Health inspection·November 21, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who had a diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought) and mood disorder (a mental health condition that affects a person's emotional state, causing long periods of sadness, depression, mania, or elation). Resident 1 approached and physically became aggressive to Resident 2, while Resident 2 rested in bed and was awaken to see Resident 1 standing over him. As a result, on 11/9/2024, Resident 2 sustained a skin tear on the left ear. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including anxiety (feeling of fear, dread and uneasiness that can be a normal reaction to stress) and depressive episodes (a period of time when someone experiences a depressed mood and other symptoms for at least two weeks). A review of Resident 1's Potential to Demonstrate Abusive behavior care plan revised 12/21/2023 indicated the resident had ineffective coping skills and poor impulse control. A review of Resident 1's History and Physical (H&P) dated 5/9/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/27/2024, indicated the resident had no cognitive impairments (no problems with a person's ability to think, remember, use judgement, and make decisions). A review of Resident 1's Change in Condition form (COC) dated 11/10/2024 at 12:55 AM indicated Resident 1 had a patient-to-patient altercation on 11/9/2024 in the afternoon. The COC indicated Certified Nursing Assistant (CNA) 1 reported to the charge nurse that residents were arguing inside the room. Resident 2 was lying in his bed when Resident 1 approached him, staff intervened and separated the residents. The COC indicated Resident 1 was assessed and placed on visual monitoring to ensure safety. A review of Resident 2's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including schizophrenia, mood disorders, and depressive episodes. A review of Resident 2's MDS dated [DATE], indicated the resident had no cognitive impairment, no (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056206 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE University Park Healthcare Center 230 E Adams Blvd Los Angeles, CA 90011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)