University Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nurse obtained a physician's order prior to inserting and anchoring a urinary catheter for 1 of 3 residents reviewed for hospitalizations. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to reassess and monitor a resident after a change in condition due to possible aspiration (liquid entering airway) for 1 of 3 residents reviewed for aspiration. (Resident B) This deficient practice resulted in the resident being admitted to the hospital with pneumonia following a subsequent aspiration event.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the resident's (Resident B) right to be free from verbal abuse by CNA 6 for 1 of 3 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for 1 of 3 residents reviewed for abuse. (Residents B and C) Staff did not develop and implement immediate interventions to mitigate risk for recurrence when a cognitively impaired male resident was observed touching a cognitively impaired female resident's buttock. This failure resulted in the residents being observed within two hours following the event on the male resident's bed, with the male resident's hand in the female resident's genital area while she was unclothed from the waist down. [...]

Inspectors wroteBased on record review and interview, the facility failed to timely report alleged sexual abuse between cognitively impaired residents (Resident B and Resident C) to the administrator, Indiana Department of Health (IDOH), and the appropriate agencies for 1 of 3 residents reviewed for resident abuse. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to conduct a timely and thorough investigation of resident-to-resident sexual abuse and failed to implement immediate interventions to prevent further potential abuse while the investigation was in progress for 1 of 3 residents reviewed for abuse. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated a physically dependent resident with respect and dignity when the resident requested assistance for 1 of 1 residents reviewed for dignity. (Resident 40)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for a resident with physical limitations by ensuring the resident's call light was within reach for 1 of 1 residents reviewed for resident rights. (Resident 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents prescribed antipsychotic medications received appropriate Gradual Dose Reductions (GDR) or had individualized indication for continued use of antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 10)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dependent resident had access to drinking water or other fluids for 1 of 1 residents reviewed for hydration. (Resident 2)

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to follow physician orders to change, label and date oxygen supplies for 1 of 2 residents reviewed for respiratory services. (Resident 17)B. Based on observation, interview, and record review, the facility failed to implement physician orders for oxygen administration for 1 of 2 residents reviewed for respiratory services. (Resident 47)

Inspectors wroteBased on observation and interview, the facility failed to dispose of unlabeled and unused medications for 2 of 2 medication carts reviewed for medication storage and labeling. (100 Hall Medication Cart and Memory Care Unit Medication Cart)

Inspectors wroteBased on record review and interview, the facility failed to implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies identified during a post survey revisit survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed during dining services for 4 of 5 residents observed in the memory care dining room. (Residents 1, 21, 22, and 32)

Inspectors wroteBased on record review and interview the facility failed to provide physician ordered wound treatment for 1 of 3 residents reviewed for physician order compliance. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to implement skin assessments to identify pressure injury, failed to obtain orders for a medical device that increased the risk of skin impairment, and failed to develop and implement interventions to prevent pressure injury for 1 of 3 residents reviewed for pressure injury. (Resident B) This deficient practice resulted in Resident B developing an unstageable pressure injury to the right knee requiring hospitalization and eventual amputation of the lower leg. The deficient practice was corrected on February 10, 2025, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on record review and interview, the facility failed to identify and implement interventions for care of a surgical wound for 1 of 3 resident reviewed for wound care. (Resident B) The deficient practice was corrected on February 10, 2025, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility staff failed to report an allegation of abuse to the Administrator per facility policy for 1 of 4 residents reviewed for abuse. (Resident C) The deficient practice was corrected on 12/2/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reconciliation of controlled medications was completed for 2 of 3 medication carts reviewed. (200 Unit and 300 Unit medication carts).

Inspectors wroteA. Based on interview and record review, the facility failed to administer medications according to physician order for 2 of 9 residents reviewed for medication administration. (Residents 19 and 51) B. Based on interview and record review, the facility failed to obtain daily weights according to physician order for 1 of 3 residents reviewed for nutrition. (Resident 65)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide directed supervision and implement immediate, resident-centered interventions to prevent falls for a cognitively impaired resident for 1 of 3 residents reviewed for accidents. (Resident 14)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent verbal abuse by a staff member to a resident for 1 of 3 resident's reviewed for abuse. (NA (Nurse Aide) 6 and Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled medications were accounted for at the time of administration for 1 of 3 narcotic count observations. (Memory Care Unit).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and homelike environment for 5 of 17 resident rooms reviewed for environment when black television cable cords were strung haphazardly on the walls of the rooms (Rooms 101, 103, 104, 106, and 107) and the chair rail and baseboards were damaged for 1 of 17 rooms. (room [ROOM NUMBER])

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure light cords were within reach for 2 of 6 residents interviewed for accommodation of needs. (Residents 58 and 166)

Inspectors wroteBased on interviews and record review, facility failed to ensure a dependent resident who required two person assist during transfers was transferred according to their care plan for of 1 of 5 residents reviewed for accidents (Resident 21). Findings Include: During an interview, on 11/14/23 at 9:24 a.m., Resident 21 indicated CNA 5 transferred her alone and caused an injury. Her injury had improved, but continued with soreness. She did not let this CNA transfer her in any type of lift since the incident. The clinical record for Resident 21 was reviewed on 11/14/23 at 3:08 p.m. The diagnoses included, but were not limited to, pain in joints, repeated falls, chronic diastolic heart failure, muscle weakness, age related physical debility, and cognitive communication deficit. Current physician orders included Hoyer (mechanical) lift with two person assist, dated 5/31/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from involuntary transfers without identified necessity for 1 of 1 resident reviewed for involuntary transfers (Resident C). This deficient practice resulted in emotional distress to the resident requiring an extra dose of psychoactive medication, the resident experiencing a stressful life change, the resident being moved to a facility not of the family's choosing, and the resident now residing in a facility a greater distance for the family to drive to for visit.