Inspection Reports for Signature Healthcare of Muncie
4301 N WALNUT ST, IN, 47303
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
High
Moderate
Low
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 3
Jul 3, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00461866, IN00461690, and IN00460801, focusing on allegations related to drug diversion and medication administration.
Findings
The facility failed to report a suspected drug diversion to appropriate regulatory agencies and did not conduct a thorough investigation of the alleged drug diversion for 4 of 6 residents reviewed. Medication administration records and narcotic counts were inconsistent, and medication reconciliation was not performed. Facility policies on controlled medication accountability and drug diversion reporting were not properly followed.
Complaint Details
Complaint IN00461866 resulted in federal/state deficiencies related to drug diversion and medication administration. Complaints IN00461690 and IN00460801 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to report a suspected drug diversion to appropriate regulatory agencies for 4 of 6 residents reviewed for narcotic medication administration. | SS=D |
| Failed to conduct a thorough investigation of a suspected drug diversion for 4 of 6 residents reviewed for medication administration. | SS=D |
| Failed to ensure controlled medication administration was accurately documented and medication amounts reconciled according to facility policy for 4 of 6 residents reviewed. | SS=D |
Report Facts
Residents reviewed for narcotic medication administration: 6
Census: 120
Total licensed capacity: 120
Medicare residents: 5
Medicaid residents: 97
Other payor residents: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 15 | Licensed Practical Nurse | Named in medication error and suspected drug diversion findings. |
| LPN 16 | Licensed Practical Nurse | Involved in medication administration and narcotic count discrepancies. |
| QMA 2 | Qualified Medication Aide | Involved in medication administration and narcotic count discrepancies. |
| Corporate Nurse Consultant | Provided narcotic count sheets and conducted interviews related to the investigation. | |
| Unit Manager 18 | Unit Manager | Investigated medication cart discrepancies and reported concerns. |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
May 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457461.
Findings
No deficiencies related to the allegations in Complaint IN00457461 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457461 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 6
Medicaid census: 99
Other payor census: 15
Inspection Report
Re-Inspection
Census: 126
Capacity: 140
Deficiencies: 0
Mar 31, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 02/17/2025.
Findings
At this PSR survey, Signature Healthcare of Muncie 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.
Inspection Report
Complaint Investigation
Census: 129
Capacity: 129
Deficiencies: 0
Mar 26, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452322, IN00455757, and IN00456233.
Findings
No deficiencies related to the allegations were cited for any of the three complaints investigated. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00452322, IN00455757, and IN00456233 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 129
Total Capacity: 129
Medicare Census: 9
Medicaid Census: 90
Other Payor Census: 30
Inspection Report
Re-Inspection
Census: 127
Capacity: 127
Deficiencies: 0
Mar 11, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Investigation of Complaints IN00450001 and IN00451569 completed on January 23, 2025.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the Investigation of Complaints IN00450001 and IN00451569. Both complaints were corrected.
Complaint Details
Investigation of Complaints IN00450001 and IN00451569; both complaints were corrected.
Report Facts
Census Bed Type: 127
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 87
Census Payor Type - Other: 32
Inspection Report
Life Safety
Census: 128
Capacity: 140
Deficiencies: 5
Feb 17, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness requirements due to failure to conduct annual training and maintain documentation of emergency preparedness drills. Additionally, deficiencies were found in fire alarm system maintenance, fire watch policies, and sprinkler system out-of-service procedures.
Severity Breakdown
SS=F: 2
SS=C: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to conduct annual training for the Emergency Preparedness Program and maintain documentation of staff knowledge. | SS=F |
| Failed to analyze and maintain complete documentation of all Emergency Preparedness Program drills. | SS=C |
| Failed to ensure fire alarm system was maintained and smoke detector sensitivity testing was incomplete and undocumented. | SS=F |
| Failed to provide a complete written fire watch policy for fire alarm system out-of-service events. | SS=C |
| Failed to provide a complete written fire watch policy for sprinkler system out-of-service events. | SS=C |
Report Facts
Facility capacity: 140
Census: 128
Number of smoke detectors: 93
Number of smoke detectors tested: 43
Fire watch out-of-service duration: 4
Sprinkler system out-of-service duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Named in relation to emergency preparedness and fire safety findings |
| Maintenance Director | Named in relation to emergency preparedness and fire safety findings and corrective actions |
Inspection Report
Annual Inspection
Census: 127
Capacity: 127
Deficiencies: 10
Jan 23, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, misappropriation of resident funds, quality of care related to infection and urinary tract infection management, safe storage of smoking materials, medication labeling and storage, dietary staffing and meal delivery timeliness, arbitration agreement compliance, quality assurance program implementation, infection prevention and control, and maintenance of emergency equipment.
Complaint Details
Complaint IN00450208 - No deficiencies related to the allegations are cited. Complaint IN00449995 - No deficiencies related to the allegations are cited. Complaint IN00451745 - No deficiencies related to the allegations are cited. Complaint IN00450001 - Federal/State deficiencies related to the allegations are cited at F602. Complaint IN00451569 - Federal/State deficiencies related to the allegations are cited at F908.
Severity Breakdown
SS=D: 8
SS=E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure a self-administration assessment was completed for a resident self-administering eye drops. | SS=D |
| Failed to prevent misappropriation of resident funds by a staff member. | SS=D |
| Failed to provide increased monitoring and assessment for a resident with a worsening urinary tract infection. | SS=D |
| Failed to ensure resident smoking materials were securely stored and properly managed. | SS=D |
| Failed to ensure medications and biologicals were properly labeled and stored in medication rooms and carts. | SS=D |
| Failed to provide adequate dietary staff to ensure timely delivery of room tray meals on multiple units. | SS=E |
| Failed to ensure residents were informed of their rights to rescind binding arbitration agreements within 30 days and upon subsequent admissions. | SS=E |
| Failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. | SS=D |
| Failed to develop and implement an infection control program providing Enhanced Barrier Precautions (EBP) and isolation services for residents. | SS=D |
| Failed to ensure the automated external defibrillator (AED) was maintained in safe operating condition. | SS=D |
Report Facts
Census: 127
Licensed Capacity: 127
Medicare Census: 5
Medicaid Census: 99
Deficiency Count: 11
Meal Delivery Delay: 57
Meal Delivery Delay: 55
Meal Delivery Delay: 44
Meal Delivery Delay: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Administrator signed report and involved in interviews regarding arbitration agreements, dietary staffing, and AED maintenance. |
| Unit Manager 16 | Involved in investigation of resident fund misappropriation, CPR event, and dietary meal delivery concerns. | |
| RN 3 | Registered Nurse | Interviewed regarding medication administration and AED use. |
| RN 22 | Registered Nurse | Interviewed regarding medication storage and treatment cart observations. |
| CNA 31 | Certified Nursing Assistant | Involved in alleged misappropriation of resident funds. |
| CNA 33 | Certified Nursing Assistant | Witnessed CNA 31 taking resident debit card for pizza order. |
| DON | Director of Nursing | Interviewed regarding medication self-administration assessment, AED maintenance, and infection control. |
| IP | Infection Preventionist | Provided infection control policies and interviewed regarding Enhanced Barrier Precautions. |
| Dietary Manager | Interviewed regarding dietary staffing and meal delivery delays. | |
| District Dietary Manager | Assisted with meal delivery and interviewed regarding staffing and meal delays. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 13, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00446632 and IN00446869 completed on November 13, 2024.
Findings
Signature Healthcare Of Muncie was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations.
Report Facts
Complaint Investigation IDs: IN00446632 and IN00446869
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
Dec 12, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00448393 and IN00449006.
Findings
No deficiencies related to the allegations in complaints IN00448393 and IN00449006 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00448393 and IN00449006 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 123
Census total residents: 123
Census Medicare residents: 5
Census Medicaid residents: 99
Census other payor residents: 19
Inspection Report
Complaint Investigation
Census: 127
Capacity: 127
Deficiencies: 2
Nov 12, 2024
Visit Reason
This visit was for the investigation of complaints IN00446632 and IN00446869 concerning allegations of abuse and pressure ulcer care.
Findings
The facility failed to prevent verbal abuse from a staff member towards a resident and failed to implement the facility abuse policy. Additionally, the facility failed to accurately assess and promptly treat a new pressure injury for a resident, lacking timely physician orders and individualized care plans.
Complaint Details
Complaint IN00446632 related to abuse allegations was not substantiated after investigation. Complaint IN00446869 related to pressure ulcer care deficiencies was substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prevent verbal abuse from a staff member and failed to implement the facility abuse policy to protect the resident from further abuse. | SS=D |
| Failed to accurately and consistently assess a new pressure injury and failed to promptly initiate wound treatment to promote healing of pressure injury. | SS=D |
Report Facts
Census: 127
Total Capacity: 127
Medicare Residents: 6
Medicaid Residents: 100
Other Payor Residents: 21
Deficiency Completion Date: Dec 9, 2024
Deficiency Completion Date: Dec 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daphne New | Administrator | Named as facility Administrator involved in investigation and report |
| CNA 5 | Staff member alleged to have verbally abused Resident F | |
| CNA 6 | Witnessed verbal abuse incident and reported it | |
| RN 7 | Observed staff attitude and was notified of incident | |
| RN 3 | Provided information on wound care documentation and procedures | |
| Director of Nursing | DON | Provided information on wound care and investigation |
Inspection Report
Complaint Investigation
Census: 136
Capacity: 136
Deficiencies: 0
Sep 26, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443080 and IN00442151.
Findings
No deficiencies related to the allegations in complaints IN00443080 and IN00442151 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00443080 and Complaint IN00442151 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census SNF/NF beds: 136
Census total residents: 136
Census Medicare residents: 8
Census Medicaid residents: 110
Census other payor residents: 18
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 1
Aug 29, 2024
Visit Reason
This visit was for the investigation of complaints IN00442103, IN00441172, and IN00440421. The investigation focused on allegations related to resident care and behaviors.
Findings
The facility failed to develop a resident-centered care plan and interventions to address Resident K's use of alcohol and physical aggressive behaviors. The clinical record lacked documentation and care planning for these behaviors despite multiple incidents involving aggression and alcohol use.
Complaint Details
Complaint IN00442103 was substantiated with federal/state deficiencies cited at F656. Complaints IN00441172 and IN00440421 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop a resident-centered care plan and interventions to address Resident K's use of alcohol and physical aggressive behaviors. | SS=D |
Report Facts
Census: 130
Total Capacity: 130
Medicare Residents: 4
Medicaid Residents: 103
Other Residents: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Observed Resident K's physical altercation and aggressive behavior |
| RN 2 | Registered Nurse | Was on the phone with a physician during Resident K's aggression |
| LPN 3 | Licensed Practical Nurse | Responded to Resident K's aggression, called police |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding Resident K's behavior and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 29, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00442103 completed on August 29, 2024.
Findings
Signature Healthcare of Muncie was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the Complaint Investigation survey.
Complaint Details
Investigation of Complaint IN00442103; paper compliance review completed with findings of compliance.
Inspection Report
Re-Inspection
Census: 129
Capacity: 129
Deficiencies: 0
Aug 5, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00436790, IN00436945, and IN00438076 completed on July 5, 2024.
Findings
Signature Healthcare of Muncie 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 Complaints IN00436790, IN00436945, and IN00438076.
Complaint Details
Complaints IN00436790, IN00436945, and IN00438076 were investigated and found to be corrected.
Report Facts
Census Bed Type: 129
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 103
Census Payor Type - Other: 19
Inspection Report
Complaint Investigation
Census: 131
Capacity: 131
Deficiencies: 0
Aug 2, 2024
Visit Reason
This visit was conducted to investigate complaints IN00440141, IN00439524, IN00438722, and IN00438474 at Signature Healthcare of Muncie.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00440141, IN00439524, IN00438722, and IN00438474 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 131
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 101
Census Payor Type - Other: 22
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 4
Jul 5, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00435272, IN00435893, IN00436790, IN00436945, and IN00438076) regarding alleged abuse, neglect, and medication issues at Signature Healthcare of Muncie.
Findings
The facility was found to have deficiencies related to verbal abuse by a staff member, failure to report abuse allegations timely, failure to provide dependent residents with showers/bed baths per care plans and preferences, and failure to obtain physician-ordered medication for a resident. Corrective actions and plans of correction were provided for each deficiency.
Complaint Details
The investigation was triggered by complaints IN00435272, IN00435893, IN00436790, IN00436945, and IN00438076. Complaints IN00435272 and IN00435893 had no deficiencies cited. Complaints IN00436790, IN00436945, and IN00438076 had federal/state deficiencies cited related to medication, ADL care, and abuse reporting.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was free from verbal abuse from a staff member for 1 of 3 residents reviewed for abuse. | SS=D |
| Facility failed to report an allegation of abuse to the State Agency in a timely manner for 1 of 3 reportable abuse allegations reviewed. | SS=D |
| Facility failed to ensure dependent residents received showers/bed baths per the resident care plan and resident preference for 2 of 4 residents reviewed. | SS=D |
| Facility failed to ensure physician ordered medication was obtained to continue treatment for a resident for 1 of 1 residents reviewed for neglect. | SS=D |
Report Facts
Census: 120
Total Capacity: 120
Medicare Census: 5
Medicaid Census: 99
Other Payor Census: 16
Showers received vs scheduled: 4
Showers scheduled: 12
Bed baths received vs scheduled: 2
Bed baths scheduled: 13
Medication order delay: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justin Hobbs | RN, DON | Signed the report as Director of Nursing |
| CNA 6 | Named in verbal abuse deficiency involving Resident F; employment terminated | |
| Resident F | Resident involved in verbal abuse incident with CNA 6 | |
| RN 12 | Present during verbal altercation between CNA 6 and Resident F | |
| Administrator | Interviewed regarding abuse allegations and investigation | |
| Resident E | Resident with bathing care deficiencies | |
| Resident M | Resident with bathing care deficiencies | |
| CNA 12 | Interviewed regarding shower scheduling and completion | |
| CNA 7 | Interviewed regarding bed bath care for Resident M | |
| QMA 13 | Interviewed regarding shower completion on day and evening shifts | |
| Nurse Practitioner | Involved in medication order and delay for Resident B | |
| Pharmacy Technician | Interviewed regarding medication order receipt and delay | |
| DON | Director of Nursing interviewed regarding medication and abuse reporting | |
| Corporate Nurse Consultant | Provided facility policies and interviewed regarding bathing preferences and medication policies |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
May 23, 2024
Visit Reason
This visit was for the investigation of complaints IN00433469 and IN00435051, conducted in conjunction with the Post Survey Revisit to Investigation of Complaint IN00432324 completed on April 16, 2024.
Findings
No deficiencies related to the allegations in complaints IN00433469 and IN00435051 were cited. Complaint IN00432324 was corrected. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00433469 - No deficiencies related to the allegations are cited. Complaint IN00435051 - No deficiencies related to the allegations are cited. Complaint IN00432324 - Corrected.
Report Facts
Census Bed Type: 120
Total Census: 120
Medicare Census: 4
Medicaid Census: 97
Other Payor Census: 19
Inspection Report
Re-Inspection
Census: 120
Capacity: 120
Deficiencies: 0
May 23, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00432324 completed on April 16, 2024, conducted in conjunction with the Investigation of Complaints IN00433469 and IN00435051 completed on May 23, 2024.
Findings
Complaint IN00432324 was corrected. No deficiencies related to the allegations were cited for Complaints IN00433469 and IN00435051. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00432324 was corrected. Complaints IN00433469 and IN00435051 had no deficiencies related to the allegations cited.
Report Facts
Census Bed Type: 120
Total Census: 120
Medicare Census: 4
Medicaid Census: 97
Other Payor Census: 19
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 16, 2024
Visit Reason
The document is a paper compliance report for the Post Survey Revisit (PSR) that exited on 03/26/24, related to the Life Safety Code Recertification and State Licensure Survey that exited on 02/22/24.
Findings
Signature Healthcare of Muncie was found in compliance with 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 (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 124
Capacity: 124
Deficiencies: 1
Apr 15, 2024
Visit Reason
This visit was for the investigation of complaint IN00432324 regarding federal and state deficiencies related to allegations of inadequate care.
Findings
The facility failed to ensure effective monitoring and timely transfer of Resident B to the hospital after acute abdominal pain and nausea, resulting in delayed treatment for a perforated bowel with sepsis requiring surgery and ongoing care. Documentation and physician notification were inadequate, and staff failed to respond appropriately to the resident's requests for hospital transfer.
Complaint Details
Complaint IN00432324 was substantiated with federal/state deficiencies cited at F684 related to quality of care and failure to respond to change in condition.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure effective monitoring and timely hospital transfer for Resident B with acute abdominal pain and constipation. | SS=G |
Report Facts
Census: 124
Total Capacity: 124
Medicare Census: 12
Medicaid Census: 91
Other Payor Census: 21
Hydrocodone-acetaminophen doses: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding Resident B's care and medication administration on 12/22/23 |
| CNA 2 | Certified Nursing Assistant | Reported family request for hospital transfer and resident's condition on 12/24/23 |
| LPN 3 | Licensed Practical Nurse | Reported resident pain and hospital transfer request on 12/24/23 but did not notify physician or document |
| Unit Manager 4 | Unit Manager | Provided information on Resident B's history of constipation |
| Weekend Supervisor | Weekend Supervisor | Interviewed about resident transfer and awareness of hospital request |
| RN 99 | Registered Nurse | Assigned care of Resident B on 12/25/23 and sent resident to hospital; declined interview |
| Regional Care Consultant | Regional Care Consultant | Provided policy information and interview regarding resident care and notification requirements |
Inspection Report
Re-Inspection
Census: 120
Capacity: 120
Deficiencies: 0
Mar 28, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on February 9, 2024, including a PSR to the Investigation of Complaints IN00426662 and IN00426952, and was in conjunction with the Investigation of Complaint IN00431153.
Findings
Signature Healthcare of Muncie was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaints IN00426662 and IN00426952. Complaints IN00426662 and IN00426952 were corrected.
Complaint Details
Complaint IN00426662 was corrected. Complaint IN00426952 was corrected. The visit was in conjunction with the Investigation of Complaint IN00431153.
Report Facts
Census SNF/NF: 120
Total licensed capacity: 120
Medicare census: 9
Medicaid census: 87
Other payor census: 24
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
Mar 28, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00431153 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on February 9, 2024, including investigations of Complaints IN00426662 and IN00426952.
Findings
No deficiencies related to Complaint IN00431153 were cited. Complaints IN00426662 and IN00426952 were corrected. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00431153 was investigated with no deficiencies found related to the allegations. Complaints IN00426662 and IN00426952 were corrected.
Report Facts
Census SNF/NF: 120
Total Capacity: 120
Medicare Census: 9
Medicaid Census: 87
Other Payor Census: 24
Inspection Report
Re-Inspection
Census: 123
Capacity: 140
Deficiencies: 1
Mar 26, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/22/24 was performed to verify compliance with federal and state requirements.
Findings
The facility was found not in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers related to sprinkler system maintenance and testing. Specifically, the facility failed to maintain one of two sprinkler systems in accordance with NFPA 25 standards, with an obstruction investigation pending for the East system. The deficiency was previously cited and a systemic plan of correction was not implemented in time.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain 1 of 2 sprinkler systems in accordance with NFPA 25, including lack of obstruction investigation for the East system. | SS=F |
Report Facts
Certified beds: 140
Census: 123
Deficiency citation date: Feb 22, 2024
Scheduled obstruction investigation date: Apr 8, 2024
Plan of correction completion date: Apr 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric P. Ahlbrand | CEO-Administrator | Named in relation to exit conference and monitoring of corrective actions |
| Plant Manager | Interviewed regarding sprinkler system inspection and deficiency |
Inspection Report
Life Safety
Census: 134
Capacity: 140
Deficiencies: 3
Feb 22, 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 was found not in compliance with Life Safety Code requirements. Deficiencies included inadequate egress lighting outside the 900 Hall exit, incomplete sprinkler system maintenance documentation, and a corridor door to resident room 702 that would not close and latch properly.
Severity Breakdown
SS=E: 1
SS=F: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Egress lighting for 1 of 8 exit means of egress was not arranged so failure of any single lighting fixture would not leave the area in darkness, affecting the 900 Hall exit. | SS=E |
| Failed to maintain 1 of 2 sprinkler systems in accordance with NFPA 25; incomplete internal inspection documentation for the West sprinkler system. | SS=F |
| Corridor door to resident room 702 would not close and latch into the frame, failing to resist passage of smoke. | SS=D |
Report Facts
Facility capacity: 140
Census: 134
Deficiencies cited: 3
Completion date for egress lighting correction: Mar 8, 2024
Completion date for sprinkler system correction: Mar 23, 2024
Completion date for corridor door repair: Mar 8, 2024
Inspection Report
Annual Inspection
Census: 119
Capacity: 119
Deficiencies: 10
Feb 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00426662, IN00426952, and IN00427329.
Findings
The facility was found deficient in multiple areas including grievance process failures, incomplete abuse investigations, failure to notify Ombudsman of resident discharges, inadequate discharge planning, failure to notify physician of significant weight changes, medication storage and reconciliation issues, food quality and palatability concerns, food safety violations, and infection control breaches related to isolation precautions.
Complaint Details
Complaint IN00426662 - Federal/state deficiencies related to the allegations are cited at F585 and F804. Complaint IN00426952 - Federal/state deficiencies related to the allegations are cited at F610. Complaint IN00427329 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=E: 3
SS=D: 7
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to utilize grievance process to promptly resolve resident grievances and follow up with corrective action for residents and group interviews. | SS=E |
| Failed to complete thorough investigations of alleged abuse for residents reviewed. | SS=D |
| Failed to notify the Ombudsman of resident discharge for residents reviewed. | SS=D |
| Failed to provide sufficient preparation and orientation to a resident to ensure safe and orderly discharge. | SS=D |
| Failed to notify physician of weights outside ordered parameters for a resident at risk for fluid imbalance. | SS=D |
| Failed to ensure narcotics were reconciled per facility policy for medication carts reviewed. | SS=D |
| Failed to ensure medications stored in medication storage rooms and treatment carts were labeled with resident identifiers and directions. | SS=D |
| Failed to ensure food was attractive, palatable, and contained satisfying portions for residents reviewed. | SS=E |
| Failed to ensure food was prepared, served, and distributed in a manner to prevent possible cross contamination during meal service. | SS=E |
| Failed to follow infection control guidelines related to isolation procedures for a resident on isolation precautions. | SS=D |
Report Facts
Census: 119
Total Capacity: 119
Medicare Census: 9
Medicaid Census: 88
Other Payor Census: 22
Deficiency counts: 10
Narcotic reconciliation missing shifts: 34
Residents orally consuming food: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric P. Ahlbrand | CEO-Administrator | Signed the report |
| RN 15 | Nurse involved in infection control deficiency related to PPE use | |
| LPN 11 | Nurse involved in medication cart narcotic reconciliation observation | |
| LPN 8 | Nurse involved in medication storage observation | |
| Cook 2 | Dietary staff involved in food service cross contamination observation | |
| Dietary Manager | Dietary staff involved in food service cross contamination observation | |
| Administrator | Interviewed regarding grievance process and food concerns | |
| Social Services Director | Interviewed regarding Ombudsman notification and discharge planning | |
| DON | Director of Nursing involved in multiple interviews and education | |
| Regional Dietary Manager | Provided education on food palatability and portion size |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 22, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00422607 completed on November 30, 2023.
Findings
Signature Healthcare of Muncie 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 Complaint Investigation.
Complaint Details
Investigation of Complaint IN00422607 completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 4
Nov 30, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00422593, IN00422607, IN00421064, IN00420081, and IN00429331) at Signature Healthcare of Muncie.
Findings
The facility was found deficient related to complaint IN00422607 involving failure to treat a resident with dignity, failure to notify a resident's representative timely regarding an allegation of neglect, failure to immediately report an allegation of neglect to the administrator, and failure to follow infection control protocols. Other complaints had no deficiencies related to the allegations. Unrelated deficiencies were also cited.
Complaint Details
Complaint IN00422607 was substantiated with federal/state deficiencies cited related to the allegations. Other complaints (IN00422593, IN00421064, IN00420081, IN00429331) had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure a resident was treated with dignity for 1 of 3 residents reviewed for nursing services (Resident G). | SS=D |
| Failure to notify a resident's representative regarding an allegation of neglect in a timely manner for 1 of 2 residents reviewed for notifications (Resident G). | SS=D |
| Failure to ensure an allegation of neglect was immediately reported to the Administrator for 1 of 4 residents reviewed for abuse (Resident G). | SS=D |
| Failure to ensure staff practiced appropriate infection control practices while providing care for a resident in transmission-based precautions (Resident J). | SS=D |
Report Facts
Census: 113
Total Capacity: 113
Medicare Census: 5
Medicaid Census: 86
Other Payor Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric P. Ahlbrand | CEO-Administrator | Signed the report |
| CNA 6 | Named in dignity and neglect findings related to Resident G | |
| LPN 27 | Named in dignity and neglect findings related to Resident G | |
| Unit Manager 12 | Interviewed regarding neglect and notification failures | |
| Social Service Director | Interviewed regarding neglect investigation | |
| CNA 1 | Named in infection control deficiency for failure to don PPE | |
| LPN 3 | Interviewed regarding PPE education | |
| Interim Director of Nursing | Interim DON | Provided policies and interviews related to neglect and infection control |
| Administrator | Interviewed regarding family notification |
Inspection Report
Re-Inspection
Census: 116
Capacity: 116
Deficiencies: 0
Oct 25, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00418061 and IN00417645 completed on September 28, 2023, and in conjunction with the PSR to the Investigation of Complaints IN00416092 and IN00417257 completed on September 12, 2023.
Findings
Signature Healthcare of Muncie 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 Investigations of Complaints IN00418061 and IN00417645. All complaints investigated were corrected.
Complaint Details
The visit was related to complaint investigations IN00418061, IN00417645, IN00416092, and IN00417257. All complaints were found to be corrected.
Report Facts
Census Bed Type: 116
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 85
Census Payor Type - Other: 18
Inspection Report
Re-Inspection
Census: 116
Capacity: 116
Deficiencies: 0
Oct 25, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00416092, IN00417257, IN00418061, and IN00417645 completed on September 12 and September 28, 2023.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the investigations of the complaints. All cited complaints were corrected.
Complaint Details
This visit was related to complaint investigations IN00416092, IN00417257, IN00418061, and IN00417645. All complaints were found to be corrected.
Report Facts
Census Bed Type: 116
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 85
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 118
Capacity: 118
Deficiencies: 4
Sep 28, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00418061 and IN00417645 regarding federal and state deficiencies related to notification of changes and freedom from abuse and neglect.
Findings
The facility failed to notify physicians of significant changes in blood sugar levels for 2 of 3 residents reviewed, failed to protect a resident from verbal abuse by a CNA, and failed to timely report and investigate allegations of abuse for 3 residents. The facility implemented corrective actions including staff education, audits, and re-education on abuse prohibition.
Complaint Details
Complaint IN00418061 involved failure to notify physicians of significant changes in residents' conditions related to blood sugar levels. Complaint IN00417645 involved failure to protect residents from verbal abuse and failure to report and investigate abuse allegations timely and thoroughly.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify resident's physician when blood sugars were outside of parameters for 2 of 3 residents reviewed. | SS=D |
| Failure to protect a resident from verbal abuse by CNA 4. | SS=D |
| Failure to timely report allegations of abuse to the State Agency for 3 residents. | SS=D |
| Failure to thoroughly investigate allegations of abuse for 3 residents. | SS=D |
Report Facts
Census: 118
Total Capacity: 118
Survey Dates: 3
Residents with diabetes reviewed: 3
Residents reviewed for abuse allegations: 7
Residents with substantiated abuse allegations: 3
Days of CNA 4 suspension: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Ahlbrand | CEO-Administrator | Signed the inspection report |
| CNA 4 | Named in verbal abuse finding and subsequent suspension | |
| RN 25 | Involved in reporting and investigation of verbal abuse incident | |
| CNA 6 | Named in abuse reporting and investigation deficiencies; no longer employed | |
| DON | Director of Nursing | Responsible for abuse investigations and reporting |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 109
Deficiencies: 2
Sep 12, 2023
Visit Reason
The visit was conducted for the investigation of complaints IN00416092, IN00417257, IN00417178, and IN00416923 at Signature Healthcare of Muncie.
Findings
The facility failed to prevent staff to resident verbal abuse for 2 of 3 residents reviewed and failed to report allegations of staff to resident abuse for 1 of 3 allegations reviewed. Investigations found verbal abuse incidents involving CNAs and residents, with some staff failing to report the incidents as required. The facility implemented corrective actions including resident assessments, staff re-education on abuse prohibition, and ongoing monitoring.
Complaint Details
Complaints IN00416092 and IN00417257 had federal/state deficiencies related to the allegations cited at F600 and F609 respectively. Complaints IN00417178 and IN00416923 had no deficiencies related to the allegations. The allegations involved verbal abuse by staff towards residents and failure to report such abuse. Investigations included interviews with residents, staff, and review of clinical records and policies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to prevent staff to resident verbal abuse for 2 of 3 residents reviewed (Residents B, Resident D, CNA 13 and CNA 14). | SS=D |
| Facility failed to report allegations of staff to resident abuse for 1 of 3 allegations reviewed (CNA 14 and Resident D). | SS=D |
Report Facts
Census: 109
Total Capacity: 109
Medicare Residents: 7
Medicaid Residents: 76
Other Residents: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Ahlbrand | CEO | Signed the report as the provider/supplier representative. |
| RN 11 | Witnessed verbal abuse incident and physical altercation; did not report the incident. | |
| CNA 13 | Certified Nursing Assistant | Used inappropriate language with Resident B. |
| CNA 14 | Certified Nursing Assistant | Verbally abused Resident D and failed to report the incident. |
| CNA 12 | Certified Nursing Assistant | Heard CNA 14 yelling and using inappropriate language; did not report incident to Administrator but reported to RN 11. |
| Employee 7 | Witnessed CNA 14's intimidating behavior towards Resident D; did not report the incident. |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 0
Jul 18, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00412504, IN00412025, and IN00410926.
Findings
No deficiencies related to the allegations in complaints IN00412504, IN00412025, and IN00410926 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00412504, IN00412025, and IN00410926 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 117
Total Capacity: 117
Medicare Census: 13
Medicaid Census: 81
Other Payor Census: 23
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
Jun 5, 2023
Visit Reason
This visit was for the investigation of complaints IN00409122 and IN00409126.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00409122 - No deficiencies related to the allegations are cited. Complaint IN00409126 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 123
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 86
Census Payor Type - Other: 31
Inspection Report
Complaint Investigation
Census: 123
Capacity: 123
Deficiencies: 0
Apr 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00402027 and IN00404609.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00402027 and Complaint IN00404609 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 123
Total Capacity: 123
Medicare Census: 9
Medicaid Census: 93
Other Payor Census: 21
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 20, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on December 21, 2022.
Findings
Signature Healthcare of Muncie was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
Jan 10, 2023
Visit Reason
This visit was for the investigation of complaints IN00424302, IN00424358, and IN00425322.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00424302, IN00424358, and IN00425322 were investigated with no deficiencies found related to the allegations.
Report Facts
Census: 120
Total Capacity: 120
Medicare Census: 11
Medicaid Census: 89
Other Payor Census: 20
Inspection Report
Life Safety
Census: 128
Capacity: 140
Deficiencies: 3
Jan 9, 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 in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain spare sprinklers properly, corridor doors that did not latch properly, and use of a multi-plug adapter in a resident room.
Severity Breakdown
SS=C: 1
SS=E: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 sprinkler systems were provided with spare sprinklers properly secured in a sprinkler cabinet with a sprinkler wrench on the premises. | SS=C |
| Failed to ensure 2 of 2 resident room corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. | SS=E |
| Failed to ensure 1 of 1 resident rooms did not use multi-plug adaptors as a substitute for fixed wiring. | SS=D |
Report Facts
Facility capacity: 140
Census: 128
Spare sprinklers in cabinet: 7
Resident rooms with door issues: 2
Resident rooms with multi-plug adapter: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ben Wells | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Involved in observations and corrective actions for sprinkler cabinet, corridor doors, and multi-plug adapter findings |
Inspection Report
Life Safety
Deficiencies: 0
Jan 9, 2023
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and health care occupancy regulations.
Findings
Signature Healthcare of Muncie was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2.
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 21, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident safety, nutrition, and care.
Findings
The facility was found deficient in preventing falls for a dependent resident requiring two-person assistance, resulting in injury. Additionally, the facility failed to provide preferred foods and serve foods prepared according to resident preferences and medical orders for several residents.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prevent a fall resulting in bruising for a dependent resident due to inadequate supervision and failure to follow care plan requiring two staff members for transfers. | SS=D |
| Failed to offer preferred foods and serve foods prepared in a manner preferred by residents and failed to provide serving sizes and supplemental foods as ordered by the medical provider. | SS=D |
Report Facts
Deficiencies cited: 2
Fall incidents: 3
Staff review frequency: 5
Staff review frequency: 1
Staff review frequency: 1
Dietary audit frequency: 5
Dietary audit frequency: 1
Dietary audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ben Wells | Administrator | Signed the inspection report and responsible for oversight of corrective actions |
| CNA 5 | Interviewed regarding resident care and transfer assistance | |
| CNA 4 | Interviewed regarding resident cooperation and fall incident | |
| CNA 6 | Interviewed regarding fall incident on 12/10/22 | |
| Interim Director of Nursing | Director of Nursing | Interviewed regarding resident falls and care plan |
| Corporate Nurse Consultant | Interviewed regarding fall prevention and care plan compliance | |
| Dietary Aide 10 | Observed and interviewed regarding meal preparation and serving sizes | |
| District Dietary Manager | Interviewed regarding dietary orders and resident preferences | |
| Regional Dietary Manager | Interviewed regarding dietary preferences and food formulary |
Inspection Report
Complaint Investigation
Census: 113
Capacity: 113
Deficiencies: 0
Nov 29, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00395401 and IN00390895.
Findings
Both complaints IN00395401 and IN00390895 were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00395401 - Substantiated with no deficiencies cited. Complaint IN00390895 - Substantiated with no deficiencies cited.
Report Facts
Census Bed Type: 113
Medicare Census: 17
Medicaid Census: 76
Other Payor Census: 20
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Aug 4, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386645.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00386645 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 119
Census Payor Type Medicare: 13
Census Payor Type Medicaid: 84
Census Payor Type Other: 22
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 0
Jul 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385618.
Findings
The complaint IN00385618 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00385618 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Medicare census: 15
Medicaid census: 80
Other payor census: 19
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