge, IL
Eden Vista Burr Ridge
4-star overall rating with 4-star inspections with 8 recent health deficiencies
6801 Highgrove Boulevard, Burr Ridge, IL
(630) 920-2900
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
29
Certified beds
Average residents
20
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-10-11
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.90
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.91
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.41
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.89
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
2.13
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.75
CMS adjusted RN staffing hours
Adjusted total hours
4.53
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,207
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.89% · Performance 25.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.89
Baseline 7.15% · Performance 6.37% · Measure score 4.89 · Achievement 4.89 · Improvement 3.10
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.38% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 179 · Observed rate 11.17% · Lower 95% interval 8.34% |
| Discharge to community | 48.5% |
50.57%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 42.86% · Lower 95% interval 39.05% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 98 |
| Discharge self-care score | 49.06% |
53.69%
4.6 pts worse
|
Numerator 26 · Denominator 53 |
| Discharge mobility score | 64.15% |
50.94%
13.2 pts better
|
Numerator 34 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 98 · Adjusted rate 1.55% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 5.17% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 0.76% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 131 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 117 |
| Discharge function score | 47.17% |
56.45%
9.3 pts worse
|
Numerator 25 · Denominator 53 |
| Transfer of health information to provider | 97.06% |
95.95%
1.1 pts better
|
Numerator 33 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 55 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 16 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
89.6%
0.6 pts better
|
93.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 90.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
50.3%
43.6 pts better
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.5%
2.5 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
18.5%
2.5 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.0% |
22.8%
7.2 pts worse
|
16.7%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
15.0%
1.7 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.0% |
21.3%
16.7 pts worse
|
19.8%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.0% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
5.2%
1.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.5% |
68.8%
2.3 pts worse
|
81.7%
15.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.7% · Q2 74.0% · Q3 57.6% · Q4 46.6% · 4Q avg 66.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
14.0%
2.4 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.5% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
2.3%
0.2 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.4% · Q3 0.0% · Q4 2.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.2% |
63.0%
8.2 pts better
|
79.7%
8.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.4% |
26.2%
9.2 pts worse
|
23.9%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.4% · Observed 34.6% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-19 · Fire 2024-04-19
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Cycle 3
Health 2023-05-18 · Fire 2023-05-18
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-19
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-05-13
F · Potential for more than minimal harm
2023-05-18
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-03
F · Potential for more than minimal harm
2023-05-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-30
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-30
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-30
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-04
G · Actual harm
2024-04-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-04-19
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-05-13
F · Potential for more than minimal harm
2023-05-18
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-05-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-05-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-05-18
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-29
Penalties and ownership
What sits behind the stars
Ownership
Burr Ridge Senior Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Burr Ridge Senior Operations LLC
Operational/Managerial Control · Organization
Chicagoland Senior Living Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Stesel, Maxim
5% Or Greater Indirect Ownership Interest · Individual
Stesel, Maxim
Operational/Managerial Control · Individual
Woods, Lynn
Operational/Managerial Control · Individual
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