River View Rehab Center: Wound Care Failures - IL
The resident, identified in inspection records as R3, had no care plan warning that he was at risk for skin breakdown before May 19, 2025. That was the same day a wound nurse found an open wound on his coccyx measuring 7.6 by 6.8 centimeters. The care plan was updated that day to reflect the injury. It had taken a wound appearing to prompt the documentation that should have helped prevent one.
Three days later, a specialty physician found things were worse than the initial assessment had captured. The sacrum wound had grown to 8 by 7 centimeters and was unstageable due to necrosis, with 40 percent of the tissue dead and moderate drainage seeping from it. The physician also identified a second facility-acquired wound on R3's right medial heel, unstageable because a blood-filled blister made it impossible to determine how deep the damage went. That wound measured 5.5 by 6 centimeters.
Both wounds were labeled facility-acquired. The facility caused them.
R3 needed limited to extensive assistance with toileting throughout May 2025, according to his ADL records. That level of dependence on staff placed him squarely in the population most vulnerable to pressure injuries, the kind of resident whose skin demands close, consistent watching.
River View's own policy said exactly that. The facility's Pressure Injury and Skin Condition Assessment Policy, dated September 2016, required CNAs to observe each resident for skin breakdown daily during care and on bath days. Any sign of redness, swelling, blistering, discoloration, bleeding, drainage, lesions, or changes in skin temperature was supposed to be reported promptly to the charge nurse, who would then complete an initial assessment. At the earliest sign of breakdown, documentation was to go into the resident's clinical record immediately.
The records show that didn't happen for R3.
His Bath and Skin Report Sheet for May 2025 showed his last completed weekly skin check was May 12. The next one, scheduled for May 19, was never documented. Whether the check wasn't done or simply wasn't recorded, the result was the same: no written evidence that anyone looked at his skin on the day a significant open wound was first discovered on it.
The wound nurse's initial assessment on May 19 identified the coccyx wound but failed to document the type of wound or the type of tissue present, both of which the facility's own policy required. A licensed nurse was responsible for assessing, measuring, and recording wounds in the Wound Assessment Form, and that form was supposed to include the site, the stage, and a comprehensive description. The assessment was incomplete.
The facility's director of nursing, identified in inspection records as V19, told inspectors he expected staff to follow the pressure injury prevention and wound assessment policy so that residents at risk could be managed appropriately. He said residents at risk for skin breakdown should be identified early to prevent deterioration.
R3 was never identified as at risk before the wounds appeared.
The inspection, conducted November 17, 2025, cited the facility for actual harm under the federal tag governing pressure ulcer prevention and treatment. The citation covered a few residents.
By the time the specialty physician completed his evaluation on May 22, R3 had two open wounds of undetermined depth, one of them unstageable because necrosis had obscured what lay beneath the surface, and another unstageable because blood had pooled under a blister too thick to see through. The physician's report documented what the daily checks, had they been done and recorded, were supposed to catch before it reached that point.
They weren't. And it did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River View Rehab Center from 2025-11-17 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 21, 2026 · Our methodology
RIVER VIEW REHAB CENTER in ELGIN, IL was cited for violations during a health inspection on November 17, 2025.
The resident, identified in inspection records as R3, had no care plan warning that he was at risk for skin breakdown before May 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.