Inspection Reports for
Signature Healthcare of Bremen

The complaint investigation was substantiated, involving Resident B's family reporting that the resident was given ketchup despite a tomato allergy and that pressure ulcer dressings were not changed as ordered.

The facility failed to ensure that Resident B's care plan for food allergies was followed, resulting in the resident being given tomato ketchup despite a documented allergy. Additionally, the facility failed to provide appropriate pressure ulcer care for Resident B, with missed dressing changes documented and confirmed by staff interviews.

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.

The investigation of complaints IN00450422, IN00452469, IN00451149, and IN00450663 found no deficiencies related to the allegations cited.

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.

The facility had multiple deficiencies including failure to ensure completion of advance directives, timely notification of hospital transfers to the ombudsman, accurate resident assessments, comprehensive care plans, assistance with activities of daily living, skin assessments after hospital return, behavior monitoring, sanitary food storage and preparation, and infection control during medication administration.

This inspection was complaint-related, addressing issues such as failure to provide timely toileting assistance, missed medications, inadequate shower provision, medication errors, and improper catheter care.

The facility was found deficient in multiple areas including failure to provide timely toileting assistance, missed and incorrect medication administration, inadequate shower provision for residents, improper catheter care, and failure to develop appropriate care plans for seizures. Several residents experienced medication errors, missed showers, and improper catheter maintenance.

Complaint IN00445742 - Federal/state deficiencies related to the allegations are cited at F677, F684 and F755.

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.

This inspection relates to Complaint IN00443084 involving failures in physician notification, transfer/discharge documentation, bed hold notification, diabetes management, and PICC line care.

The facility failed to notify physicians of PICC line removal and low blood glucose levels for residents, did not provide required transfer/discharge forms or bed hold notifications, lacked adequate diabetes management orders, and failed to perform timely PICC line dressing changes for a resident.

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.

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.

This citation relates to Complaint IN00434550.

The facility failed to follow physician orders for transferring Resident C, who was non-weight bearing and required mechanical lift transfers. A CNA attempted to transfer the resident without using the required mechanical lift, resulting in the resident being lowered to the floor without injury.

Complaint IN00434550 was substantiated with a federal/state deficiency cited at F689. Complaints IN00435197 and IN00434488 had no deficiencies related to the allegations.

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.

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.

The facility was found deficient in multiple areas including honoring resident bathing preferences, providing timely and complete transfer/discharge notices, developing comprehensive person-centered care plans, providing adequate ADL assistance, ensuring proper medication management, and addressing nutrition and skin integrity concerns.

Complaint IN00429013 was investigated and no deficiencies related to the allegations were cited.

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.

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.

This Federal tag relates to complaint IN00397720. The investigation included review of resident rights, care planning, medication administration, skin integrity, nutrition, respiratory care, and food safety.

The facility was found deficient in multiple areas including failure to accommodate resident rights, incomplete and untimely care plans, failure to notify physicians of low blood sugars, inadequate skin integrity assessments, failure to provide and document prescribed nutritional supplements, improper storage of respiratory equipment, and unsanitary food storage practices.

Complaint IN00397720 was substantiated related to resident rights.

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.