University Nursing Center

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

exhibitionism.Identification: Abuse Includes: 2. Resident to resident abuse of any type.Types of Abuse:.3.

Sexual abuse.Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed, In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services. Resident to Resident Abuse: 1. Any individual who witnesses resident-to-resident abuse will immediately separate and protect the residents involved. 2. Staff member(s) will maintain the resident initiating the abuse under direct supervision until the initial investigation is complete and resident safety is maintained. 3. The Individula who witnessed the abuse will report the situation immediately to his/her supervisor and Executive Director. 4. The staff member in charge will initiate the investigation immediately.6. The DNS/Designee will assess both residents involved to determine if physical injuries have occurred.b. Statements will be taken from individuals witnessing the incident.7. The attending physician will be notified, and any orders will be noted and initiated.8. The family of the resident(s) and/or resident representative will be notified. 9. It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via

the IDOH(Indiana Department of Health) gateway system.19. If staff suspect a crime has occurred, refer to reporting suspicion of a crime policy.Protection: 1. All residents will be protected from physical and psychological harm during and after the allegation and investigation. This will include: a. Responding immediately to protect the alleged victim and protect the integrity of the investigation. b. Assess the resident alleged to be harmed for any sign of injury, including a physical exam, or psychosocial assessment when indicated. c. Provide increased supervision of the alleged victim and other residents. d. Implement room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.Reporting/Response:

1. 1. All abuse allegations must be reported to the Executive Director immediately.2. The Executive Director

will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours to the Long-Term Care Division of the Indiana Stated Department of Health via the Gateway Portal.9.Copies of the completed investigation will also be sent to Adult Protective Services.10. It is the responsibility of every employee of American Senior Communities to report abuse situations, but also suspicion of abuse and unusual observations and circumstances to his/her immediate supervisor and to the Executive Director.12. Each covered individual shall report to the State Department of Health Long Term Care Division via Gateway Portal, and to one or more law enforcement entities any reasonable suspicion of a crime against any resident in the facility.ASC QAPI.Physical or Sexual abuse by staff or other residents will be tracked by the Quality Assessment and Assurance Committee (QAA). The immediate jeopardy that began on 10/3/25 was removed on 10/10/25 when the facility completed abuse training for all staff, increased monitoring and surveillance for Resident B and Resident C, updated care plans, and Resident C was sent to be evaluated at a psychiatric facility. The deficient practice was corrected by 10/7/25, after the facility implemented a systemic plan that included the following actions: education of all staff regarding resident abuse, completed physical assessments of residents on the secured dementia care unit, and developed quality assurance actions for ongoing monitoring. This citation relates to Intake 2636500.3.1-27(a)(1)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

University Nursing Center

1564 S University Blvd Upland, IN 46989

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

suspicion of crimes committed against a resident of the facility.3) Purpose: a) The purpose is to ensure that American Senior Communities comply with the requirements to notify covered individuals of their duty to report crimes to the Indiana State Department of Health and local law enforcement. 4) a) Facility Responsibilities.ii) The facility will post a notice in a conspicuous location that informs all covered individual of his/her reporting obligation under the Elder Justice Act to report a suspicion of a crime to the Indiana Department of Health and local law enforcement.iv) the facility will annually provide all covered individuals a document describing his/her obligations to comply with the reporting law and the facility reporting of crimes policy and procedures.5) Covered individual Responsibilities ( staff herein refers to covered individuals) a) When staff suspect a crime has occurred against a resident at the facility, he/she must report the incident to

the Executive Director who will report to the Indiana Department of Health and at least one local law enforcement entity. b) The ED will coordinate timely reporting to the Indiana Department of Health and to law enforcement.f) Staff must report the suspicion of a crime to the Executive Director or designee immediately. g) Examples of crimes that would be reported, but are not limited to: iii) Rape; iv) Assault and battery; v) Sexual abuse.Cross reference F-F600.This citation relates to Intake 2636500.3.1-28(c)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

University Nursing Center

1564 S University Blvd Upland, IN 46989

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility investigation provided and was not provided to IDOH when the facility was made aware of the additional information to ensure the IDOH acted timely on the resident's behalf. A current facility policy, revised June 2023, titled Abuse Prohibition, Reporting, and Investigation, provided by the DON on 10/8/25 at 11:00 a.m., indicated the following: .Policy: .Investigation: The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed. In the absence of the Executive Director, this responsibility will be delegated to the Director of Nursing Services.2. Staff member(s) will maintain the resident initiating the abuse under direct supervision until the initial investigation is complete and resident safety is maintained. 3.

The individual who witnessed the abuse will report the situation immediately to his/her supervisor and Executive Director. 4. The staff member in charge will initiate the investigation immediately.9. It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH (Indiana Department of Health) gateway system.19. If staff suspect a crime has occurred, refer to reporting suspicion of a crime policy .Cross reference F-F600.This citation relates to Intake 2636500.3.1-28(d)

Event ID:

Facility ID:

If continuation sheet