Aperion Care University Park

F-F812 for additional information about current kitchen sanitation findings.

A QAPI (Quality Assurance Performance Improvement) committee list was provided by the Executive Director (ED) on 6/3/24 at 11:41 AM. The member list included Executive Director, DON, ADON, Admissions director, MDS coordinator, Medical Records in central supply, Therapy Director, Business Office manager, HR director, Director of Food services, Maintenance Director, Medical Director, Nurse practitioner.

The 2nd quarter QAPI Plan, dated 5/24/24, was reviewed. The QAPI Plan indicated segments of care including Performance Improvement Plan (PIP) for environment, human resources, social services, operations, dietary, staff development, environmental services, and maintenance were reviewed in each monthly QAPI meeting. The dietary discussion included: 1) development of the ballpark style menu that catered to the request of residents, 2) development of an alternative menu option that catered to the request of residents, 3) hiring and development of dining and food service staff, 4) staff development, and 5) deep clean of kitchen with staff assistance. Completion timeline goal 6/21.

In an interview on 06/06/24 at 11:36 PM, the Executive Director (ED) indicated dietary was an ongoing topic

in QAPI meetings. He indicated there was a current PIP pertaining to dietary but the PIP was not located in

the 5/24/24 QAPI Plan.

A current policy titled Food Safety and Sanitation, undated, provided by the Administrator on 6/3/24 at 8:56 AM, indicated all foods requiring temperature control for safety should be labeled, covered, and dated. The policy indicated when a food package is opened, the food item should be marked to indicate the open date, and the open date should be used to determine when to discard the food.

A current policy titled Food Storage, undated, provided by the Administrator on 6/3/24 at 8:56 AM, indicated plastic containers with tight fitting covers or sealable bags must be used for dry stored products. All containers or storage bags must be legible and accurately labeled and dated.

3.1-52

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 155567 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155567 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

University Park Rehabilitation and Healthcare 1400 Medical Park Dr Fort Wayne, IN 46825

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)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46156

Residents Affected - Some Based on observation, interview and record review, the facility failed to ensure a clean environment was maintained in 4 of 5 rooms reviewed. 4 residents resided in the 4 rooms affected (Resident 35, Resident 14, Resident 21, Resident 5, and Resident 32).

Findings include:

During an observation on 6/2/24 at 10:49 AM, Resident 35's floor (room [ROOM NUMBER]) had multiple dime to quarter sized yellow/orange spots on the right side of the bed. The resident had a foley catheter hanging in this location. The catheter was emptied by staff. On the left side of Resident 35's bed, near the top, 5 disposable chucks/chux pads (incontinence pad used under resident to protect mattresses by containing urine or feces) were observed wadded up and piled on the floor in the corner of the room by the left side near the head of the bed. A strong urine odor was in the room and radiated to the hall. A Mountain Dew and empty pop bottles were on the floor.

During an observation on 6/2/24 at 10:32 AM, Resident 14's floor (room [ROOM NUMBER]) had multiple gray spots and marks consistent with wheelchair wheels. The floor in the area of the marks was sticky.

During an observation on 6/2/24 at 1:52 PM, Resident 5's (room [ROOM NUMBER]) dirty clothes were observed on the floor behind her bed.

During an observation on 6/3/24 at 9:31 AM, Resident 32's (room [ROOM NUMBER]) room had a pervasive urine odor eminating into the hall. The Assistant Director of Nursing (ADON) indicated the urine odor was coming frim the matterss.

Daily Housekeeping Schedules indicated housekeeping should wipe furniture (tables, dressers, etc ), toilet bowl and seat (spot clean walls, etc ), restock paper supplies, empty waste basket, sweep, and mop.

The Daily Housekeeping Schedule dated from 5/20/24 to 6/4/24 indicated 300 Hall rooms were cleaned 5/27/24, 5/31/24, 6/4/24.

The Floor Tech Cleaning Schedule indicated on 5/24/24 room [ROOM NUMBER] no mention what was done, and 6/4/24 room [ROOM NUMBER]'s floor was waxed.

In an interview on 06/04/24 at 10:23 AM, the Chief Nursing Officer (CNO) indicated the hall was hard to keep clean and smelling good because so many residents refuse to bathe, ad/or leave the room. The CNO indicated the facility had thrown away 2 mattresses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 155567 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155567 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

University Park Rehabilitation and Healthcare 1400 Medical Park Dr Fort Wayne, IN 46825

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)

F 0921 In an interview on 06/06/24 11:36 PM with the Executive Director (ED) and Regional Director of Operations (RDO) they indicated the environment of the facility was part of their Performance Improvement Plan (PIP). Level of Harm - Minimal harm or The facility Quality Assurance and Performance Improvement (QAPI) indicated the facility had been focusing potential for actual harm on the East and South halls (100 and 200 units) deep cleaning one to two resident rooms daily and developed a cleaning guide for housekeeping with a completion timeline of 7/5/24. There was no indication Residents Affected - Some the 300 hall had been included in the plan.

A current policy titled, Daily Cleaning in Residents Rooms, provided by the ED on 6/4/24 at 11:30 AM, indicated the floor should be swept and mopped thoroughly; mattresses should be washed if bed is stripped and needed cleaned.

3.1-19(4)(f)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 155567