City View Multicare Center: Resident Fall After Attack - IL
The incident happened September 19, 2025. The resident, identified in inspection records only as R1, had taken another resident's coffee and spilled it. The other resident swung at him. R1 fell.
By the time a nurse supervisor named in the report as V7 documented the incident in R1's medical record the following evening, R1 was already in pain and waiting on an x-ray of his right arm. V7 noted he had called R1's family member back and assured them the x-ray would be done, and that R1 was receiving pain medication in the meantime. V7 told inspectors on October 20 that he didn't recall many details beyond what his note said, but confirmed the note was accurate.
The x-ray results came back the morning of September 21. The fracture was confirmed. R1 also had discoloration around his right eye.
R1 paces the nursing unit daily. The inspection report notes he experiences regular periods of anxiety and that pacing is a consistent part of his routine. That detail matters because it speaks to what staff on the eighth floor would have known about him, what his movements looked like on any given shift, and what kind of supervision his documented behavior called for.
The nurse supervisor told inspectors that a dining room staff member, identified as V6, was not responsible for assisting on the eighth-floor unit because all residents there were considered independent. V6 confirmed this to inspectors, saying she had not gone to the dining room to help after being told R1 was on the floor, and had not gone afterward either.
What inspectors found when they turned to the question of who was actually working that day was more troubling than the incident itself.
V8, a certified nurse aide, told inspectors on October 22 that she had worked both the day shift and evening shift on September 19, but that she had not been assigned to the eighth floor where R1 lived. The facility's own staffing assignment sheet said otherwise. Her name was on it. Her initials were next to her name.
She denied it anyway.
There is no indication in the inspection report that the facility had taken any action in response to that denial before inspectors raised it.
The violation was cited under F0689, which covers accident hazards and supervision, and was assessed at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory floor, not necessarily the experience of a man who waited hours in pain for an x-ray that confirmed a broken bone, or of his family member who had to call the facility and request a supervisor callback to find out what had happened to him.
City View's fall prevention and management policy, dated August 2017, states that when a fall occurs, additional interventions will be implemented to prevent another fall. The inspection report does not describe what interventions, if any, were put in place for R1 after September 19.
R1's family member was eventually reached by phone. They were told about the coffee, the swing, the fall, the pain medication, the pending x-ray. The nurse supervisor, by his own account, assured them everything was being handled.
The fracture was real. The staff member who may have been present denied being there. And a resident who paces the unit every day because of anxiety had, somewhere between breakfast and the end of the day shift, ended up on the floor with a broken arm and a bruised eye.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for City View Multicare Center from 2025-10-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
CITY VIEW MULTICARE CENTER in CICERO, IL was cited for violations during a health inspection on October 28, 2025.
The incident happened September 19, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.