Cityview Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jul 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free of abuse for 3 of 5 residents (Residents #6, #7 and #8) reviewed for abuse. The facility failed to ensure Residents #7 and #8 had the right to be free from abuse when Resident #6 hit Resident #7 in the face on 06/26/25 and put his hands around Resident #8's neck on 07/02/25. An IJ was identified on 07/10/25. The IJ began on 06/26/25 and was removed on 07/06/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 07/06/25, the facility remained out of compliance with a scope of pattern and severity level of no actual harm with potential for more than minimal harm . The failure placed residents at risk for abuse. […]

• Immediate jeopardy, patternF689Jan 31, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 6 (Resident #3, #4, and #5) residents reviewed for use of assistance devices for positioning and transfers. 1. On 01/13/25 Hospice Aide K failed to use a drawsheet when repositioning Resident #3 in bed and instead raised her up underneath her armpits hard to pull her up in bed and heard a loud crack or pop. The facility ordered x-rays, and it was determined the resident had sustained a displaced humeral neck fracture (shoulder/upper arm fracture) due to the improper transfer and failure to use a drawsheet to position her in bed. 2. […]

• Immediate jeopardy, patternF697Sep 17, 2024

  Based on observation, interview, and records review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #1) reviewed for pain management. The facility failed to obtain physician orders for the intrathecal pain pump from the Pain Physician for Resident #1 upon admission on 09/07/24 for immediate care and needs. […]

• Immediate jeopardy, patternF726Sep 17, 2024

  Based on observation, interview, and records review, the facility failed to ensure that licensed nurses have the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan for one (Resident #1) of one resident reviewed for nursing care/services, in that: Prior to admission, the facility failed to determine the knowledge, competencies, or skill sets of nursing staff to meet the needs of Resident #1 with an intrathecal pain pump (a surgically implanted device that delivers medication directly to the fluid surrounding the spinal cord). […]

• Actual harm, isolatedF684Aug 25, 2026

  Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 resident (Resident #1) reviewed for quality of care.The facility failed to identify and intervene timely after Resident #1 had an unwitnessed fall on 08/16/2026 at 5:45 AM. Resident #1 was found to have left hip pain on assessment and was not sent to the hospital until approximately 3.5 hours later at 9:10 AM. This failure could place residents at risk of delayed treatment and not receiving needed care. […]