The scene at University Park Rehabilitation and Healthcare on June 2 was so pungent that the urine odor radiated into the hallway. Federal inspectors documented similar conditions in four of five resident rooms they reviewed during their visit.
In another room that same morning, inspectors found floors marked with gray spots and streaks consistent with wheelchair wheels. The surface was sticky to the touch.
Behind one resident's bed, dirty clothes lay scattered on the floor. In a fourth room, the urine smell was so pervasive it emanated into the hallway, with the Assistant Director of Nursing telling inspectors the odor was coming from the mattress itself.
The Chief Nursing Officer acknowledged the facility's cleaning struggles during an interview on June 4. She told inspectors the hall was "hard to keep clean and smelling good because so many residents refuse to bathe, and/or leave the room." The facility had already thrown away two mattresses.
Daily housekeeping schedules showed rooms on the 300 hall were cleaned only three times in two weeks — on May 27, May 31, and June 4. The schedule indicated housekeeping should wipe furniture, clean toilet bowls and seats, restock supplies, empty waste baskets, and sweep and mop floors.
Floor cleaning records were sparse. For one room, the May 24 entry contained no description of work completed. Another room had its floor waxed on June 4, according to the Floor Tech Cleaning Schedule.
The Executive Director told inspectors on June 6 that the facility's environment was part of their Performance Improvement Plan. The Quality Assurance and Performance Improvement committee had been focusing on deep cleaning one to two resident rooms daily in the East and South halls, with a completion timeline of July 5.
But there was no indication the 300 hall — where inspectors found the worst conditions — had been included in the cleaning plan.
The facility's own policies contradicted what inspectors observed. A policy titled "Daily Cleaning in Residents Rooms" stated floors should be "swept and mopped thoroughly" and mattresses should be washed when beds are stripped and cleaning is needed.
University Park's Quality Assurance committee includes the Executive Director, Director of Nursing, Assistant Director of Nursing, and directors from admissions, therapy, food services, maintenance, and human resources. The committee also includes the Medical Director and a nurse practitioner.
The facility's second quarter Quality Assurance plan, dated May 24, indicated Performance Improvement Plans covered environment, human resources, social services, operations, dietary, staff development, environmental services, and maintenance. Each segment was supposed to be reviewed in monthly committee meetings.
During his interview, the Executive Director said dietary was an ongoing topic in the committee meetings and there was a current Performance Improvement Plan for dietary issues, though that plan wasn't located in the May 24 documentation.
The dietary plan mentioned in committee records included developing a "ballpark style menu" and alternative menu options based on resident requests, hiring dining and food service staff, staff development, and a deep clean of the kitchen with staff assistance.
But the cleaning problems extended beyond the kitchen. In the resident rooms inspectors visited, basic sanitation had broken down. Mountain Dew bottles and empty pop containers sat on floors alongside medical waste and bodily fluids.
The facility policy on food safety and sanitation, undated but provided by the Administrator on June 3, required all foods needing temperature control to be labeled, covered, and dated. When food packages were opened, items should be marked with the open date to determine when to discard them.
A separate food storage policy required plastic containers with tight-fitting covers or sealable bags for dry stored products. All containers and storage bags must be legibly and accurately labeled and dated.
The inspection findings affected residents across multiple rooms and hall areas. Resident 35 lived with the catheter area floor stains and piled incontinence pads. Resident 14's room had the sticky, marked floors. Resident 5's dirty clothes remained on the floor behind her bed. Residents 21 and 32 dealt with rooms where urine odors were strong enough to reach the hallway.
The Regional Director of Operations joined the Executive Director for the June 6 interview about the facility's environmental issues. Both acknowledged the problems were significant enough to warrant inclusion in their formal improvement planning process.
The facility's housekeeping schedules showed a pattern of inconsistent room cleaning, with some areas receiving attention while others — like the 300 hall where the worst conditions were found — appeared to be neglected in the improvement planning.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting some residents. The inspection was completed on June 6, 2024.
The contrast between written policies requiring thorough floor cleaning and mattress washing when needed, and the reality of urine-soaked surfaces and wadded incontinence pads in corners, illustrated the gap between the facility's standards and daily operations.
University Park Rehabilitation and Healthcare sits at 1400 Medical Park Drive in Fort Wayne. The facility's Quality Assurance committee had been meeting monthly to address various operational issues, but the environmental problems persisted in resident living areas where basic cleanliness standards were not being met.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Park Rehabilitation and Healthcare from 2024-06-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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