River View Rehab Center
RIVER VIEW REHAB CENTER in ELGIN, IL — inspection on November 17, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
breakdown on residents at risk should be identified early to aid in preventing potential deterioration. V19 said he expected the facility staff to follow their pressure injury prevention and wound assessment policy to ensure residents at risk could be managed appropriately. R3's comprehensive care plan did not indicate he was at risk for skin breakdown prior to 5/19/2025.
The care plan was updated on 5/19/2025 to indicate R3 had new facility-acquired wounds to his sacrum on 5/19/2025 and right medial heel on 5/22/2025. R3's ADL report from 5/01/2025-5/26/2025 showed he required limited to extensive assistance with his toileting needs. R3's Bath and Skin Report Sheet for May 2025 showed his weekly (every 7 days) comprehensive skin check was last done on 5/12/2025.
The following scheduled skin assessment on 5/19/2025 was not documented.R3's Treatment Nurse Initial Skin Alteration Review (Wound Nurse) report dated 5/19/2025 said R3 had a new facility identified open wound to his coccyx area.
The wound measured 7.6 x 6.8 x 0.1 cm.
The assessment did not indicate the type of wound and the type of tissue present.R3's Specialty Physician Initial Wound Evaluation and Management Summary report dated 5/22/2025 said R3 had a facility-acquired unstageable (due to necrosis) sacrum full thickness wound.
The wound had 40% necrotic tissue with moderate serous drainage and measured 8 x 7 x 0.1 cm.
The report also said R3 had another facility acquired unstageable DTI of the right medial heel undetermined thickness wound.
The wound measured 5.5 x 6 cm x unknown depth due to blood blood-filled blister.
The facility's policy titled Pressure Injury and Skin Condition Assessment Policy, dated 09/2016, said the policy was established to provide guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring interventions were implemented.
The policy said each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA.
Changes shall be promptly reported to the Charge Nurse, who will perform the initial assessment.
Skin notifications include redness/swelling, blisters, skin discoloration, bleeding, wound drainage, any type of lesion, and changes in skin temperature.
The policy said that at the earliest sign of pressure injury or other skin breakdown, and initial assessment and documentation, should be completed in the resident's clinical record. A licensed nurse was responsible for assessing, measuring, and recording pressure wounds in the Wound Assessment Form.
The form documentation should include the site, stage of the pressure ulcer, and a comprehensive description of the wound.
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