Inspection·May 1, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a physical abuse allegation to the State Agency. This failure applied to one (R1) of three residents reviewed for abuse. Findings include: R1 is a [AGE] year-old female, who originally admitted to the facility on [DATE], and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: COPD (Chronic Obstructive Pulmonary Disease), migraine, muscle spasms, anxiety, ADHD (Attention Deficit Hyperactivity Disorder), intervertebral disc degeneration, behavioral and emotional disorders, PTSD, insomnia, and dental restoration. R2 is a [AGE] year-old male, who originally admitted to the facility on [DATE], and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: bipolar disorder, strange and inexplicable behavior, violent behavior, anxiety, brief psychotic disorder, and depression. On 4/30/2025 at 10:45AM, R1 said, One day last week, I was in the elevator and (R2) physically assaulted me. (V4, Licensed Practical Nurse) was present at the time of the assault and is aware. (V5, Licensed Practical Nurse) was on duty at the time of this incident and is aware. (V3, Psychotherapist) and (V7, Physician's Assistant) were also informed of this physical abuse, but nothing was done. I was never interviewed about the incident after this day by (V1, Administrator) or (V2, Director of Nursing). The police were never called, and an incident report was never filed. At 1:50PM, V1 said, On 4/22/2025, (V4) called me and told me (R1) was alleging that she got beat up, and that her dentures were broken. I could hear her sobbing on the other end of the phone, screaming for an anxiety medication. She had no physical marks on her face. She would not talk to me or get on the phone. She went to sleep that night and she was fine. I checked in with her the following day, and she was fine. She did not bring anything up regarding the abuse, and her topics she wanted to discuss were all over the place. Typically, I file an abuse report right away, however, since she could not give me any sort of description and did not want to talk to me about it, I did not file a report. V1 was asked if R1 alleged physical abuse, and she said, Yes, I should have reported it. V1 filed an initial facility reported incident for R1 on 4/30/2025, 8 days after alleged incident. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145850 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145850 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE City View Multicare Center 5825 West Cermak Road Cicero, IL 60804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)