Resident 69 had been hospitalized from August 8 through August 12 for metabolic encephalopathy and acute kidney failure.
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The citation lasted from June 6 through June 7, when the facility corrected the problems before the formal investigation began three months later.
LPN #202 discovered Resident #70 smoking from a pipe while sitting in his wheelchair just inside the bathroom doorway.
Despite working with Resident 1 from July through September 2025, the resident's physical therapy goals had remained completely unchanged.
The resident, who has dementia and severe cognitive impairment, depends entirely on facility staff for basic activities like bathing, dressing and toileting.
Resident 2 told inspectors he immediately reported the incident to the charge nurse on duty.
The altercation began when one resident grabbed belongings from another resident's table.
Neither supervisor informed the regional administrator that thermostats weren't working properly in resident rooms.
Federal inspectors found the equipment violation during a September 11 complaint investigation at University Rehabilitation Center.
The administrator thought the infection preventionist had reported it.
The designation means inspectors found conditions that could cause serious injury, harm, impairment or death to residents.
That day, Resident 2 grabbed the harasser's neck and punched him in the stomach after being called names and having his personal space invaded.