Inspection Reports for Cityview Nursing and Rehabilitation Center

The facility was found deficient in multiple areas including failure to involve residents and responsible parties in care plan development, failure to develop and implement comprehensive care plans addressing resident preferences, failure to review and revise care plans timely, inadequate foot care resulting in overgrown toenails, lack of physician orders for respiratory devices, and improper medication administration via gastrostomy tube.

The complaint investigation involved 5 residents regarding call light accessibility and 3 residents regarding abuse. An Immediate Jeopardy (IJ) was identified on 06/26/25 related to abuse by Resident #6 against Residents #7 and #8, which was removed on 07/06/25. The facility remained out of compliance with no actual harm but potential for more than minimal harm. The investigation included interviews, record reviews, and observations confirming the incidents and ongoing risks.

The facility failed to ensure call lights were within reach for 5 residents, posing a risk of harm. Additionally, the facility failed to protect 3 residents from abuse by another resident exhibiting aggressive behaviors, resulting in an Immediate Jeopardy (IJ) that was removed prior to the survey but with ongoing noncompliance.

The complaint involved an alleged sexual interaction between Resident #1 and Resident #2 on 02/02/25. The facility investigated, intervened immediately, placed Resident #2 on 1:1 supervision, notified families and relevant parties, and provided psych services. Resident #2 denied the incident. The facility found no evidence of abuse and corrected the noncompliance promptly.

The facility failed to provide adequate supervision to two residents with cognitive impairments, resulting in an incident where Resident #1 was found fully clothed in Resident #2's bed, and Resident #2 was undressed below the waist. The facility intervened immediately, placed Resident #2 on 1:1 supervision, and provided education and psych services. No further incidents were noted, and the facility corrected the noncompliance before the survey began.

The complaint investigation revealed Resident #1 hit Resident #2 causing bruises and a skin tear. The incident was witnessed by staff and documented. The facility also investigated improper transfer techniques by hospice staff leading to a fracture in Resident #3. The immediate jeopardy was identified on 01/29/25 and the facility took corrective actions including education and removal of the hospice aide.

The facility failed to protect residents from abuse when Resident #1 struck Resident #2 causing bruises and a skin tear. The facility also failed to ensure adequate supervision and use of assistive devices for positioning and transfers for Residents #3, #4, and #5, resulting in an immediate jeopardy due to a fractured humeral neck in Resident #3 caused by improper repositioning by a hospice aide. The facility provided education and implemented corrective actions including staff in-service and removal of the hospice aide involved.

The complaint investigation revealed that Resident #1 was admitted with an intrathecal pain pump but the facility failed to obtain proper orders, assist with bolus doses, assess pain, and ensure nursing staff competency. Immediate Jeopardy was identified on 09/15/24 and removed on 09/17/24 after corrective actions.

The facility failed to provide safe and appropriate pain management for Resident #1 who required an intrathecal pain pump, including failure to obtain proper physician orders, assist with patient-controlled bolus doses, assess pain adequately, and ensure nursing staff competency related to pain pump care. Immediate Jeopardy was identified but later removed after the facility implemented corrective actions including staff education and updated care plans.

The facility was found deficient in multiple areas including failure to provide private meeting space for resident groups, failure to provide proper notice of Medicare/Medicaid coverage changes, inadequate assistance with activities of daily living for several residents, improper catheter care, failure to follow feeding tube care orders, lack of physician orders and documentation for dialysis patients, medication administration errors, failure to maintain respiratory care standards, incomplete facility-wide assessment regarding dialysis services, inadequate clinical record documentation, lack of privacy in resident rooms, and ineffective pest control program leading to mosquito bites.

The facility was found deficient in multiple areas including failure to provide private meeting space for resident groups, failure to issue Medicare notices, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, improper catheter care, lack of physician orders for oxygen and dialysis, medication administration errors, incomplete dialysis communication, lack of contracts with dialysis providers, incomplete clinical records, failure to don PPE for infection control, inadequate pest control, and insufficient privacy in resident rooms.

The complaint involved Family Member #1 being banned from visiting Resident #2 despite the resident's right to receive visitors, which led to emotional distress and isolation. The facility also failed to safeguard Resident #1's private health information and maintain accurate medical records, including documentation of an AMA discharge. The complaint was substantiated based on interviews and record reviews.

The facility failed to ensure Resident #2's right to receive visitors, resulting in emotional distress and isolation. Additionally, the facility failed to prevent unauthorized disclosure of Resident #1's private health information and did not maintain complete and accurate medical records, including documentation of Resident #1's discharge against medical advice.

The facility failed to ensure contaminated sharps bins attached to nurse medication carts and a wound care cart were not overfilled beyond the designated fill line, posing a risk of exposure to contaminated sharps and blood borne pathogens to residents and staff. Interviews confirmed staff responsibility for changing sharps bins and acknowledged the hazard of overfilled bins.

The facility failed to ensure that Medication Cart #1 was locked when unattended and that Medication Cart #2's keys were secured by the assigned RN. This failure posed a risk of unauthorized access to medications and potential harm or drug diversion.

The complaint investigation was triggered by grievances and reports of rats in the kitchen and dry storage room. The Maintenance Director and Dietary staff confirmed sightings and evidence of rodents. The pest control company was scheduled for follow-up treatment after the rat sightings were documented.

The facility failed to maintain an effective pest control program, resulting in the presence of rats in the kitchen and dry storage room. Multiple interviews and record reviews confirmed sightings of rats and rat droppings, and inadequate monitoring and cleaning practices were noted.

The complaint investigation focused on issues including delayed response to call lights, inaccessible call lights, failure to submit discharge MDS assessments for residents, and poor food quality and preparation affecting multiple residents.

The facility failed to timely respond to call lights and ensure call lights were within reach for residents, failed to submit discharge MDS assessments for four residents, and failed to prepare food that was palatable, attractive, and properly seasoned for multiple residents. These deficiencies posed risks to resident safety, communication with CMS, and resident quality of life.