Hyde Park Healthcare Center

In the surveyor’s words

From the most serious findings on record at Hyde Park Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 11, 2025

  Based on interview, and record review, the facility failed to ensure one of five (5) sampled residents (Resident 1), who was confused with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), suicidal ideations (thoughts, wishes, or preoccupations with death or self-harm), bipolar disorder (a mental condition marked by alternating periods of elation and depression), major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and diabetes mellitus (DM, abnormal blood sugar level), did not elope from the facility on 9/25/2025. The facility failed to: 1. […]

• Actual harm, isolatedF600Jan 26, 2026

  Based on observation, interview, and record review, the facility failed to implement its policy and procedure (P/P) titled Abuse and Neglect Prohibition Policy, dated 6/2022, which indicated the facility prohibited abuse for all residents, for one of four sampled residents (Resident 1), who lacked the ability to consent and had severe cognitive impairment (a profound decline in thinking, memory, and reasoning, that prevents independent living). Resident 2, who had a history of sexually inappropriate behaviors sexually assaulted Resident 1.This deficient practice resulted in Resident 2 forcing penile-vaginal penetration onto Resident 1 on 1/17/2026. […]

• Actual harm, isolatedF600Dec 8, 2025

  Based on interview and record review the facility failed to ensure a resident was free from physical abuse when was pushed to the floor by another resident and sustained an injury for one of four sampled residents (Resident 1). These deficient practices resulted in Resident 2 on 11/30/2025 pushing Resident 1 to the floor and sustaining a 1.0-inch posterior (back of the head) scalp (skin covering the head) laceration (skin tear) which required evaluation and treatment in a general acute care hospital (GACH). Resident 1 received two staples (a piece of thin wire with a long center portion and two short end pieces) for the scalp laceration. […]

• Actual harm, isolatedF689Feb 28, 2025

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall and sustain an acute (immediate) fracture (broken bone) of the right femoral neck (part of the thigh bone below the hip joint). […]

• Actual harm, isolatedF600Jul 21, 2023

  Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 63 and Resident 17) were free from sexual abuse. Resident 8, a resident who exhibited hyper sexually active (increased in sex drive) behavior was observed to have escalating behaviors of inappropriate touching. Resident 8 touched Residents 63 and 17 inappropriately. This failure resulted in Resident 17 becoming upset, screamed, and was frightened when Resident 8 pushed Resident 17, in her wheelchair, into his room and slammed the door shut on 7/18/2023. Resident 17 stated Resident 8 touched her inappropriately. On 6/17/2023, Certified Nurse Assistant (CNA) 3 walked into Resident 63's room and witnessed Resident 8 putting his hand on Resident 63's adult protective brief. […]