University Plaza Rehabilitation And Nursing Center

under sanitary conditions related to a buildup of ice in the ice cream freezer with the potential to affect 139 out of 143 residents who eat orally residing in the facility at the time of that survey.

During this survey with an exit dated 05/22/2025, repeated deficient practice was identified for F-F812-Food Procurement, Store/Prepare/Serve/Sanitary, related to the walk-in refrigerator containing flower bouquets on

the shelves among the fruits and vegetables which has the potential to affect 128 out of 133 residents who eat orally residing in the facility at the time of this survey. F-F867-Quality Assurance and Performance Improvement was cited due to the QAPI/QAA committee's failure to monitor previous problem areas identified with existing need for improvement based on the committee's continued evaluation of their performance improvement projects.

Interview with the Administrator, and Director of Nursing (DON) on 05/22/2025 at 12:10 PM, revealed The QAPI committee meets monthly on the fourth Thursday of each month. The most recent meeting was held

on April 24, 2025. The committee includes: the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Registered Dietitian, Maintenance Director, Activities Director, Social Services Director, and other department heads. Each department is assigned specific objectives or focus areas to monitor and report on monthly. During QAPI meetings, department representatives-such as those from nursing, social services, and environmental services. These meetings serve as a collaborative forum for identifying trends, discussing concerns, and exploring opportunities for improvement. 08/26/2025

F-F867-Quality Assurance and Performance Improvement was cited due to the QAPI/QAA committee's failure to monitor previous problem areas identified with existing need for improvement based on the committee's continued evaluation of their performance improvement projects.

Interview with the Administrator, and Director of Nursing (DON) on 05/22/2025 at 12:10 PM, revealed The QAPI committee meets monthly on the fourth Thursday of each month. The most recent meeting was held

on April 24, 2025. The committee includes: the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Registered Dietitian, Maintenance Director, Activities Director, Social Services Director, and other department heads. Each department is assigned specific objectives or focus areas to monitor and report on monthly. During QAPI meetings, department representatives-such as those from nursing, social services, and environmental services. These meetings serve as a collaborative forum for identifying trends, discussing concerns, and exploring opportunities for improvement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 106100