Park View Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to affirm the right of one (R5) resident to be free from physical abuse. The deficient practice resulted in actual harm when R5 sustained nondisplaced fracture of the distal tip of the nasal bones.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate supervision for one (R2) resident who was identified at risk for elopement and requires supervision with community access.

Inspectors wroteBased on interviews and records review, the facility failed to ensure three (R4, R6, R13) of seven residents reviewed remained free from physical and mental abuse in a sample of 14. Findings Include: 1. Facility Reported Incident Report, sent to Illinois Department of Public Health (IDPH), initial dated 10/24/2025, final dated 10/29/2025, related to R4 and R6 documents: Based on the known facts from medical records review and interviews, the following conclusions have been determined about the original allegation: Abuse is substantiated. On 01/29/2026 at 2:20PM, V1(Administrator) stated on 10/24/2025, V1 was notified by nursing staff (no names provided), R4 was verbally aggressive and loud towards R6, telling R6 to turn off his music playing from R6's phone. R6 pushed R4 on R4's face for being verbally aggressive towards him. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the residents rights to be free from physical abuse by residents. This failure affected 3 (R4, R6, and R12) residents and resulted in R6 sustaining a nasal bone fracture and subdural hematoma. Findings Include: 1. R6's Face Sheet, dated 1/23/2026, documents diagnoses of but not limited to Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter, Unspecified Injury of Head- Subsequent Encounter, Fracture of Nasal Bones-Subsequent Encounter for Fracture with Routine Healing, Acute Embolism and Thrombosis of Unspecified Vein, Schizophrenia, and bipolar disorder. R6's Minimum Data Set Section C, dated 11/19/2025, documents a BIMS (Brief Interview Mental Status) Score is 15, which indicates an intact cognition. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician of allegation of abuse. This failure affected 2 (R5, and R12) residents reviewed for abuse in the total sample of 16 residents.

Inspectors wroteF564Based on interview and record review, the facility failed to ensure residents had full and equal visitation privileges consistent with resident preferences. This affected one resident (R1) in the sample reviewed for visitation privileges.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate weekend staff for the facility. The facility's weekend short staffing has the potential to affect all 116 residents residing in the facility. Findings Include:On 9/11/25 at 11:30 AM, V15, Assistant Director of Nursing, stated, During the third quarter of April 1,2025 to June 30,2025, the facility was short staff sometimes on the weekends, mainly due to call offs. The nursing staffing schedules are as follows:First floor day, evening and night shift; There is one nurse and two certified nurse assistants [CNA]. Second floor day and evening; There is one nurse and four CNA's, night shift one nurse and two CNA's. Third floor day, evening, and night shift; There is one nurse and two CNAs on all shifts. On 9/11/25 at 11:50 AM, V15 the nurse staffing schedules for April to June were reviewed. V15 stated the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date stored food; failed to cover and label open food; and failed prepare food in a clean area. These failures have the potential to affect all 114 residents receiving food prepared for the nursing skilled facility.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure corridor handrails used by residents are firmly secured on all floors (1st, 2nd and 3rd). These failures have the potential to affect all 116 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to a.) ensure physician orders for Advanced Directives were obtained and railed to ensure Advanced Directives were properly documented and accessible for 4 (R1, R8, R11, R12) residents reviewed for advance directives in a sample of 25. Findings Include:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. This affected five (R1, R11, R30, R107, R110) out of nine residents during medication administration task. The facility had six errors out of 25 opportunities, resulting in a 24% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with professional standards for two of two storage rooms reviewed, and one of two medications carts reviewed for medication storage and labeling.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide hand splints for one resident (R31) out of a total sample of 25 residents.

Inspectors wroteBased on observation, interview, and record review. the facility failed to provide sufficient notification of SNF - ABN (Skilled Nursing Facility - Advance Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) to 3 out of 3 residents (R19, R98 and R112). These failures affect 3 residents (R19, R98 and R112) in exercising their rights and options afforded by notification procedure.

Inspectors wroteBased on interview and record review, the facility failed to ensure qualified personnel submit an accurate Level I PASRR (Pre-admission Screening and Resident Review) assessment for one resident (R7) out of a total sample of 25 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards and administer medications in a timely manner for two (R11 and R31) out of a total sample of 10 residents reviewed for medication times.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy for self-urethral catheterization on obtaining physician order and failed to provide documentation a urinary catheter was being changed for 1 out of 1 resident (R5) for a total sample of 25 residents. R5 is [AGE] years old, initially admitted on [DATE]. R4 medical diagnosis includes paraplegia, flaccid neuropathic bladder, and neuromuscular dysfunction of the bladder. On 09/09/2025 at 11:28 AM, R5 was seen in his room sitting on his bed. In front was his wheelchair with the urinary catheter bag attached. R5 was alert and verbally able to express thoughts well. R5 has a BIMS (Brief Interview for Mental Status) score of 15 on last MDS review, dated 07/30/2025, which indicates resident cognition is intact. R5 said, I change my own catheter, somebody taught me when I was on the street. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide a plan of care for the use of enteral feeding and failed to ensure a resident received enteral nutrition feedings via G-tube per physician orders for 3 out of 3 residents (R4, R60, R95) out of a total of 25 residents reviewed for enteral feeding.

Inspectors wroteBased on interview and record review, the facility failed to report and investigate a misappropriation of property allegation for one (R2) of four residents reviewed for abuse in a sample of five.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of ten residents (R2, R3, R7, and R9) were free from abuse. This failure affected R2, R3, R7, and R9 who were physically hit, pushed, and punched by peers. As a result of this failure, R3 was hit, pushed, and punched, and sustained a laceration to the forehead requiring 8 stitches.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident has the right to be free of abuse in 3 of 5 residents (R1, R2 and R4) included in the sample reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was administered as scheduled per physician order to 1 (R1) out of 3 residents reviewed for medication administration. Findings Include: R1's face sheet shows included diagnoses but not limited to insomnia and anxiety disorder. R1's Minimum Data Set, dated [DATE], shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R1's Medication Admin Audit Report, printed on 2/11/25 at 11:21 AM, shows ]on 1/27/25, R1 had ordered and scheduled medication Zolpidem Tartrate (Ambien) 10 mg by mouth at bedtime for Insomnia, Seroquel 200 mg 1 tablet by mouth, and Tamsulosin 0.4 mg 1 capsule by mouth all to be administered at 9:00 PM, but were documented administered at 10:35 PM, more than one hour past the scheduled administration time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure availability of anti-anxiety medication as ordered by physician, andfailed to document medication ordered by physician as being administered as per policy. These failures involved 1 out of 1 resident (R1) for a total sample of 3 residents.

Inspectors wroteBased on interview and record review, the facility failed to use extensive assistance of two staff members during a manual bed-to-wheelchair transfer for one resident (R2) out of three residents reviewed for resident injury and falls. This failure resulted in R2 falling in the facility on 09/17/2024, during a manual bed-to-wheelchair transfer, sustaining a head injury and requiring four staples to the head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date prepared food items in the refrigerator, and failed to ensure Dietary staff wear hair covering. These failures have the potential to affect all 119 residents receiving an oral diet in the facility. On 8/18/24 at 9:30 AM in the walk-in refrigerator, surveyor observed 4 green leaf salads, 5 cold cut sandwiches wrapped in plastic wrap, and a bowel of egg salad covered with plastic wrap, not dated. On 8/19/24 at 11:00 AM, V26 (Cook) was pureeing food with mask hanging at the chin level, and hair above upper lip not covered. On 8/18/24 at 9:35 AM V25 (Cook) stated, The salads, sandwiches, and egg salad in the refrigerator should have been dated. The staff know that their supposed to date open and prepared items. The cook from last night did not put a date on those items. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBP) signs were placed on the resident's door, failed to don appropriate personal protective equipment while caring for a resident on EBP, failed to change gloves after touching dirty surfaces while providing incontinence care to a resident on EBP, failed to perform hand hygiene after doffing gloves during wound care, and failed to ensure linen was handled in a manner that prevents contamination. These failures affects 6 residents (R59, R68, R98, R96, R48 and R33), in a sample of 58, and has the potential to affect all residents within the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct care plan conferences timely and involve the resident in the development of their plan of care. This failure affects 4 residents (R2, R27, R25, R59) in a sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of hazards for 1 resident (R82). This failure has the potential to affect all residents residing on the first floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medication from the medication cart, and failed to ensure medication cart was free of loose pills. These failures have the potential to affect all 41 residents assigned to the 3rd floor medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's urinary drainage bag was kept privately. Thais failure affects 1 resident (R59) in a sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident the ability to safely self-administer medication. This failure affects 1 (R83) resident reviewed for self-administration of medications in the total sample of 58 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a light fixture has no missing fluorescent tube light and cover; failed to ensure the encasement of the air conditioning unit was appropriately sealed; and failed to ensure the dresser has no missing drawer/s in an effort to provide a homelike environment for 2 (R83 and R99) residents reviewed for homelike environment in the total sample of 58 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete the MDS (Minimum Data Set) accurately. This failure affects 1 resident (R60) in the sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were signed out when administered for two residents (R71 and R91). This failure affected two residents in the sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date the humidifier bottle for one resident (R36), in a sample reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident (R100) the correct consistency diet. This failure affected one resident in a total sample size of 58 reviewed for diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal refrigerators were kept at safe temperatures. This failure affects 1 resident (R59) in a sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident (R1) was free from sexual abuse and mental anguish. This failure affected R1 who experienced sexual abuse and mental anguish in form of another resident exposing themselves to R1 in the facility elevator.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on abuse for one (R1) resident of three reviewed. This deficiency led to R1 being punched by R2 on the top of his head, and R1 suffered a laceration requiring/receiving two staples.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with food and drinks that are palatable, attractive, and at a safe and appetizing temperature for two residents (R8, R7) of three residents reviewed for cold food being served. This deficiency has the potential to affect all residents on unit two.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on resident right to be free from any physical restraints for two (R10, R11) of three residents reviewed for restraints.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision, failed to ensure that staff intervene timely, and failed to prevent a physical altercation for two of four residents (R3, R4) reviewed for abuse. These failures resulted in R4 sustaining a right eye abrasion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions, failed to repair equipment, and failed to ensure staff transfer residents safely for one of four residents (R1) reviewed for incidents/accidents. These failures resulted in R1 sustaining a right lower leg laceration on 12/4/23, which required 11 staples to repair.

Inspectors wroteBased on interview and record review, the facility failed to failed to define resident to resident contact, failed to conclude physical abuse was substantiated when residents intentionally struck each other, and failed to report resident injury to IDPH (Illinois Department of Public Health) for one of four residents (R4) reviewed for abuse. These failures have the potential to affect 126 residents residing in the facility.

Inspectors wroteBased upon interview and record review, the facility failed to ensure that care plans are individualized, and failed to review and/or revise comprehensive care plans with preventive interventions for four of four residents (R1, R2, R3, R4) reviewed for incidents/accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure R6 was free from verbal abuse, which affected one resident (R6) in the sample of four residents (R2, R4, R5 and R6) reviewed for verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to timely submit the final abuse investigation report to the State Agency within 5 business day, which affected one resident (R6) in the sample of four residents (R2, R4, R5 and R6) reviewed for verbal abuse.

Inspectors wroteBased on interview and record review, the facility failed to adequately supervise a resident (R126). This failure resulted in R126 eloping from the facility from the patio area. R126 has not returned to the facility. This was identified as an Immediate Jeopardy which began on 7/10/23, when R126 eloped from the facility under no staff supervision. On 10/6/23 at 3:32 PM, the Administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy began on 7/10/23, and was removed on 10/12/23. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan.

Inspectors wroteBased on interview and record review, the facility failed to report to IDPH (Illinois Department of Public Health) when a resident (R126) was known to have eloped from the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis to care for resident's needs. This failure has the potential to affect 123 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure on proper thawing of frozen meats and failed to ensure there was a functioning thermometer to measure adequate temperature control in the freezer where frozen foods are stored. These failures have the potential to affect 122 residents in the facility who are receiving oral diet. The Findings Include: On 10/03/23 at 9:45 AM, during the initial tour in the kitchen, the main freezer's external thermometer read 18 degrees Fahrenheit (F). V10 (Dietary Cook) stated they don't use the outside thermometer to check the temperature in the freezer because it does not work. V10 stated they use the thermometers inside. Surveyor entered the freezer with V10, and noted that both thermometers were broken. The thermometers' lines were cracked in half. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed of properl,y by not closing the lids of the dumpsters outside the facility. This deficient sanitation practice has the potential to affect all 123 residents who reside in the facility. The Findings Include: On 10/3/23 at 10:09 AM, an observation of the outside garbage dumpster was conducted with V11 (Dietary Manager). The lid of the outside garbage dumpster fully opened. V11 stated, They leave it open because it's hard to close. At 10:14 AM, V12 (Maintenance Director) stated, The lids of the dumpster should be closed when not in used so no rodents get in there, and no debris would fly out. The lids should be closed for pest control, and if it's open the garbage would attract flies and rodents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) Assessments for nine out of a total of 123 residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to revise 4 (R15, R56, R88, R84) out of 24 residents' comprehensive care plan to address their current condition, needs, and services in a sample of 24. The Findings Include: 1. R15's electronic medical records (EMR) show an initial admission date of 8/3/06, with listed diagnoses not limited to Encephalopathy, Essential Hypertension, Unsteadiness on Feet, and Weakness. R15's Quarterly Minimum Data Set (MDS), dated [DATE], shows R15 received restorative programs of active range of motion (AROM) and dressing/grooming. R15's Restorative Nursing Review, dated 8/16/23, shows R15 to continue dressing/grooming and AROM restorative programs. R15's comprehensive care plan shows Restorative care plan was last revised on 9/15/20, and R15's dressing/grooming restorative program is not addressed in the care plan. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were locked and secured while unattended, and failed to refrigerate an unopened insulin pen and label liquid medication that had been open in two of two medication storage rooms reviewed for medication labeling and storage. These failures have the potential to affect 45 residents residing in the facility (all residents on the third floor, and R21 on the first floor). Findings Include: On 10/04/2023 at 8:37AM, V19 (Registered Nurse/RN) was observed leaving medication cart (identified as 3rd floor medication cart) unlocked and unattended, with medication cart keys on top of the medication cart. V19 stated residents can potentially get access to the medications if the cart is left unlocked and unattended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect during meal assistance for two (R97, R118) out of a total sample of 24 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to develop and implement a comprehensive person-centered care plan that includes measurable objectives with timeframes and interventions to address current conditions and medications use, for 2 (R14, R107) out of 24 residents in a final sample of 24. The Findings Include: 1. R107's electronic medical records (EMR) show R107 was initially admitted on [DATE], and has diagnoses not limited to Bipolar Disorder, Dementia, Depression, and Anemia. R107's October Medication Administration Record (MAR) shows R107 is receiving antidepressant and antipsychotic medication daily. R107's physician order sheet (POS) shows an order of Citalopram 20mg by mouth in the morning for antidepressant ordered on 6/21/22 and Risperidone 0.5mg by mouth two times a day ordered on 7/18/22. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a qualified staff member provide meal assistance to a resident with a diagnosis of dysphagia (swallowing disorder) for one (R97) out of a total sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meal setup assistance to a dependent resident for one (R14) out of a total sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through the physician's recommendations to address a resident's (R84) weight loss. This failure had the potential to affect 1(R84) out of 1 resident reviewed for nutrition in a total sample of 24. The Findings Include: R84's electronic medical records (EMR) show R84 has listed diagnoses not limited to Paranoid Schizophrenia, Depressive Episodes, Gastroesophageal Reflux Disease Without Esophagitis, and Functional Dyspepsia. On 10/03/23 at 10:57 AM, R84 was lying in bed alert and able to verbalize needs. R84 stated R84 thinks R84 lost weight, and does not like the food in the facility. At 12:50 PM, R84 was eating lunch in R84's room. R84's main entrée consisted of chopped ham, mashed potatoes, and broccoli. R84 stated, I'm not going to eat that. I try not to eat pork. R84 only ate the mixed fruits. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received enteral nutrition feedings via G-tube per physician orders for one (R99) resident reviewed for tube feedings in a sample of 24 residents.

Inspectors wroteBased on interview and record review, the facility failed to acquire authorization/order from a medical professional for R126 to be outside of the facility without staff supervision.

Inspectors wroteBased on interview and record review, the facility failed to keep an accurate count of all narcotic medications for three (R9, R30, R116) residents reviewed for medications in a total sample of 24 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain a consent for an antipsychotic medication prior to administering it to a resident (R14), and failed to ensure as needed (PRN) orders for anti-psychotic drugs were limited to fourteen days for 1 (R107) out of 5 residents reviewed for unnecessary medications in a total sample of 24. The Findings Include: 1. R107's electronic medical records (EMR) show R107 has diagnoses not limited to Bipolar Disorder, Dementia, Depression, and Anemia. R107's Physician Order Sheet (POS) shows R107 had the following orders: Haloperidol Lactate Injection Solution 5 MG/ML (Haloperidol Lactate) Inject 5 mg intramuscularly every 6 hours as needed for psychosis and Haloperidol Oral Tablet 5 MG (Haloperidol) Give 1 tablet by mouth every 6 hours as needed for psychosis. These PRN antipsychotic medications were ordered on 7/11/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for two (R15, R32) of nine residents reviewed for medication administration resulting in a 7.41% error rate. Findings Include: 1. R32's electronic medication administration record (eMAR) documents: Loratadine tablet 10mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. On 10/04/2023 at 8:47AM, surveyor observed this medication was not given during the 9:00AM medication administration pass with V19 (Registered Nurse/RN). 2. R15's electronic medication administration record (eMAR) documents: Risperdal Oral Solution- Give 4 ml by mouth every 12 hours scheduled at 9:00AM. On 10/04/2023 at 9:21AM, V19 had R15's eMAR deployed on the computer, and was beginning to prepare R15's medication for administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure survey results from 2023 and the applicable plan of corrections were accessible and readily available for review. This had the potential to affect all 123 residents who reside in the facility.