Cityview Healthcare and Rehabilitation

Inspectors wroteBased on observation, staff interview, and review of the facility policy and procedure, the facility failed to ensure food was stored in a manner to prevent spoilage and failed to maintain a clean and sanitary kitchen and cooking equipment. This had the potential to affect all 91 residents residing in the facility. The facility census was 91.

Inspectors wroteBased on review of Quality Assurance (QA) meeting sign-in sheets and staff interview, the facility failed to ensure the Medical Director and the Administrator were active participants and attended QA meetings as required. This had the potential to affect all 91 residents residing in the facility. The facility census was 91.

Inspectors wroteBased on staff interview and review of the facility policy, the facility failed to maintain documentation in the staff files indicating the staff were provide education related to the COVID-19 vaccination and offered the vaccination. This had the potential to affect all 91 residents residing at the facility. The facility census was 91.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 91 residents residing in the facility. The facility census was 91.

Inspectors wroteBased on observation, staff interview, and resident interviews, the facility failed to ensure resident rooms and common areas were maintained at comfortable temperatures to promote a safe and comfortable homelike environment. This had the potential to affect 24 (#1, #3, #7, #13, #14, #16, #18, #23, #41, #42, #43, #46, #53, #58, #66, #67, #68, #71, #73, #76, #78, #79, #81, and #83) of 24 residents residing on the Blue Sky Living Unit (400 Hall). The facility census was 91.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop comprehensive care plans to specify resident care needs. This affected five (#9, #20, #44, #64, and #80) of 30 residents reviewed for care plans. The facility census was 91.

Inspectors wroteBased on observation, staff interview, review of the Resident Council meeting minutes, and review of a facility policy and procedure, the facility failed to ensure residents received large portions according to their diet orders. This had the potential to affect 34 (#4, #5, #7, #11, #14, #15, #17, #19, #20, #28, #36, #38, #39, #40, #44, #47, #48, #49, #52, #54, #55, #57, #62, #63, #64, #70, #76, #77, #82, #85, #86, #87, #88, and #90) of 91 residents who received large portions. The facility census was 91.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of personnel records, review of employee timesheets, and review of the employee handbook, the facility failed to ensure residents were provided with a dignified living environment. This affected one (#17) of two residents reviewed for dignity. The facility census was 91.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure a resident's choice for bathing method and frequency was honored. This affected one (#89) of four residents reviewed for bathing preferences/schedule. The facility census was 91.

Inspectors wroteBased on medical record review, staff interview, review of a clinical census, and review of a facility policy, the facility failed to ensure a legal guardian was notified of a change in condition. This affected one (#49) of three residents reviewed for hospitalizations. The facility census was 91.

Inspectors wroteBased on medical record review, review of self-reported incidents and related documents, resident and staff interview, and facility policy review, the facility failed to ensure residents were free from abuse. This affected two (#11 and #64) of six residents reviewed for abuse. The facility census was 91.

Inspectors wroteBased on medical record review, staff interview, review of a self-reported incident, and review of a facility policy, the facility failed to ensure an allegation of abuse was timely reported to the state survey agency. This affected one (Resident #11) of six residents reviewed for abuse. The facility census was 91.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion, as required. This affected one (#84) three residents reviewed for MDS assessment submissions. The facility census was 91.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure one (#44) of four residents reviewed for activities of daily living (ADLs) was properly assessed and provided services to address a decline in ADLs self-care. The facility census was 91.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of shower schedules, the facility failed to ensure adequate fingernail care was completed for dependent residents. This affected one (#89) of four residents reviewed for bathing/showers. The facility census was 91.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure one (#20) resident received assistance with his glasses to ensure consistency with utilizing the prescribed glasses. This affected one (#20) of three residents reviewed for ancillary services. The facility census was 91.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure orders for urostomy care were obtained and completed. This affected one (#25) of one resident reviewed for urostomy care. The census was 91.

Inspectors wroteBased on medical record review, staff interview, and review of a dialysis agreement, the facility failed to ensure ongoing assessments of a resident's condition and monitoring for complications before and after dialysis treatments were consistently completed. This affected one (#6) of one resident reviewed for dialysis. The facility census was 91.

Inspectors wroteBased on observation, staff interviews, medical record review, and review of the facility policy, the facility failed to ensure staff maintained proper infection control practice when providing care for residents in enhanced barrier precautions (EBP). This affected two (#5 and #33) of eight residents observed for EBP. The facility census was 91.

Inspectors wroteBased on staff interview and review of the facility assessment, the facility failed to develop and implement a facility assessment that addressed all necessary components. This had the potential to affect all 91 residents. The facility census was 91.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, review of Self-Reported Incident (SRI) investigations, and facility policy review, the facility failed to protect Resident #69 and Resident #12's right to be free from physical abuse by Resident #89. This affected two residents (#12 and #69) of five residents reviewed for physical abuse. The facility census was 88. Actual harm occurred on 09/08/25 when Resident #69 was physically abused by Resident #89 when the resident was struck in the head with a [NAME] requiring transfer to the hospital for evaluation and treatment of a skin tear requiring a thick layer of dermal glue and bruising on the left eye. [...]

Inspectors wroteBased on observation, closed record review, review of emergency services report, review of hospital records, facility policy review and interview, the facility failed to maintain a safe environment to prevent Resident #51 from accessing a locked soiled utility room and falling from the third-floor secured unit to the facility basement via a laundry chute. This resulted in Immediate Jeopardy and Actual Harm on 08/07/25 at approximately 1:30 P.M. when Resident #51 was observed in the laundry chute room, inside a laundry bin, behind a locked door in the facility's basement. Maintenance Director (MD) #400 reported he had been in the facility basement outside of the laundry chute room when he heard a loud thud sound from inside the room. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure a clean sanitary environment for Resident's #12, #13, #32, #33, #37, #44, #53, #56, #70, #74, #84, #89 and #92 who resided on the third floor nursing unit and failed to ensure phone calls to the facility were answered timely. This had the potential to affect all residents residing in the facility. The facility census was 93.

Inspectors wroteBased on observation, interview, record review, review of the facility Activity Calendar and review of facility policy the facility failed to ensure residents were provided activities as scheduled and failed to ensure Resident's #11, #33, #47 #67, and #82's care planned interventions were implemented for activities and activities were offered per their preferences. This had the potential to affect all the residents in the facility. The facility census was 93.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #19 and #43 received appropriate incontinence care timely. This affected two residents (Resident's #19 and #43) out of three residents reviewed for incontinence. The facility census was 93.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure Resident #19's physician orders and care planned interventions for enhanced barrier precautions were followed. This affected one resident (Resident #19) of two residents observed for enhanced barrier precautions. The facility census was 93.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed medical record review, review of an Emergency Medical Service (EMS) report, review of medical examiner records, facility policy review and interviews with facility staff, Medical Director, Certified Nurse Practitioners (CNP) #332 and #334, the facility failed develop and implement comprehensive, individualized and effective interventions/treatment and services to meet the behavioral health care needs of Resident #93 and to assist the resident to attain/maintain his highest practicable mental and psychosocial well-being. [...]

Inspectors wroteBased on closed record review, facility policy review, and interview, the facility failed to report an incident of potential neglect involving Resident #93 to the State Agency as required. This affected one resident (#93) of nine residents reviewed for abuse and neglect. The facility census was 91.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility self-reported incidents (SRIs), policy review, and review of facility corrective action, the facility failed to ensure residents were free from resident-to-resident physical abuse. This affected five (#2, #20, #21, #22, and #23) of five residents reviewed for abuse. The facility census as 98. Findings Include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, dementia, and dysphagia. [...]

Inspectors wroteBased on observation, medical record review, facility policy review and interviews, the facility failed to ensure a safe environment free from a potential accident hazard when smoking materials were not secured to prevent unsafe smoking in resident rooms. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on [DATE] at 1:03 P.M. when Resident #38, who was assessed to require staff supervision and the use of a smoking apron (device worn to protect from burns caused by hot ashes or lit cigarettes) was observed alone in his room with a strong cigarette odor and visible cigarette smoke in the air. [...]

Inspectors wroteBased on observation, resident and staff interview and review of Resident Council meeting minutes, the facility failed to ensure meals were served at an appropriate temperature and were palatable. This had the potential to affect all residents, except Resident #50 was what identified by the facility as receiving no food from the kitchen. The facility census was 101.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident call lights were in working order and able to be reached by residents. This affected 14 residents (#41, #42, #43, #44, #63, #64, #80, #81, #83, #84, #89, #90, #91 and #92) of 14 residents observed for call lights. The facility census was 101.

Inspectors wroteBased on resident interview, observation and staff interview, the facility failed to ensure a clean and sanitary environment. This affected two residents (#39 and #46) of three residents reviewed for environment. The facility census was 101.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure Resident #8 was free from resident-to-resident physical abuse by Resident #59. This affected one resident (#8) of three residents reviewed for abuse. The facility census was 104.

Inspectors wroteBased on interview, record review and review of the facility policy the facility failed to ensure Resident #103 received an orderly discharge from the facility. This affected one resident (Resident #103) out of three residents reviewed for discharge.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, and record review the facility failed to fix a broken basement door lock to maintain safe environment. This had the potential to affect all 104 residents living in the facility.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure falls were thoroughly investigated and failed to ensure safe smoking practices. This affected five residents (#43, #48, #58, #60, and #80) of seven residents reviewed for accidents. The facility census was 104.

Inspectors wroteBased on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to follow their abuse policy regarding reporting allegations of abuse timely and thoroughly investigate all allegations of abuse. This affected three residents (#20, #48 and #50) of four residents reviewed for abuse. The facility census was 104.

Inspectors wroteBased on record review, interview, self-reported incident review, and facility policy review the facility failed to report allegations of abuse to the state agency in a timely manner. This affected two residents (#20 and #50) of four residents reviewed for abuse. The facility census was 104.

Inspectors wroteBased on record review, interview, self-reported incident review, and facility policy review the facility failed to ensure allegations of abuse were thoroughly investigated. This affected three residents (#20, #48, and #50) of four residents reviewed for abuse. The facility census was 104.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure care plans were updated annually and as needed. This affected one resident (#43) of ten residents reviewed for accurate care plans. The facility census was 104.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to notify the physician of a radiology report for Resident #48 in a timely manner. This affected one resident (#48) of three residents reviewed for notification. The facility census was 104.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure medical records were accurate and complete. This affected two residents (#48 and #63) of ten residents reviewed for assessments. The facility census was 104.

Inspectors wroteBased on observation, medical record review, review of Emergency Medical Service (EMS) records, hospital record review, review of the facility Elopement and Secure Unit policy and procedures and interviews, the facility failed to provide adequate supervision and individualized interventions to prevent Resident #87 from eloping from the third floor secured behavioral unit. This resulted in Immediate Jeopardy on 09/02/23 at approximately 9:00 P.M. when Resident #87, with a known history of elopement and poor judgement and insight, was last seen by facility staff before eloping from the facility third floor secure behavioral unit without staff knowledge. Actual serious harm/injury occurred when Resident #87 exited the window of his third story room and either jumped/fell to the ground or descended via a ledge to a first story rooftop before jumping/falling to the ground. [...]

Inspectors wroteBased on interview and record review the facility did not ensure Resident #48 received an annual dental exam. This affected one of three residents reviewed for dental. The facility census was 96. Finding Include: Review of the medical record for Resident #48 revealed an admission date of 07/27/21. Diagnoses included dementia and partial traumatic amputation of right forearm. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/16/22, revealed the resident had severely impaired cognition. Review of the physician's orders revealed an order for dental consult as needed on 07/28/21. Review of the medical record revealed Resident #48 had not had a dental exam. Interview on 10/31/22 at 12:30 P.M. with Resident #48's sister revealed the resident had not seen the dentist in quite a while and his teeth were a mess. Interview on 11/02/22 at 3:02 P.M. [...]

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to ensure Resident #9's bathroom ceiling was in good repair. This affected one (Resident #9) of five residents reviewed for environment. The facility census was 96. Findings Include: Interview on 10/31/22 at 10:09 A.M. with Resident # 9 revealed the ceiling in Resident #9's bathroom had been leaking for a couple of weeks. The staff put a sign on her bathroom door to alert others of the leaking ceiling and to not use the bathroom. Observation on 10/31/22 at 10:12 A.M. of Resident #9's bathroom revealed water leaking from small holes in the ceiling tiles. The holes looked uniform in shape, as if made with a drill. Interview and observation on 10/31/22 at 1:05 P.M. [...]

Inspectors wroteBased on observations, resident interview and staff interview the facility failed to ensure resident rooms were free from infestation of gnats. This affected two (Resident #9 and #50) of five Residents reviewed for environment. The facility census was 96. Findings Include: 1. Interview on 10/31/22 at 10:09 A.M. with Resident #9 revealed her room had an infestation of gnats Resident #9 attributed to the leaking ceiling in her bathroom. Resident #9 stated staff knew about the bathroom ceiling and the gnats in her room. Observation on 10/31/22 at 10:10 A.M. of Resident #9's room revealed gnats flying in her room and in bathroom. 2. Interview on 10/31/22 at 10:32 A.M. with Resident #50 stated he had been having problems with gnats in his room for months and the gnats were coming out of the sink in his room. Resident #50 stated he told staff he had gnats in his room. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure food items were properly stored in the kitchen and in the nursing unit refrigerators to prevent contamination and/or food borne illness. The facility also failed to maintain the nursing unit refrigeration in a sanitary condition to prevent contamination. This had the potential to affect all residents residing in the facility who received meal trays with the exception of Resident #13 and #123 who received nothing by mouth. The facility census was 126.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to implement a surveillance plan to identify, track, monitor and/or report infections, failed to initiate contact isolation procedures timely for Resident #105, failed to ensure Registered Nurse (RN) #404 applied gloves prior to a treatment to Resident #132's peripherally inserted central catheter (PICC) line and failed to implement linen/laundry precautions to prevent the spread of infection. This affected two residents (#105 and #132) and had the potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure each resident received adequate supervision to prevent accidents related to smoking safety. This affected five residents (#40, #69, #71, #110 and #122) of six residents reviewed for accidents of 43 residents identified as smokers who resided on the two of four unsecured floors of the facility.

Inspectors wroteBased on observation, staff interview and facility insulin storage instructions revealed the facility failed to ensure insulin storage guidelines were followed. This affected five residents (#40, #82, #89, #102 and #112) of 17 residents receiving insulin on 100 and 400 halls. The facility census was 126.

Inspectors wroteBased on observation, record review and interview the facility failed to provide Resident #49 double entrée as ordered. The facility failed to use the correct scoop sizes for the pureed diet during observation of the tray line for residents. The facility also failed to serve the appropriate meal for the residents who had orders for renal diets also during observation of the tray line. This affected one resident (#49) of four residents (#44, #49, #69, and #110) reviewed for double portions, three residents (#106, #129, and #133) of three residents who received a pureed diet and five residents (#41, #43, #85, #100, and #112) of five who received a renal diet.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents. This affected five residents (#62, #86, #90, #99 and #126) of 126 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to promote a dignified dining experience for Resident #129 as State Tested Nursing Assistant (STNA) #409 was observed standing to provide feeding assistance to the resident. This affected one resident (#129) of six residents the facility identified as requiring feeding assistance on the fourth floor.

Inspectors wroteBased on record review and interview the facility failed to timely notify Resident #82 and Resident #120's physician of significant weight loss. This affected two residents (#82 and #120) of seven residents reviewed for nutrition.

Inspectors wroteBased on observation, record review and interview the facility failed to revise Resident #13's plan of care related to nutrition/hydration following orders for the resident to receive nothing by mouth. This affected one resident (#13) of one resident reviewed for tube feeding.

Inspectors wroteBased on record review and interview the facility failed to timely initiate nutritional interventions following Resident #82 and #120's significant weight loss and Resident #90's nutrition recommendations from dialysis. This affected three residents (#82, #90, and #120) of seven residents reviewed for nutrition.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to assess, educate and monitor Resident #13 while independently administering enteral (tube) feed and other fluids. This affected one resident (#13) of three residents who received enteral feeding.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #44 was provided the facility bed hold policy at the time he was transferred to the hospital for a pre-planned surgery. This affected one resident (#44) and had the potential to affect all 126 residents residing in the facility.