Cityview Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Cityview Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 17, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF742Feb 13, 2025

  THE 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. […]

• Immediate jeopardy, isolatedF689Nov 19, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Sep 18, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF687Aug 9, 2023

  Based on observation, closed medical record review, review of Centers for Disease Control (CDC) guidance, review of American Diabetes Association guidance, review of the facility policy for wound care, review of the facility diabetes clinical protocol and interview, the facility failed to implement an individualized and effective plan of care to prevent the development of a foot ulcer for Resident #107, who was admitted with intact skin, identified to be a risk for pressure ulcer development and had co-morbidities including diabetes and diabetic neuropathy, peripheral circulatory disorders, renal failure and was visually impaired requiring extensive assistance of one staff with bed mobility and staff supervision for dressing and personal hygiene. […]