Inspection Reports for Signature Healthcare of Bremen
316 WOODIES LANE, IN, 46506
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 60
Capacity: 73
Deficiencies: 0
May 21, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/25/25.
Findings
At this PSR survey, Signature Healthcare of Bremen was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinkled and had appropriate fire alarm and smoke detection systems in place.
Report Facts
Facility capacity: 73
Census: 60
Detached sheds: 5
Generator power: 200
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 0
Apr 8, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00456154.
Findings
No deficiencies related to the allegations of the complaint were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00456154 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 6
Medicaid census: 37
Other payor census: 19
Inspection Report
Annual Inspection
Census: 60
Capacity: 73
Deficiencies: 9
Mar 25, 2025
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements, Life Safety Code, and state regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but had deficiencies in maintaining a documented all-hazards risk assessment, emergency preparedness drill documentation, fire ceiling barrier assemblies, exit signage, fire alarm system maintenance, sprinkler system maintenance, corridor smoke detection, corridor door latching, and GFCI protection for receptacles near sinks.
Severity Breakdown
SS=C: 3
SS=E: 5
SS=D: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to maintain an Emergency Preparedness Plan based on a documented facility-based and community-based risk assessment utilizing an all-hazards approach. | SS=C |
| Failed to analyze and maintain complete documentation of all Emergency Preparedness Program drills and exercises. | SS=C |
| Failed to maintain 2 of 5 one-hour fire ceiling barrier assemblies to ensure fire resistance. | SS=E |
| Failed to ensure 3 of 9 exit doors did not have conflicting exit signs. | SS=E |
| Failed to maintain fire alarm system; one pull station was broken and could not be reset. | SS=C |
| Failed to ensure 1 of 4 sprinklers in the laundry room were free of corrosion. | SS=E |
| Failed to provide electrically supervised automatic smoke detection system for a lounge open to the corridor in the memory care wing. | SS=E |
| Failed to ensure 1 of 25 resident room corridor doors latched properly due to tape over the latch. | SS=D |
| Failed to ensure 4 of 40 receptacles within 6 feet of a sink or wet location had ground fault circuit interrupter (GFCI) protection. | SS=E |
Report Facts
Facility capacity: 73
Census: 60
Deficiencies with fire ceiling barrier: 2
Exit doors with conflicting signage: 3
Sprinklers with corrosion: 1
Resident room corridor doors not latching: 1
Receptacles without GFCI protection: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness, fire safety, and maintenance issues |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 9
Feb 17, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of four complaints (IN00450422, IN00452469, IN00451149 & IN00450663).
Findings
The facility was found deficient in multiple areas including advance directives, notification of hospital transfers to the ombudsman, accuracy of Minimum Data Set (MDS) assessments, development and implementation of comprehensive care plans, ADL care provision, skin assessments after hospital return, behavioral health services, food storage and sanitation, and infection control during medication administration.
Complaint Details
The investigation of complaints IN00450422, IN00452469, IN00451149, and IN00450663 found no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 7
SS=E: 1
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure an advance directive was completed upon admission for 1 of 24 residents reviewed. | SS=D |
| Failed to notify the ombudsman of hospital transfers for 1 of 4 residents reviewed. | SS=D |
| Failed to accurately complete the Minimum Data Set assessment for 1 of 4 residents reviewed for accidents. | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan for skin issues and abusive behaviors for 3 of 19 residents reviewed. | SS=D |
| Failed to ensure residents received scheduled showers for 2 of 4 residents reviewed for ADL care. | SS=D |
| Failed to ensure a resident who returned from a hospital stay was assessed for new and/or existing skin issues for 1 of 2 residents reviewed. | SS=D |
| Failed to implement effective behavior monitoring to prevent resident to resident altercations from recurring. | SS=D |
| Failed to ensure food was stored, prepared and served under sanitary conditions in the kitchen and nutrition pantries. | SS=E |
| Failed to follow infection control procedures during medication pass for 2 of 4 residents observed. | SS=F |
Report Facts
Residents reviewed for advance directives: 24
Residents reviewed for hospital transfer notification: 4
Residents reviewed for accidents: 4
Residents reviewed for comprehensive care plans: 19
Residents reviewed for ADL care: 4
Residents reviewed for skin issues: 2
Residents reviewed for behavioral health: 1
Residents affected by food sanitation issues: 59
Residents observed for infection control during medication pass: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Interviewed regarding advance directives and other findings. |
| LPN 6 | Observed breaking tablets without gloves and coughing into bare hand during medication pass. | |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control, skin assessments, and behavior management. |
| QMA 3 | Interviewed regarding shower documentation. | |
| Corporate Dietician | Interviewed regarding kitchen sanitation and food storage. | |
| Executive Director | Interviewed regarding behavior management and policies. |
Inspection Report
Renewal
Deficiencies: 0
Feb 17, 2025
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on February 17, 2025.
Findings
Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 13, 2024
Visit Reason
Paper Compliance Review to the Investigation of Complaint IN00445742 completed on November 1, 2024.
Findings
Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Investigation of Complaint IN00445742.
Complaint Details
Investigation of Complaint IN00445742 completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 9
Nov 1, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00445742, which included federal and state deficiencies related to the allegations cited at F677, F684, and F755.
Findings
The facility was found deficient in multiple areas including failure to provide timely toileting assistance resulting in incontinence, failure to notify physicians of changes in condition and missed medications, failure to develop a comprehensive care plan for seizures, failure to provide adequate showering and personal care for dependent residents, failure to administer physician ordered medications, failure to ensure medication availability and administration per orders, failure to avoid unnecessary drug use, failure to prevent significant medication errors, and failure to maintain urinary catheter equipment in a sanitary manner.
Complaint Details
Complaint IN00445742 - Federal/state deficiencies related to the allegations are cited at F677, F684 and F755.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to provide timely toileting assistance resulting in an incontinence episode for Resident C. | SS=D |
| Failure to notify physician of elevated heart rate, seizure activity, and missed medications for Residents N and E. | SS=D |
| Failure to develop a care plan for seizures for Resident E. | SS=D |
| Failure to ensure showers were provided as needed for 8 residents (H, J, L, C, N, P, M, Q). | SS=E |
| Failure to administer physician ordered medications for Residents J and L. | SS=D |
| Failure to ensure routine medications were available and dispensed according to physician's orders for Residents M, L, and C. | SS=D |
| Failure to ensure an antianxiety drug was not administered for excessive duration for Resident M. | SS=D |
| Failure to ensure Resident E was free from significant medication errors related to omissions and overdosing/underdosing of antiseizure medications. | SS=D |
| Failure to ensure urinary catheter equipment was positioned and maintained in a sanitary manner for Resident J. | SS=D |
Report Facts
Residents reviewed for medication: 10
Residents reviewed for ADL care: 17
Residents reviewed for medication errors: 7
Residents reviewed for catheter use: 2
Residents receiving narcotic medications audited: 5
Residents receiving psychoactive medications audited: 5
Residents with catheters audited: 5
Residents receiving anticonvulsant medications audited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Signed the report and involved in interviews regarding medication and care issues |
| RN 1 | Interviewed regarding change in condition and notification procedures | |
| LPN 9 | Interviewed regarding Resident C toileting and care | |
| CNA 10 | Observed and interviewed regarding Resident C toileting assistance | |
| QMA 8 | Interviewed regarding toileting assistance | |
| CNA 11 | Interviewed regarding Resident C toileting and catheter care | |
| LPN 12 | Interviewed regarding medication administration and physician notification | |
| RN 13 | Interviewed regarding medication availability and pharmacy communication | |
| CNA 1 | Interviewed regarding shower frequency and documentation | |
| CNA 2 | Interviewed regarding shower frequency and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 31, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00443084.
Findings
Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Complaint Details
Investigation of Complaint IN00443084 completed on October 4, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 5
Oct 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443084 regarding federal and state deficiencies related to physician notification, transfer/discharge notices, bed hold policies, quality of care, and parenteral/IV fluids management.
Findings
The facility failed to notify physicians of PICC line removal and low blood glucose levels for certain residents, did not provide required transfer/discharge forms or bed hold notices, lacked adequate physician orders for diabetes management, and failed to provide timely PICC line dressing changes. Corrective actions including audits and staff re-education were planned.
Complaint Details
Complaint IN00443084 was substantiated with federal and state deficiencies cited at tags F580, F623, F625, F684, and F694 related to physician notification failures, transfer/discharge documentation, bed hold notices, diabetes management, and PICC line care.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify the physician of removal of a PICC line and resident discharge, and failed to notify physician of low blood glucose levels for 2 of 3 residents reviewed. | SS=D |
| Failed to ensure a transfer/discharge form was provided for 1 of 3 residents reviewed for transfer and discharge. | SS=D |
| Failed to ensure a bed hold form was provided for 1 of 3 residents reviewed for transfer and discharge. | SS=D |
| Failed to write an order to send a resident to the emergency room or have adequate orders in place for diabetes management for 1 of 3 residents reviewed. | SS=D |
| Failed to provide dressing changes for a PICC site for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 57
Total Capacity: 57
Medicare Census: 3
Medicaid Census: 38
Other Payor Census: 16
Blood Sugar Reading: 49
Blood Sugar Reading: 56
PICC Dressing Change Dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Signed the inspection report |
| Director of Nursing | Provided interviews and described policies and corrective actions related to deficiencies |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Jul 24, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00437808.
Findings
No deficiencies related to the allegations are cited. Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00437808.
Complaint Details
Complaint IN00437808 - No deficiencies related to the allegations are cited.
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 2
Medicaid Census: 33
Other Payor Census: 15
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 13, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00434550.
Findings
Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Complaint Details
Investigation of Complaint IN00434550 completed on June 13, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 1
Jun 11, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00435197, IN00434550, and IN00434488). Deficiencies related to complaint IN00434550 were cited.
Findings
The facility failed to ensure a resident (Resident C) was transferred as ordered, resulting in a deficiency related to accident hazards and supervision. No deficiencies were found related to the other two complaints. The facility provided corrective actions including audits and staff re-education to prevent recurrence.
Complaint Details
Complaint IN00434550 was substantiated with a federal/state deficiency cited at F689. Complaints IN00435197 and IN00434488 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was transferred as ordered, violating accident hazard and supervision requirements. | SS=D |
Report Facts
Census: 51
Medicare residents: 3
Medicaid residents: 30
Other residents: 18
Survey dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Signed the report and provided policy information during interviews |
Inspection Report
Life Safety
Census: 52
Capacity: 82
Deficiencies: 0
May 23, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and life safety code requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility beds: 82
Resident census: 52
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Apr 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430992.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00430992 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 8
Medicaid census: 30
Other payor census: 14
Inspection Report
Life Safety
Census: 50
Capacity: 82
Deficiencies: 7
Apr 1, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified related to maintenance and documentation of battery-operated smoke alarms, ceiling penetrations near sprinkler heads, corridor door latching, generator weekly inspection documentation, improper use of multi-plug adapters, and lack of staff training on oxygen transfilling procedures.
Severity Breakdown
SS=F: 2
SS=E: 3
SS=C: 1
SS=D: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure documentation for preventative maintenance of 33 of 33 battery operated smoke alarms was complete. | SS=F |
| Failed to ensure proper maintenance and function of 1 of 33 battery operated smoke alarms; battery removed causing device to be nonfunctional. | SS=F |
| Failed to maintain ceiling construction in 1 of 5 smoke compartments; ceiling penetration near sprinkler head. | SS=E |
| Failed to ensure 1 of 34 corridor doors near the 300-Wing had proper latching and resisted passage of smoke. | SS=E |
| Failed to maintain written record of weekly inspections for the emergency generator for 1 of 52 weeks. | SS=C |
| Used multi-plug adapters as a substitute for fixed wiring in 1 resident room. | SS=D |
| Failed to ensure staff was properly trained on oxygen transfilling procedures in 1 oxygen storage room. | SS=E |
Report Facts
Beds: 82
Census: 50
Battery smoke alarms: 33
Corridor doors inspected: 34
Generator inspection weeks: 52
Residents affected by multi-plug adapter: 2
Residents/staff near oxygen storage: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Named in relation to findings and exit conference |
| Director of Plant Operations | Named in relation to multiple findings including smoke alarm maintenance, ceiling penetrations, door latching, generator inspection, and oxygen transfilling training |
Inspection Report
Annual Inspection
Census: 51
Capacity: 51
Deficiencies: 13
Mar 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00429013.
Findings
The facility was found deficient in honoring resident bathing preferences, providing written notice before transfer or discharge, developing comprehensive person-centered care plans, providing adequate activities, ensuring ADL care including grooming, addressing nutrition recommendations timely, responding to pharmacist recommendations timely, limiting psychotropic medication use, and medication reconciliation upon readmission. No deficiencies were cited related to the complaint investigation.
Complaint Details
Complaint IN00429013 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to honor resident preferences related to bathing choices for 1 of 3 residents reviewed (Resident 48). | SS=D |
| Failed to ensure a complete written notice of transfer or discharge was provided for 2 of 3 residents reviewed (Residents 23 and 49). | SS=D |
| Failed to ensure a written notice of the bed hold policy form was provided for 3 of 3 residents reviewed for hospitalization (Residents 23, 48, and 49). | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan for activities for 1 of 3 residents reviewed (Resident 42). | SS=D |
| Failed to conduct timely care plan meetings for 1 of 4 residents reviewed (Resident 35). | SS=D |
| Failed to provide ADL assistance related to grooming and personal hygiene for 2 of 3 dependent residents reviewed (Residents 22 and 35). | SS=D |
| Failed to provide a person-centered activity program for 1 of 3 residents reviewed (Resident 42). | SS=D |
| Failed to ensure a splint and brace were applied as ordered for 1 of 2 residents reviewed for limited range of motion (Resident 35). | SS=D |
| Failed to obtain a Physician's Order for the use of a Foley catheter for 1 of 2 residents reviewed for urinary catheters (Resident 26). | SS=D |
| Failed to address Registered Dietitian recommendations timely related to significant weight loss for 1 of 3 residents reviewed for nutrition (Resident 22). | SS=D |
| Failed to ensure physician responded timely to pharmacy recommendations for unnecessary medication use for 1 of 5 residents reviewed (Resident 2). | SS=D |
| Failed to limit Ativan PRN order to 14 days and follow physician orders for psychotropic medications for 1 of 5 residents reviewed (Resident 49). | SS=D |
| Failed to ensure anticoagulant medication was continued upon readmission after hospitalization for 1 of 5 residents reviewed for medication use (Resident 48). | SS=D |
Report Facts
Survey dates: 5
Census: 51
Medicare census: 1
Medicaid census: 25
Other payor census: 25
Weight loss: 6.6
Weight loss: 15.48
Weight loss: 12.23
Ativan dose: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Lewis | Administrator | Signed the report |
| LPN 4 | Provided information about medication and care practices | |
| CNA 2 | Interviewed about bathing and ADL care | |
| CNA 3 | Interviewed about bathing and appointment scheduling | |
| Physical Therapist 6 | Interviewed about therapy and splint orders | |
| Occupational Therapist 7 | Interviewed about splint orders | |
| Regional Social Service Director | Interviewed about transfer/discharge forms | |
| Director of Nursing | Provided information about transfer/discharge forms and audits | |
| Activity Director | Interviewed about activities program and care plans | |
| Regional Executive Director | Provided psychiatric progress note | |
| RN 5 | Interviewed about skin assessments and supplements |
Inspection Report
Renewal
Deficiencies: 0
Mar 12, 2024
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 0
Jan 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425439 and IN00423341.
Findings
No deficiencies related to the allegations in complaints IN00425439 and IN00423341 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00425439 and Complaint IN00423341 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census Bed Type: 56
Medicare Census: 5
Medicaid Census: 38
Other Payor Census: 13
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Sep 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415802.
Findings
No deficiencies related to the allegations in Complaint IN00415802 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00415802 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 49
Total Capacity: 49
Medicare Census: 3
Medicaid Census: 38
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
May 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402983.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00402983 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Medicare census: 2
Medicaid census: 36
Other payor census: 14
Inspection Report
Life Safety
Census: 52
Capacity: 82
Deficiencies: 0
Apr 11, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Life Safety
Census: 51
Capacity: 82
Deficiencies: 11
Mar 13, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found not in compliance with several Life Safety Code requirements including means of egress obstructions, delayed egress locking arrangements, hazardous area door self-closing devices, fire alarm system out-of-service policies, sprinkler system maintenance and testing, fire hydrant maintenance, corridor door smoke resistance, electrical outlet protection, and annual fire door inspections. Corrective actions and monitoring plans were provided for each deficiency.
Severity Breakdown
SS=E: 7
SS=F: 4
SS=D: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Means of egress were obstructed by storage in the Serenity Hall exit corridor. | SS=E |
| Delayed egress locking arrangement on 200 hall exit door did not release properly with excessive force required. | SS=E |
| Exit gate in Serenity Hall courtyard was magnetically locked without posting the exit code. | SS=E |
| Corridor door to hazardous storage room 211 was not self-closing. | SS=E |
| Fire alarm system policy did not include proper reporting methods via IDOH Gateway link or email. | SS=F |
| Two private fire hydrants had unresolved leaks and were not maintained in reliable operating condition. | SS=F |
| Dislodged escutcheon plate in 200 hall janitor closet created a gap around sprinkler head. | SS=F |
| Fire watch plan lacked complete procedures for sprinkler system impairment over 10 hours. | SS=F |
| Door to room 211 had a hole above the door handle, compromising smoke resistance. | SS=E |
| Electrical outlet cover missing in office corridor near administrator's office. | SS=D |
| Annual inspection and testing of fire door assembly for oxygen storage/transfilling room was not completed. | SS=E |
Report Facts
Beds: 82
Census: 51
Residents affected: 35
Residents affected: 20
Residents affected: 18
Staff affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Syer | Admin | Facility representative present during survey and exit conference |
| Maintenance Director | Interviewed and involved in observations and corrective action discussions | |
| Plant Ops Director | Responsible for monitoring corrective actions and inspections |
Inspection Report
Annual Inspection
Census: 51
Capacity: 51
Deficiencies: 8
Feb 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00397720.
Findings
The facility was found to have deficiencies related to resident self-determination, comprehensive care plans, quality of care including insulin administration, skin integrity, nutrition and hydration, respiratory care, and food safety practices.
Complaint Details
Complaint IN00397720 was substantiated related to resident rights.
Severity Breakdown
SS=D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide accommodations for resident rights for 1 of 1 resident reviewed (Resident B). | SS=D |
| Failed to ensure care plans were in place for 1 of 22 residents reviewed for care plans (Resident 27). | SS=D |
| Failed to ensure care plan timing and revision for 1 of 22 residents reviewed for care plans (Resident 27). | SS=D |
| Failed to notify physician for blood sugars less than 100 mg/dL for 1 of 3 residents reviewed for insulin administration (Resident 157). | SS=D |
| Failed to provide skin integrity assessments while an AFO was in place to prevent pressure ulcers for 1 of 2 residents reviewed for skin conditions (Resident 33). | SS=D |
| Failed to provide prescribed supplementation and document consumption for 1 of 4 residents reviewed for nutrition (Resident 1). | SS=D |
| Failed to properly store resident's C-PAP mask for 1 of 2 residents reviewed for respiratory devices (Resident 33). | SS=D |
| Failed to ensure food and beverages were dated/labeled and store pots, mixing bowls, and colanders in a sanitary manner. | SS=D |
Report Facts
Survey dates: February 8, 9, 10, 13, 14 and 15, 2023
Census: 51
Total Capacity: 51
Blood sugar readings: Multiple blood sugar values below 100 mg/dL for Resident 157
Weight loss percentage: 10.3
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 15, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey and Complaint Investigation to IN00397720 completed on February 15, 2023.
Findings
Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation.
Inspection Report
Re-Inspection
Census: 48
Capacity: 48
Deficiencies: 0
Aug 15, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00379864 completed on June 29, 2022.
Findings
Signature Healthcare of Bremen was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00379864.
Complaint Details
Complaint IN00379864 - Corrected.
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 3
Medicaid Census: 39
Other Payor Census: 6
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