Landmark of Hyde Park Rehabilitation and Nursing C

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's (R4) right to be free from verbal and mental abuse. This failure affects one resident (R4) of nine residents reviewed for abuse in a total sample of nine residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse Prevention Program policy by failing to notify the State Survey Agency immediately of abuse allegations. This failure affects two residents (R1, R4) of nine residents reviewed for abuse in a total sample of nine residents.

Inspectors wroteBased on observation, interview and record review, facility failed to follow their policy to ensure residents are allowed to go out on pass individually for one (R8) out of three residents reviewed for community pass in a sample of 20. The facility also failed to replace a voters' registration card after being voiced to staff and documented in a grievance form for one resident (R6) in a total sample 20. Findings Include:1. On 05/27/2026 at 10:57 AM, R8 was in his room. R8 stated that he is not allowed to go out on pass. I am compliant with my medications. I have no physical or mental limitations. R8 stated that his pass was revoked on 04/28/2026 for some reason. They never gave me a reason. Just something that the doctor ordered me a red pass. On 05/27/2026 at 1:16 PM, V8 (Social Service Director) stated that social service does the community skills assessment. [...]

Inspectors wroteBased on interview and record review, facility failed to ensure residents are free from physical abuse for one (R10) out three residents reviewed for abuse in a sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to properly report allegation of misappropriation of property for one (R9) out of three residents reviewed for misappropriation of property in a sample of 20. Facility also failed to report abuse within 2 hours of notification of abuse allegation for two (R10, R12) out of three residents reviewed for reporting of abuse allegation in a sample of 20.

Inspectors wroteBased on interviews and record reviews, facility failed to ensure necessary post fall interventions, to rule out injury, were completed for one (R11) out of three residents reviewed for falls in a sample of 21.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to provide COVID-19 vaccination upon readmission to the facility for one (R6) resident in a sample of 20 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure four [R1, R4, R5, R13] of eight residents remained free from abuse. This failure resulted in: R2 sustained a closed fractured tooth, human bite, swollen lip and pain. R4 sustained displaced fracture of distal phalanx of right ring finger and displaced fracture of proximal phalanx of right little finger, and pain. R5 sustained forehead altered skin integrity, that required 911 transport for emergency treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow a resident's fall care plan for 1 (R10) of 3 residents reviewed in a total sample of 18.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their 'Abuse Prevention Policy' and report any alleged violations involving mistreatment, or suspecting resident abuse, to the Administrator for one [R1] of five [R2, R3, R4 R5] residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a homelike environment for one resident (R30) in the sample of 80 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy to inventory the belongings of one (R4) resident of eight reviewed for personal property.

Inspectors wroteBased on interview and record review, the facility failed to assert the rights of the residents and prevent and protect residents from resident-to-resident abuse. This failure affects two of three residents (R1, R2) reviewed for abuse.

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision and implement fall prevention interventions for one of six residents (R1) reviewed for high risk for falls. These failures caused R1 to sustain a fall and was sent out to the local hospital with a laceration to the right eyebrow, a large subdural hematoma with mass effect, effacement of the right lateral ventricle, and a right zygomatic facial fracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's care needs were being met by permitting one employee (V15) to sleep on duty. This failure has the potential to affect 16 residents on the unit V15 was assigned.

Inspectors wroteBased on interview, and record review the facility failed to consistently administer bilevel positive airway pressure (BIPAP) therapy as ordered by a physician for one resident (R2) out of three residents reviewed for respiratory care in a total sample of seven residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free from abuse. This failure affects two residents (R1, R2) reviewed for abuse. This failure lead to physical assault by R2, which resulted in R1 sustaining a laceration to the head.

Inspectors wroteBased on interview and record review, the facility staff failed to report an allegation of abuse to the administrator for one of three residents (R1) in a total sample of four.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that residents' rooms (R10, R11 and R12) were free from urine on the floor and urine odors.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that urostomy supplies for one resident (R10) were available. This failure resulted in R10's lower abdomen and bedroom floor being saturated with urine.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident the physician ordered diabetic diet. This failure affected one resident (R2) out of 9 residents reviewed for therapeutic diets.

Inspectors wroteBased on observation, interview and record review the facility failed to label and date stored food, failed to cover and label open food, failed to prepare food in a clean area, and failed to store, date and label prepared foods properly. These failures have the potential to cause food borne illness to all residents receiving food prepared for the nursing skilled facility. Findings Include, On 1/28/25 at 9:11 AM, during initial kitchen tour with V10 [Dietary Cook], the following items were found in walk-in refrigerator: Open uncovered to environment chopped lettuce, no open nor expiration date. Pack of open turkey slices open and uncovered to environment, no open nor expiration date. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of kitchen garbage properly in a contained dumpsters and failed to keep the dumpster area clean free of debris, the garbage area was not maintained in a sanitary condition to prevent harborage and feeding of pest. These failures could affect all residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective pest control program. This has the potential to affect all the residents that reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident (R387) with surgical wound and peripherally inserted central catheter (PICC) line was placed on an Enhanced Barrier Precaution (EBP) and failed to disinfect blood equipment between use for three residents (R225, R226 & R138) for four of nine residents reviewed for infection control. Findings Include: 1. On 1/29/25 at 08:32 AM V6 (Licensed Practical Nurse) returned to the medication cart after exiting R225's room with signage posted indicating Enhanced Barrier Precautions. V6 placed the wrist blood pressure monitor on top of the medication cart after taking R225 blood pressure without disinfecting it. On 01/29/25 at 08:44 AM V6 (Licensed Practical Nurse) entered R226's room with signage posted indicating Enhanced Barrier Precautions. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumonia vaccinations in a timely manner for (R21, R24, R54, R73, R486), offer the influenza vaccine to (R24), and obtain written consent prior to administering an influenza vaccine to (R486). These failures affected five out of five residents reviewed for immunizations on the total sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate and follow a resident's preference to get up out of bed (R65) and a resident's preference (R194) for a shower for two residents (R65 & R194) of two residents reviewed for accommodation of needs and preferences on the total sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician when a residents blood pressure was not within the ordered parameters for (R177), failed to follow their policy for positioning a resident when obtaining a blood pressure for (R138) and failed to place a dressing on R65's permacath. This failure affected 3 residents (R177, R138 and R65) reviewed for quality of care on the sample of 35. Finding Include: 1. R177 has diagnosis not limited to End Stage Renal Disease, Essential (Primary) Hypertension, Hypertensive Urgency, Chronic Obstructive Pulmonary Disease, Encephalopathy, Schizophrenia, Suicidal Ideations, and dependence on Renal Dialysis. On 01/28/25 at 12:34 PM V6 (Licensed Practical Nurse) entered R177's room and applied the wrist blood pressure monitor to her right wrist obtaining a blood pressure reading of 99/56 pulse 68. [...]

Inspectors wroteBased on observation, interview, and record review the failed to ensure a low air loss mattress was on the correct setting for one (R157) resident with a history of alterations in skin integrity in a sample of 35. Finding Include: R157 has diagnosis not limited to Type 2 Diabetes Mellitus, Anemia, Peripheral Vascular Disease, Primary Osteoarthritis, Thrombocytosis, Spinal Stenosis, Lumbar Region with Neurogenic Claudication, Hyperlipidemia, Abnormal Weight Loss, Depression and Contracture other Specified Joint. R157's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate cognitive impairment. Care plan document in part: R157 has a self-care deficit: Impaired Bed Mobility and would benefit from participation in a Bed Mobility Restorative Nursing Program as evidenced by the following risk factors and potential contributing Diagnosis: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure anti-contracture devices were applied as ordered and ensure the care plan was updated to reflect the correct area of splint application for one (R72) of four residents reviewed for limited range of motion in a sample of 35. Findings Include: R72 has diagnosis not limited to Psychosis, Epilepsy, Hemiplegia, Unspecified Affecting Right Dominant Side, Weakness, Cerebral Infarction, History of Falling, Personal History of Transient Ischemic Attack (Tia), Schizophrenia, Bipolar Disorder, Obesity, and Injury of Head. R72's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate cognitive impairment. Care Plan document in part: Focus: R72 is at risk for complications related to Cerebral Vascular Accident (Stroke) Hemiplegia affecting Right Dominant side. Focus: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure expired dialysis nutritional supplements were not store and administered to two (R177, R183) of three residents reviewed for nutrition in a sample of 35. Findings Include: On [DATE] at 01:05 PM the second-floor medication room was reviewed with V5 (Registered Nurse). An opened box containing twenty 8-ounce cartons of Nova Source Renal 19% was observed on the counter with a use by date of [DATE]. V5 stated we use the Nova Source for dialysis residents, and this is the only box. There are 3 or 4 dialysis residents on the floor. On [DATE] at 01:15 PM surveyor asked V4 (Registered Nurse) are there any dialysis residents on the floor. V4 responded, R114, R177 and R183 are dialysis residents. Surveyor asked do they receive the Nova Source Renal 19%. V4 responded; they receive it every day unless they refuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to evaluate for the appropriateness of antipsychotic medication and ensure that as needed orders for anti-psychotic medications are limited to 14 days for one (R170) of six residents reviewed for unnecessary medications on the total sample of 35. Findings Include: R170's clinical records show an initial admission date of 10/16/24 with included diagnoses but not limited to Schizoaffective Disorder Bipolar type, Generalized Anxiety Disorder, and Major Depressive Disorder. R170's Minimum Data Set, dated [DATE] shows R170 has moderately impaired cognition. R170's physician orders with active orders as of 1/29/25 read in part: Haloperidol Lactate Injection Solution inject 5 mg intramuscularly every 6 hours as needed for agitation and Haloperidol 5 mg 1 tablet every 6 hours as needed (PRN) for agitation (ordered 12/27/24). [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that a foot rest was placed on the wheelchair of one resident (R8), who had a diagnosis of left- sided weakness. This failure resulted in R8's left foot dragging on the floor, causing R2 to fall out of his wheelchair while being propelled by an employee.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a pest and rodent free environment. This deficient practice has the potential to affect all 229 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dependent resident with nail care for one of three residents (R2) reviewed for activities of daily living (ADL) in the sample of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain hot foods on the service steam table for meal tray assembly at 135 degrees Fahrenheit or higher and failed to serve hot foods to the residents at a temperature not less than 125 degrees F which affected R5 and has the potential to affect 60 residents residing on the floor utilizing the steam table.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform timely incontinence checks and care for one resident (R2) in the sample of three residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide aseptic wound care treatments for pressure ulcer wounds; failed to ensure that a resident with pressure ulcers was repositioned timely; and failed to ensure that a resident's low air loss mattress setting for weight were at the appropriate weight which affect one resident (R2) in the sample of three residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the diet prescribed by the physician to residents in the form to meet the needs of the residents. This failure affects two residents (R3, R4) and has the potential to affect seven additional residents (R8, R9, R10, R11, R12, R13, R14) that have orders for a pureed diet at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free of physical abuse for one (R3) resident in a sample of three. This failure resulted in physical injury to R3's face requiring transfer to a hospital and R3 receiving three sutures to R3's face.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor residents on the outside patio of the facility for safety. This failure has the potential to affect 4 residents (R8, R16, R17, R18) who use wheelchairs and are at risk for falls and other unsafe conditions on the patio.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that provider orders were followed for three residents (R2, R3, R4) out of three residents reviewed for Hepatitis C treatment. This failure resulted in R2 not receiving treatment for Hepatitis C resulting in liver damage, hepatocellular carcinoma, and progression of R2's liver tumor giving strong evidence of carcinomatosis (cancer is spreading).

Inspectors wroteBased on observation, interviews and record review, the facility failed to supervise and monitor one resident (R1) of 4 residents reviewed for supervision. This failure resulted in R1 eloping from the facility by climbing over the fence surrounding the smoking patio.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were labeled and dated; failed to ensure food items were 6 inches off the floor; failed to ensure food items which passed their shelf life, use-by-date and/or expiration date were discarded, and failed to ensure staff donned beard covers in an effort to prevent food borne illness. These failures have the potential to affect all 199 residents who receive food from the kitchen at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dumpsters were kept closed and failed to ensure the ground surrounding the dumpster was free of trash in an effort to prevent pest and rodents migration to the facility. These failures have the potential to affect all 224 residents residing at the facility.

Inspectors wroteBased upon interview and record review, the facility failed to ensure that the facility's designated Infection Preventionist staff member has completed the specialized training in infection prevention and control for the facility's infection prevention and control program (IPCP). This failure has the potential to affect all 224 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that the facility is free of rodents. This failure has the potential to affect all 224 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for four residents (R45, R61, R77, R107) reviewed for homelike environment on the sample list of 63.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of the three medication carts were kept clean and free from clutter. This deficient practice has the potential to affect 51 residents on one floor and 25 residents on an additional floor who receive medications from the medication carts.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct hand hygiene prior to passing meal trays and failed to ensure that Personal Protective Equipment was accessible for rooms requiring this equipment. These failures affected 5 residents (R97, R145, R160, R219 and R467) reviewed for infection control on the sample list of 63 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter drainage bag was covered. This failure affects one resident (R467) reviewed for dignity on the sample list of 63 residents. Findings Include: R467's admission record includes diagnoses of atherosclerotic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, coronary angioplasty, and anemia. R467's (3/8/24) Minimal Data Set documents, a Brief Interview for Mental Status (BIMS) score of 13 which indicates that R467 is cognitively intact. On 3/17/24 at 9:50 am surveyor observed R467's indwelling catheter drainage bag hanging on the lower right side of the bed visible from the hallway. The drainage bag was not covered with a privacy bag. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that the call light was within reach for 2 residents (R134 and R76) out of 63 residents reviewed for call lights.

Inspectors wroteBased on interview and record review, the facility failed to ensure preadmission screening assessments were completed as needed for residents identified to have a mental illness. This failure affects 2 (R98 and R113) residents reviewed for pre-admission screening on the sample list of 63 residents.

Inspectors wroteBased on interview and record review, the facility failed to refer residents with possible serious mental disorders for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This failure affects two residents (R38, R78) reviewed for screening on the sample list of 63.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a privacy curtain to provide privacy as needed. This failure affects two residents (R68 and R155) reviewed for privacy on the sample list of 63 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure reducing devices for wheelchairs as stated in the assessments for residents at risk for pressure ulcers. This failure affected five residents (R3, R4, R5, R6 and R7) of 6 residents, reviewed for pressure ulcer prevention interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so the the facility is free of rodents on 3 of 4 (2nd , 3rd and 4th) resident floors and in the Dietary area (1st floor). This affects all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff to resident mental and verbal abuse did not occur for one of four residents (R4) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a shared shower room on the third floor was free of feces on the floor. This failure has the potential to affect all 61 residents that utilize the third floor shower room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two resident (R2 and R5's) room was free of odor, and without feces on the floor and waste basket.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dietary orders were followed for four residents (R1, R6, R7, and R8). This failure has the potential to affect all 226 residents that receive meals/ nutrition from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility: failed to obtain a physician order for oxygen administration upon admission for a resident with a diagnosis of Respiratory Failure; failed to ensure that a physician order is obtained before administering oxygen; failed to replace the humidifier bottle when empty; and failed to check pulse oximetry reading per policy. These failures affected one resident (R4) of two residents reviewed for oxygen administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one resident's (R1) scheduled pain medication was entered into the resident's orders to manage pain. This failure has affected one of eight residents reviewed for pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' call light system is maintained, functional and adequately equipped to allow residents to call for staff assistance. This failure affected one resident (R5) of three residents, reviewed for functional resident call system.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that kitchen staff perform appropriate and timely hand hygiene; failed to ensure that kitchen staff wear gloves when handling food; failed to label opened food items with an open date; failed to discard expired foods; failed to wash produce properly; failed to ensure that kitchen staff store their personal items and drinks out of the facility kitchen; failed to ensure that hair restraints covered all head hair of the kitchen staff; failed to properly sanitize kitchen dishware, utensils and equipment in the 3 compartment sink and allow to air dry before next use; failed to maintain cooked food items on the steam table at 135 degrees Fahrenheit (F) or higher; failed to sanitize the thermometer between food items when obtaining food temperatures; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed appropriate hand hygiene during dining on 5th floor, failed to ensure the 4th floor's ice cooler's lid was not touching the floor and ice scoop was contained, and failed to ensure dirty linens were bagged prior to tossing in a laundry chute in an effort to prevent the spread of infectious microorganisms, including COVID-19. These failures have the potential to affect all 204 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean the lint compartment which housed the lint screen in an effort to provide a safe environment to the residents. This failure has the potential to affect all 204 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were not using disposable cutlery during lunch in an effort to promote dignity during dining. This failure affected R85 and has the potential to affect 94 residents residing on the 4th and 5th floors of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident environment remained free of accident hazards for two residents (R159 and R458); failed to ensure fall interventions were in place for one resident (R204); and failed to ensure smoking supervision and interventions were in place for one resident (R137). These failures affect 4 residents (R19, R458, R204, and R137) reviewed for safety and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label, date, and contain oxygen equipment in accordance to the facility policy. This failure affected one resident (R52) reviewed for oxygen equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly log refrigerator temperatures for one resident (R194).