University Nursing Center

In the surveyor’s words

From the most serious findings on record at University Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 10, 2025

  Based 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. […]

• Actual harm, isolatedF684Feb 20, 2026

  Based 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.Findings include:An anonymous report submitted to Indiana Department of Health, on 2/16/26 at 12:00 p.m., indicated Resident B choked on his food and clearly aspirated but wasn't sent out to be evaluated. He aspirated again and had to be sent out to the emergency room (ER) for evaluation and was diagnosed with aspiration pneumonia.Resident B's clinical record was reviewed on 2/18/26 at 10:20 a.m. […]

• Actual harm, isolatedF686Feb 25, 2025

  Based 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. Findings include: Resident B's closed clinical record was reviewed on 2/25/25 at 1:26 p.m. […]

• Actual harm, isolatedF622Sep 28, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF851Nov 20, 2023

  Based on interview and record review, the facility failed to accurately report the weekend nursing schedule was not excessively low-staffed for 9 of 13 weekends triggered on a Payroll Based Journal Report for Fiscal Year 2023 Quarter 3. Findings include: A Payroll Based Journal (PBJ) report, compiled on 11/6/23, indicated excessively low weekend staffing hours. A form that listed dates and PPD's (Per Patient Day), provided by the Administrator on 11/20/23 at 9:52 a.m., indicated weekend days with a PPD less than 2.70 included the following: 4/1/23, 4/2/23, 4/8/23, 4/9/23, 4/15/23. 4/22/23, 4/23/23, 4/29/23, 5/13/23, 5/14/23, 5/21/23, 6/18/23, and 6/25/23. During an interview, on 11/15/23 at 9:33 a.m., the DON indicated their goal was to have a 2.70 or greater PPD. […]