Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on interview and record review, the facility failed to update one resident's falls care plan with new
interventions to prevent or reduce the risk of further falls. This affected one of three residents (R1) reviewed
for plan of care.Findings include: R1's falls care plan, initiated 3/18/25, notes R1 is not at risk for falls as
evidenced by the following risk factors and potential contributing diagnosis: bipolar disorder with mood
and/or behavioral disturbance. The only intervention noted: nursing staff will complete a fall risk assessment
per facility fall protocol. This intervention was reviewed on 3/18, 6/23, and 9/22.There is not an at risk for
falls care plan initiated prior to R1's fall or a high risk for falls due to actual fall care plan initiated post fall on
9/19/25.R1's falls report, dated 9/19/25, notes V4 (nurse) observed R1 on floor lying near table on stomach.
R1 stated R1 moved away, another resident was going to touch R1, R1 took the other resident's coffee, and
it spilled. Predisposing physiological factors include impaired memory, impulsive, agitated/anxious,
delusions, use of high-risk medications, decreased safety awareness, receives antipsychotics, and
hallucinations.R1's hospital record, dated 9/21/25, notes R1 presented to the emergency room after a
traumatic fall. R1's CT (computed tomography) scan of right shoulder shows an acute traumatic
comminuted fracture through the lateral greater tuberosity and transverse surgical neck fracture. There is
5mm (millimeters) impacted foreshortening across the surgical neck fracture. A fracture line is noted along
the deep lateral portion of the bicipital groove. Generalized soft tissue swelling around the shoulder and
posttraumatic joint effusion. CT scan of R1's facial bones show a mildly displaced left nasal bone
fracture.R1's fall risk review, dated 9/23/25, notes fall history - does R1 have a history of falls within the last
three months; response documented is no. Health conditions - does resident have any health condition that
predisposes them to be at risk for falls (other fractures); response documented is none.R1's occupational
therapy evaluation, dated 9/24/25, notes R1 with a decline in strength, balance, activity tolerance, and
non-weight bearing right arm. R1 requires maximum staff assistance with ADLs (activities of daily living).
Due to the documented physical impairments and associated functional deficits, R1 is at risk for falls.On
10/20/25 at 1:20 PM, V2, DON (Director of Nursing) stated a residents care plan should be reviewed and
updated after each fall. V2 stated V2 completed R1's fall risk review when R1 was re-admitted after a fall on
9/23/25. When questioned reason V2 noted ‘no' on R1's fall history (does R1 have a history of falls within
the last three months), V2 responded V2 interpreted this to mean falls other than the current fall on 9/19. V2
stated R1 is not at risk for falls.On 10/27/25, V1 (Administrator) presented the following: any resident who
comes into the facility is always at risk [for falls]. When someone falls, they are put on high risk for falls no
matter how many falls they have had. They are given a yellow wrist band. Care plans are at risk for falls.
The facility's care plan policy, undated, notes residents' care plans will be reviewed and updated with any
significant changes in condition.The facility's fall prevention and management program policy, dated
8/3/2017,
(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 4
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
10/28/2025
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)
F 0657
notes the purpose is to ensure that in the event a fall occurs, additional interventions will be implemented to
prevent another fall from occurring.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145850
If continuation sheet
Page 2 of 4
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
10/28/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview, and record review, the facility failed to effectively monitor/supervise
residents in the dining room to prevent an avoidable accident. This affected one of three residents (R1)
reviewed for supervision.Findings include:R1's medical record notes diagnoses including but not limited to
generalized anxiety disorder, paranoid schizophrenia, drug induced secondary Parkinsonism,
encephalopathy, psychoactive substance abuse with psychoactive substance-induced psychotic disorder
with delusions, and strange and inexplicable behavior.R1's functional abilities assessment, dated 6/24/25,
notes R1 requires supervision or touching assistance with walking 10 feet, 50 feet with two turns, and 150
feet.R1's fall risk review, dated 7/30/25, notes R1's fall risk score is 3; R1 is not at risk for falls.R1's fall risk
review, dated 9/23/25, was completed for re-admission after hospitalization for a traumatic fall. R1's fall risk
score is 3; R1 is not at risk for falls.R1's BIMS (Brief Interview of Mental Status) score, dated 7/2/25, notes
R1's score is 10 out of 15. R1's cognitive is moderately impaired.R1's fall report, dated 9/19/25 at 9:00 PM,
V4 (nurse) noted R1 observed on the floor lying near table on stomach. R1 stated, I moved away, he was
going to touch me, I took his coffee, and it spilled. R1's hospital record, dated 9/21/25, notes R1 presented
to the emergency room after a traumatic fall. R1's CT (computed tomography) scan of right shoulder shows
an acute traumatic comminuted fracture through the lateral greater tuberosity and transverse surgical neck
fracture. There is 5mm (millimeters) impacted foreshortening across the surgical neck fracture. A fracture
line is noted along the deep lateral portion of the bicipital groove. Generalized soft tissue swelling around
the shoulder and posttraumatic joint effusion. CT scan of R1's facial bones shows a mildly displaced left
nasal bone fracture.V15's (orthopedic surgeon) note, dated 10/10/25, notes R1 with humeral head/neck
fracture and R1 will require a surgical procedure, right reverse total shoulder, to repair fracture. Surgery
scheduled for 10/15/25 at local hospital.On 10/18/2025 at 11:30 AM, V11 (nurse) and V12 (nurse) were
observed sitting at the nurses' station. Both stated there is no CNA (Certified Nurse Aide) working on this
nursing unit today. When questioned who is supervising the residents in the dining room today, V11
responded there is no staff. V11 stated the residents are independent.On 10/18/25 at 1:10 PM, V10, RN
(Registered Nurse) stated R1 was delusional daily. V10 stated R1 spoke to himself as he paced in the
hallway.On 10/18/25 at 1:30 PM, V4 (nurse) stated V4 worked the evening shift on 9/19/25. V4 stated it was
close to 10:00 PM when V4 was called to go to the dining room. V4 observed R1 lying on the floor. V4 does
not recall if R4 or R5 were in the dining room. V4 does not recall who the other residents were in the dining
room at the time of R1's fall. V4 cleared the other residents out the dining room to attend to R1. R1 was
speaking, but nothing he was saying was making any sense. R1 began talking about coffee. V4 asked R1
where he got coffee from; R1 did not respond. V4 observed spilled coffee on the floor near R1. R1 became
irate and really aggressive. V4 stated normally R1 paces in the hallway talking to no one. Typically, one
cannot have a conversation with R1. R1's baseline is disoriented. R4 and R5 typically do not interact with
others.On 10/18/25 at 1:40 PM, V14, PA (Physician Assistant for orthopedic surgeon) stated a repeat x-ray
was obtained at R1's follow-up appointment with V15 (orthopedic surgeon). V14 stated the x-ray showed
R1's right humerus fracture was more displaced than the previous x-ray. R1 had a comminuted fracture of
the head and neck of the humerus. R1's fracture could have worsened just from R1 lying in bed, because
R1 wore his sling. V14 believes R1 informed her that he fractured his arm during an altercation with another
resident.On 10/20/25 at 10:25 AM, V6, RN, stated she was at the nurses' station on 9/19 at time of R1's fall
in dining room. V6 stated there weren't many residents in the dining room, not sure who was all in there. V6
stated staff do not monitor residents
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145850
If continuation sheet
Page 3 of 4
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
10/28/2025
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
on the eighth-floor nursing unit, as they are all independent. V6 denied going into dining room to assist after
informed R1 was on the floor or afterwards.On 10/20/25 at 11:00 AM, V7 (Nurse Supervisor) stated V7
spoke with R1 and R1's family member regarding the incident. V7 stated R1 took another resident's coffee,
not sure which resident it was. The other resident swung at R1 and R1 fell. V7 stated he does not recall any
further details, but his note dated 9/20 is an accurate account of incident.R1's medical record, dated
9/20/25 at 9:13 PM, V7 (Nurse Supervisor) noted V7 was made aware R1's family member requested a call
back from supervisor as regards to R1's welfare. V7 returned call to R1's family member and updated family
member on R1's condition. V7 assured R1's family member tan x-ray of the right arm will be done due to
pain, while R1 was receiving pain medication to relieve the pain pending the outcome of the x-ray. V7 also
explained to R1's family member R1 confirmed to V7 that R1 took and spilled peers coffee, who in turn
swung back at R1, leading to a fall. On 10/22/25 at 2:00 PM, V8, CNA (Certified Nurse Aide) stated she
worked 9/19 day shift and evening shift, but denied working on the eighth-floor nursing unit where R1
resided. The facility's staffing assignment sheet, dated 9/19/25, notes V8 assigned to work on the
eighth-floor nursing unit day shift and evening shift. It also notes V8 documented her initials next to her
name.On 10/23/25 at 10:08 AM, V9, LPN (Licensed Practical Nurse) stated she worked a double shift from
9/20 at 11:00 PM until 9/21 at 3:00 PM and was assigned to provide care for R1. V9 stated R1 did complain
of pain to right arm. V9 stated she received report that R1 fell and R1 had swelling to right arm as a result.
R1 was receiving pain medication. V9 stated the x-ray results were known on 9/21 in the morning. V9 stated
the x-ray showed fracture. R1 also had discoloration to his right eye. R1 exhibits periods of anxiety in which
R1 paces on the nursing unit. R1 paces daily. The facility's fall prevention and management program policy,
dated 8/3/2017, notes the purpose is to ensure that in the event a fall occurs, additional interventions will be
implemented to prevent another fall from occurring.
Event ID:
Facility ID:
145850
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the October 28, 2025 survey of CITY VIEW MULTICARE CENTER?
This was a inspection survey of CITY VIEW MULTICARE CENTER on October 28, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CITY VIEW MULTICARE CENTER on October 28, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.