Inspection Reports for Signature Healthcare of Terre Haute
3500 MAPLE AVE, IN, 47804
Back to Facility ProfileDeficiencies per Year
16
12
8
4
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Severe
High
Moderate
Low
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Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 153
Capacity: 153
Deficiencies: 1
Jun 12, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00458972 completed on 2025-05-09, conducted in conjunction with the Investigations of Complaints IN00459393 and IN00460686.
Findings
Complaint IN00458972 was corrected. No deficiencies related to Complaint IN00459393 were cited. Federal/state deficiencies related to Complaint IN00460686 were cited at F760. The facility was found in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to Complaint IN00458972.
Complaint Details
This visit was related to the investigation of three complaints: IN00458972 (corrected), IN00459393 (no deficiencies cited), and IN00460686 (deficiencies cited at F760).
Deficiencies (1)
| Description |
|---|
| Federal/state deficiencies related to the allegations of Complaint IN00460686 cited at F760. |
Report Facts
Census SNF/NF beds: 153
Total census: 153
Medicare census: 12
Medicaid census: 115
Other payor census: 26
Inspection Report
Complaint Investigation
Census: 153
Capacity: 153
Deficiencies: 1
Jun 12, 2025
Visit Reason
The visit was conducted for the investigation of complaints IN00459393 and IN00460686, and in conjunction with a Post Survey Revisit to complaint IN00458972 completed on May 9, 2025.
Findings
The facility was found deficient related to complaint IN00460686 for failing to administer scheduled doses of comfort medication per physician order without nursing assessment and physician notification for one resident. The deficient practice was corrected prior to the survey start date and was considered past noncompliance. No deficiencies were cited related to complaint IN00459393, and complaint IN00458972 was corrected.
Complaint Details
Complaint IN00458972 was corrected. Complaint IN00459393 had no deficiencies related to the allegations. Complaint IN00460686 had federal/state deficiencies cited at F760 related to medication errors.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to administer scheduled doses of comfort medication per physician order without nursing assessment and physician notification for one resident, resulting in significant medication errors. | SS=D |
Report Facts
Census: 153
Total Capacity: 153
Medicare Census: 12
Medicaid Census: 115
Other Payor Census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| QMA 2 | Qualified Medication Aide | Failed to administer scheduled morphine doses without nursing assessment or physician notification |
| QMA 4 | Qualified Medication Aide | Failed to administer scheduled morphine doses without nursing assessment or physician notification |
| DON | Director of Nursing | Indicated that QMA's and nurses should not skip doses of scheduled medications without contacting the physician |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 154
Deficiencies: 2
May 9, 2025
Visit Reason
This visit was for the investigation of complaints IN00458586, IN00458972, and IN00459076 regarding resident care and abuse allegations.
Findings
The facility failed to timely report an allegation of suspected resident-to-resident abuse involving Resident F and Resident J, resulting in Resident F's injury and subsequent death. Additionally, the facility failed to implement resident-specific interventions for a dementia resident (Resident J) known to have behavioral issues, which led to harm. The investigation included interviews, record reviews, and observations, revealing lapses in monitoring and reporting.
Complaint Details
Complaint IN00458586 - No deficiencies related to the allegations are cited. Complaint IN00458972 - Federal/state deficiencies related to the allegations are cited at F649 and F744. Complaint IN00459076 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely report an allegation of suspected resident-to-resident abuse for 1 of 7 residents reviewed (Resident F). | SS=D |
| Failed to ensure resident-specific interventions were implemented for a dementia resident with known behaviors (Resident J), resulting in harm. | SS=G |
Report Facts
Residents present: 154
Total licensed capacity: 154
Medicare residents: 21
Medicaid residents: 129
Other payor residents: 4
Date of incident: Apr 21, 2025
Date of resident death: Apr 29, 2025
Date survey completed: May 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 7 | Certified Nursing Assistant | Witnessed Resident J walking and heard Resident F say 'ouch'; involved in reporting incident |
| CNA 8 | Certified Nursing Assistant | Reported seeing Resident J exit Resident F's room with scratches; heard Resident F say 'ouch' |
| QMA 5 | Qualified Medication Aide | Reported fall and observed Resident J's behavior; involved in medication administration |
| LPN 6 | Licensed Practical Nurse | Responded to fall, assessed Resident F, instructed staff on monitoring Resident J |
| Administrator | Administrator | Notified of incident, directed 15-minute checks for Resident J |
| Nurse Consultant | Nurse Consultant | Conducted interviews, provided information on investigation and facility practices |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 157
Deficiencies: 0
Apr 25, 2025
Visit Reason
This visit was conducted for the investigation of five complaints: IN00455678, IN00456099, IN00456232, IN00457701, and IN00457983.
Findings
No deficiencies related to the allegations in any of the five complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00455678, IN00456099, IN00456232, IN00457701, and IN00457983 were investigated and no deficiencies related to the allegations were found.
Report Facts
Census SNF/NF: 157
Total Capacity: 157
Medicare Census: 12
Medicaid Census: 134
Other Payor Census: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 11, 2025
Visit Reason
Paper compliance review of the Investigation of Complaint IN00455442 completed on March 14, 2025.
Findings
Signature Healthcare of Terre Haute 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00455442; paper compliance review completed and found in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 11, 2025
Visit Reason
Paper compliance review of the Investigation of Complaints IN00454858 and IN00454449 completed on March 5, 2025.
Findings
Signature Healthcare of Terre Haute 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 of the investigations.
Report Facts
Complaint Investigation IDs: IN00454858 and IN00454449
Inspection Report
Complaint Investigation
Census: 152
Capacity: 152
Deficiencies: 2
Mar 14, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00455442 related to federal/state deficiencies concerning discharge notice and preparation for safe discharge.
Findings
The facility failed to issue a 30-day notice of discharge prior to the planned discharge date for Resident B and did not ensure the resident was prepared for a safe and orderly discharge despite significant clinical needs including catheter care, oxygen use, and wound care. Discharge planning was delayed and incomplete, with lack of education and coordination regarding payor issues and discharge options.
Complaint Details
Complaint IN00455442 involved allegations related to failure to issue proper discharge notice and failure to ensure safe discharge planning for Resident B. The complaint was substantiated with deficiencies cited at F623 and F624.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to issue a 30-day notice of discharge prior to planned discharge for Resident B. | SS=D |
| Failed to plan for and ensure Resident B was prepared for a safe and orderly discharge including catheter care, oxygen use, and wound care. | SS=D |
Report Facts
Residents reviewed for discharge notice: 3
Census: 152
Total Capacity: 152
Medicare residents: 16
Medicaid residents: 102
Other payor residents: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Qualified Medication Aide 5 | Qualified Medication Aide | Interviewed regarding Resident B's discharge plans |
| Social Services Director | Social Services Director (SSD) | Discharge coordinator involved in discharge planning and interviews |
| Certified Nurse Aide 6 | Certified Nurse Aide | Interviewed regarding Resident B's care needs and discharge |
| Certified Nurse Aide 7 | Certified Nurse Aide | Interviewed regarding Resident B's care needs and discharge |
| Medicaid Done Right Representative 8 | Medicaid Done Right Representative | Provided contracted Medicaid application assistance and interviewed |
| Business Office Manager | Business Office Manager (BOM) | Provided notes on Medicaid and discharge discussions |
| Nurse Consultant | Nurse Consultant | Interviewed regarding discharge planning and payor issues |
| Administrator | Facility Administrator | Interviewed regarding discharge meeting and payor issues |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding discharge planning and safety concerns |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Participated in phone meeting with family about discharge |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 146
Deficiencies: 2
Mar 5, 2025
Visit Reason
This visit was for the investigation of complaints IN00454858, IN00454449, and IN00454700. Complaints IN00454858 and IN00454449 resulted in federal/state deficiencies cited at F600 and F609, while complaint IN00454700 had no deficiencies related to the allegations.
Findings
The facility failed to protect a resident's right to be free from verbal abuse when a contract Licensed Practical Nurse (LPN 4) verbally abused Resident E. The abuse was substantiated and the nurse was removed from the facility. Additionally, the facility failed to accurately report the incident to the Indiana Department of Health (IDOH), but corrected the reporting error after investigation. The deficient practices were corrected prior to the survey.
Complaint Details
The investigation was triggered by complaints IN00454858 and IN00454449 alleging verbal abuse by a contract Licensed Practical Nurse (LPN 4) towards Resident E. The abuse allegation was substantiated upon investigation. Complaint IN00454700 had no deficiencies related to the allegations. The facility initially reported the abuse allegation as unsubstantiated to IDOH in error but corrected the report after investigation.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect resident's right to be free from verbal abuse when a staff member called a resident a derogatory name. | SS=D |
| Failed to ensure an incident of verbal abuse was accurately reported to the Indiana Department of Health. | SS=D |
Report Facts
Census: 146
Total Capacity: 146
Medicare Census: 11
Medicaid Census: 102
Other Payor Census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy D. Macke | HFA, CEO | Signed the report |
| LPN 4 | Licensed Practical Nurse (contract staff) | Named in verbal abuse finding towards Resident E |
| CNA 6 | Certified Nursing Aide | Witness to verbal abuse incident involving Resident E and LPN 4 |
| CNA 7 | Certified Nursing Aide | Witness to verbal abuse incident involving Resident E and LPN 4 |
| LPN 8 | Licensed Practical Nurse | Witness and reporter of verbal abuse incident involving Resident E and LPN 4 |
| Assistant Administrator | Provided interviews and facility policy information | |
| Clinical Support Nurse | Provided interview confirming substantiation of verbal abuse |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 154
Deficiencies: 0
Feb 25, 2025
Visit Reason
This visit was for the investigation of Complaint IN00453905.
Findings
No deficiencies related to the allegations in Complaint IN00453905 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00453905 found no deficiencies related to the allegations.
Report Facts
Medicare census: 16
Medicaid census: 109
Other payor census: 29
Inspection Report
Life Safety
Census: 156
Capacity: 176
Deficiencies: 1
Feb 21, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found in substantial compliance with Life Safety Code requirements, but failed to conduct quarterly fire drills at unexpected times under varying conditions on three shifts for 3 of 4 quarters. Fire drills were mostly conducted toward the end of the month and not at unexpected times.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to conduct quarterly fire drills at unexpected times under varying conditions on three shifts for 3 of 4 quarters. | SS=C |
Report Facts
Facility capacity: 176
Census: 156
Fire drills conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy D. Macke | HFA, CEO | Signed the report and participated in exit conference |
| Plant Operations Director | Interviewed regarding fire drills and emergency preparedness findings | |
| Maintenance Director | Named in plan of correction for fire drills and emergency preparedness | |
| Regional Plant Operations Director | Named in plan of correction for in-service training on fire drills and emergency preparedness |
Inspection Report
Annual Inspection
Census: 148
Capacity: 148
Deficiencies: 10
Jan 28, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00449795.
Findings
The facility was found to have multiple deficiencies including failure to notify physicians of medication non-administration, incomplete transfer/discharge notices, lack of ombudsman notification for transfers, incomplete bed hold forms, improper scope of practice by QMAs, failure to prevent pressure ulcers, inadequate hydration, improper oxygen equipment maintenance, incomplete AIMS assessments, and medication storage issues.
Complaint Details
Complaint IN00449795 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 8
SS=E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to notify physician of not administering medications as ordered for 2 residents. | SS=D |
| Failed to ensure Notice of Transfer/Discharge forms were completed and provided for 4 residents. | SS=E |
| Failed to ensure Ombudsman was notified of resident transfers for 3 residents. | SS=D |
| Failed to ensure bed hold forms were completed and provided for 3 residents. | SS=E |
| Failed to ensure QMAs followed proper standards of practice for treatments for 1 resident. | SS=D |
| Failed to prevent new pressure wounds on 1 resident. | SS=D |
| Failed to provide adequate hydration for 2 residents. | SS=D |
| Failed to ensure oxygen tubing was dated when changed and maintained in a sanitary manner for 1 resident. | SS=D |
| Failed to ensure AIMS assessments were completed for 1 resident on psychotropic medications. | SS=D |
| Failed to ensure medications were dated when opened and stored properly in 4 of 5 medication carts. | SS=D |
Report Facts
Census: 148
Total Capacity: 148
Deficiencies cited: 10
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy D. Macke | HFA, CEO | Signed the inspection report |
Inspection Report
Renewal
Deficiencies: 0
Jan 28, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure Survey.
Findings
Signature Healthcare of Terre Haute 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 of the Recertification and State Licensure Survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 13, 2024
Visit Reason
Paper compliance review of the Investigation of Complaints IN00446006 and IN00446733 completed on November 13, 2024.
Findings
Signature Healthcare of Terre Haute 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 of the investigations.
Complaint Details
Investigation of Complaints IN00446006 and IN00446733; paper compliance review found in compliance.
Inspection Report
Complaint Investigation
Census: 149
Capacity: 149
Deficiencies: 2
Nov 12, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00446006, IN00446241, IN00446496, IN00446733, and IN00446882) regarding the facility's compliance with federal and state regulations.
Findings
The facility was found deficient in two complaints: failure to ensure post-fall assessments and vital signs were completed for 72 hours post-fall for one resident, and failure to assist a resident with transportation to a physician appointment. Other complaints had no deficiencies cited.
Complaint Details
Complaint IN00446006 and IN00446733 had federal/state deficiencies cited related to the allegations. Complaints IN00446241, IN00446496, and IN00446882 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure post fall assessments and vital signs were completed for 72 hours post fall for 1 of 3 residents reviewed for accidents (Resident P). | SS=D |
| Failed to assist the resident in transportation from the facility to a physician office appointment for 1 of 1 resident reviewed for transportation (Resident C). | SS=D |
Report Facts
Residents present: 149
Total licensed capacity: 149
Medicare residents: 8
Medicaid residents: 104
Other payor residents: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy D. Macke | HFA, CEO | Signed report as Laboratory Director's or Provider/Supplier Representative |
| Assistant Administrator | Interviewed regarding documentation and transportation issues | |
| Registered Nurse 13 | Contracted RN | Interviewed about post-fall assessment procedures |
| Licensed Practical Nurse 5 | LPN | Interviewed about appointment scheduling and transportation |
| Executive Director | Responsible for auditing transportation arrangements and compliance |
Inspection Report
Re-Inspection
Census: 151
Capacity: 151
Deficiencies: 0
Nov 1, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00443846 completed on September 27, 2024.
Findings
Signature Healthcare of Terre Haute 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 IN00443846.
Complaint Details
Complaint IN00443846 was investigated and found to be corrected.
Report Facts
Census SNF/NF beds: 151
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 108
Census Payor Type - Other: 35
Inspection Report
Complaint Investigation
Census: 147
Capacity: 147
Deficiencies: 0
Oct 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442677, IN00443703, IN00443956, and IN00444233 at Signature Healthcare of Terre Haute.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Complaint Details
Complaints IN00442677, IN00443703, IN00443956, and IN00444233 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 147
Total Capacity: 147
Medicare Census: 5
Medicaid Census: 108
Other Payor Census: 34
Inspection Report
Complaint Investigation
Census: 152
Capacity: 152
Deficiencies: 3
Sep 27, 2024
Visit Reason
This visit was for the investigation of Complaint IN00443846 related to allegations of resident-to-resident sexual abuse and failure to protect residents from abuse.
Findings
The facility failed to protect residents from sexual abuse by another resident, resulting in Immediate Jeopardy that was removed after corrective actions. The facility also failed to report allegations of abuse immediately and failed to conduct a thorough investigation. Multiple staff observed inappropriate touching and incidents involving two cognitively impaired residents, Resident B and Resident C. The facility implemented 15-minute checks and medication adjustments but had gaps in documentation and reporting.
Complaint Details
Complaint IN00443846 involved allegations of sexual abuse between two cognitively impaired residents, Resident B and Resident C. The complaint was substantiated with findings of Immediate Jeopardy that was later removed. The facility failed to report the abuse timely and conduct a thorough investigation.
Severity Breakdown
SS=J: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect residents from sexual abuse by another resident, resulting in Immediate Jeopardy. | SS=J |
| Failed to report allegations of resident abuse immediately to the Administrator and the Indiana Department of Health. | SS=D |
| Failed to ensure allegations of resident abuse were investigated thoroughly. | SS=D |
Report Facts
Census: 152
Total Capacity: 152
Survey Dates: 2024-09-24 to 2024-09-27
Medication Dosage: 0.5
Medication Dosage: 0.25
15-minute checks: 15
Dates of 15-minute checks documentation: Sep 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Named in investigation and reporting of abuse incidents involving Residents B and C | |
| Administrator (ADM) | Notified of abuse incidents and involved in investigation and reporting | |
| Social Services Assistant (SSA) | Involved in psychosocial follow-up and care planning for Residents B and C | |
| Certified Nursing Aides (CNAs) 5, 6, 9 | Witnesses and reporters of abuse incidents between Residents B and C | |
| Qualified Medication Aide (QMA) 7 | Witnessed abuse incidents and assisted in monitoring Resident B | |
| Administrator in Training (AIT) | Communicated with staff regarding statements about the abuse incident |
Inspection Report
Life Safety
Census: 152
Capacity: 176
Deficiencies: 0
Sep 20, 2024
Visit Reason
A Life Safety Code Preoccupancy Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess 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 a fire alarm system and smoke detectors in all resident sleeping rooms and corridors.
Report Facts
Beds relocated: 3
Facility capacity: 176
Census: 152
Inspection Report
Re-Inspection
Census: 157
Capacity: 157
Deficiencies: 0
Sep 13, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00438294 completed on July 31, 2024.
Findings
Signature Healthcare of Terre Haute 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 IN00438294.
Complaint Details
Complaint IN00438294 - Corrected.
Report Facts
Census SNF/NF: 157
Census Payor Type Medicare: 16
Census Payor Type Medicaid: 104
Census Payor Type Other: 37
Inspection Report
Complaint Investigation
Census: 145
Capacity: 145
Deficiencies: 0
Aug 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440277.
Findings
No deficiencies related to the allegations in Complaint IN00440277 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00440277 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 14
Medicaid census: 101
Other payor census: 30
Inspection Report
Complaint Investigation
Census: 141
Capacity: 141
Deficiencies: 1
Jul 31, 2024
Visit Reason
This visit was for the investigation of complaints IN00438294, IN00439201, and IN00439657. The investigation focused on allegations related to resident care and behavior management.
Findings
The facility failed to provide personalized care and interventions for a resident with schizophrenia, resulting in multiple resident-to-resident altercations on a locked behavioral unit. The facility's documentation and investigation lacked evidence of interventions to prevent further incidents. The facility has initiated corrective actions including updated care plans, staff re-education, and monitoring to prevent recurrence.
Complaint Details
Complaint IN00438294 was substantiated with federal/state deficiencies cited at F742 related to treatment/services for mental/psychosocial concerns. Complaints IN00439201 and IN00439657 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide personalized care and interventions for a resident with schizophrenia leading to resident-to-resident altercations. | SS=D |
Report Facts
Census: 141
Total Capacity: 141
Medicare Census: 16
Medicaid Census: 99
Other Payor Census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided information about Resident F's behaviors and interventions | |
| Administrator (ADM) | Provided documentation of Resident F's 30-day Notice of Transfer or Discharge and care plan meeting details | |
| Qualified Medication Aide (QMA) | Reported staff interventions to redirect Resident F | |
| Social Services Director (SSD) | Participated in care plan meeting regarding Resident F |
Inspection Report
Complaint Investigation
Census: 154
Capacity: 154
Deficiencies: 0
Jun 26, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431922, IN00433984, IN00436558, and IN00436662.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00431922, IN00433984, IN00436558, and IN00436662 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 154
Total Capacity: 154
Census Medicare: 15
Census Medicaid: 103
Census Other: 36
Inspection Report
Complaint Investigation
Census: 141
Capacity: 141
Deficiencies: 3
Apr 5, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00431251, IN00427831, IN00426792, IN00426829, and IN00426190) regarding alleged deficiencies at Signature Healthcare of Terre Haute.
Findings
The facility was found deficient in respiratory/tracheostomy care and suctioning, competent nursing staff, and pharmacy services related to medication administration and availability. Specific issues included failure to date, time, and sign oxygen nebulizer tubing, failure to administer medications per physician orders, failure to notify physicians when medications were unavailable, and failure to ensure sufficient nursing competencies.
Complaint Details
The investigation was triggered by complaints IN00431251 and IN00426829 which resulted in federal/state deficiencies cited at F695, F755, and F726. Other complaints (IN00427831, IN00426792, IN00426190) had no deficiencies related to allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure oxygen nebulizer tubing and equipment were dated, timed, and signed for 1 of 3 residents reviewed for respiratory care. | SS=D |
| Failed to ensure medications were administered per physician order and failed to notify physician of medications not being available to administer for 1 of 3 residents reviewed for medication administration. | SS=D |
| Failed to provide routine and emergency drugs and biologicals to residents, including ensuring availability and proper notification when medications were unavailable. | SS=D |
Report Facts
Census: 141
Total Capacity: 141
Medicare Census: 8
Medicaid Census: 101
Other Payor Census: 32
Deficiency Count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zachary Wilson | Administrator/CEO | Signed the inspection report |
| Registered Nurse 4 | Registered Nurse | Interviewed regarding nebulizer treatment order and medication availability |
| Registered Nurse 10 | Registered Nurse | Observed preparing insulin administration and clarifying orders |
| Director of Nursing | Director of Nursing (DON) | Provided policies, interviews, and corrective action plans |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 5, 2024
Visit Reason
Paper compliance review of the Investigation of Complaints IN00431251 and IN00426829 completed on April 5, 2024.
Findings
Signature Healthcare of Terre Haute 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 of the investigations.
Complaint Details
The visit was related to investigations of complaints IN00431251 and IN00426829; compliance was found.
Inspection Report
Re-Inspection
Census: 146
Capacity: 176
Deficiencies: 0
Feb 27, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/17/24 was performed to verify compliance with life safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The building was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 176
Census: 146
Inspection Report
Re-Inspection
Census: 154
Capacity: 154
Deficiencies: 0
Jan 29, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on December 19, 2023, including a PSR to the Investigation of Complaints IN00417987, IN00420745, and IN00421358 completed on December 19, 2023.
Findings
Signature Healthcare of Terre Haute was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey. All complaints investigated were corrected.
Complaint Details
Complaints IN00417987, IN00420745, and IN00421358 were investigated and found to be corrected.
Report Facts
Census: 154
Total Capacity: 154
Medicare Census: 17
Medicaid Census: 101
Other Payor Census: 36
Inspection Report
Annual Inspection
Census: 145
Capacity: 176
Deficiencies: 4
Jan 17, 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 not in compliance with Life Safety Code requirements. Deficiencies included corridor doors not latching properly, lack of GFCI protection in a wet location, improper operation of a rolling steel fire door, and use of a power strip for high current draw equipment.
Severity Breakdown
SS=E: 3
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure all resident room corridor doors would latch into the door frame, affecting 20 residents and staff in the 300 Hall. | SS=E |
| Failed to provide ground fault circuit interrupter (GFCI) protection for 1 of over 10 wet locations, specifically an electric receptacle within three feet of the sink in the 300 Hall Clean Utility Room. | SS=D |
| Failed to ensure proper operation of 1 rolling steel fire door; the door did not close automatically upon activation or release of a fusible link or detector, affecting over 40 residents and staff in the main Dining Room and kitchen. | SS=E |
| Failed to ensure power strips were not used as a substitute for fixed wiring to provide power to equipment with a high current draw; a power strip was supplying power to a refrigerator and microwave in the Wound Nurse office. | SS=E |
Report Facts
Certified beds: 176
Census: 145
Residents affected: 20
Residents affected: 40
Power strips observed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zachary Wilson | Administrator/CEO | Named as Administrator/CEO and involved in exit conference |
| Plant Operations Director | Interviewed and involved in observations and exit conference; name not provided |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 139
Deficiencies: 0
Jan 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425455.
Findings
No deficiencies related to the allegations in Complaint IN00425455 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00425455 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 9
Medicaid census: 95
Other payor census: 35
Inspection Report
Annual Inspection
Census: 146
Capacity: 146
Deficiencies: 13
Dec 19, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey including Investigation of multiple complaints. The visit resulted in an Extended Survey due to Substandard Quality of Care with Immediate Jeopardy.
Findings
The facility was found deficient in multiple areas including resident self-determination, care planning, pressure ulcer prevention and treatment, elopement prevention, catheter care, nutrition and hydration, respiratory care, dementia care, medication storage and labeling, food palatability and temperature, sanitation of dishware and silverware, hand hygiene during feeding, and environmental maintenance.
Complaint Details
This survey included investigations of complaints IN00423213, IN00420149, IN00417987, IN00420985, IN00420745, IN00417433, IN00423085, and IN00421358. Deficiencies were cited related to complaints IN00417987, IN00420745, and IN00421358.
Severity Breakdown
SS=J: 2
SS=E: 3
SS=D: 7
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure resident preferences for showers were met for 1 of 5 residents reviewed. | SS=D |
| Failed to ensure care plan meetings were conducted for 1 of 3 residents reviewed. | SS=D |
| Failed to prevent and appropriately treat pressure ulcers resulting in immediate jeopardy for 1 of 6 residents reviewed. | SS=J |
| Failed to ensure skin assessments were completed as ordered for 1 of 6 residents reviewed for skin assessments. | SS=J |
| Failed to prevent a resident from eloping and exiting the facility unattended for 1 of 1 resident reviewed. | SS=D |
| Failed to ensure urinary catheter tubing and drainage bag were kept off the floor for 1 of 1 resident reviewed. | SS=D |
| Failed to determine root cause for significant weight loss for 1 of 4 residents reviewed for nutrition. | SS=D |
| Failed to ensure oxygen tubing was stored and applied according to policy for 1 of 2 residents reviewed for respiratory care. | SS=D |
| Failed to ensure resident specific dementia care plans were developed for 2 of 2 residents reviewed for dementia care. | SS=D |
| Failed to provide date opened on multi-dose medication vials, failed to refrigerate medications properly, failed to ensure medication room refrigerators were clean, and failed to ensure all medications had pharmacy labels for 3 of 6 medication carts and 1 of 2 medication room refrigerators observed. | SS=D |
| Failed to ensure food was served at proper temperature and was palatable for 2 of 32 residents and 1 test tray. | SS=E |
| Failed to ensure dishware and silverware were free of hard water buildup and failed to ensure hand hygiene was performed when assisting residents with eating for 1 of 2 dining observations. | SS=E |
| Failed to ensure residents were provided a comfortable and sanitary environment and failed to maintain adequate lighting and repairs in resident rooms for 2 of 29 residents. | SS=D |
Report Facts
Survey dates: 8
Census: 146
Weight loss: 22.6
Weight loss percentage: 18
Medication counts: 3
Food temperature: 119
Food temperature: 110
Food temperature: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zachary Wilson | Administrator/CEO | Signed the report |
| Kacey Barnes | Ombudsman | Conducting in-person training on Resident Rights |
| Zachary Wilson | Administrator | Provided investigation documentation related to elopement |
| RN 15 | Registered Nurse | Completed observation note on pressure ulcer letter of unavoidability and assisted with wound care |
| LPN 14 | Licensed Practical Nurse | Observed performing wound care with deficiencies |
| DON | Director of Nursing | Provided policies and information on wound care, catheter care, and other deficiencies |
| RN 28 | Registered Nurse | Observed medication cart and noted medication labeling issues |
| LPN 6 | Licensed Practical Nurse | Observed medication cart and catheter care deficiencies |
| DM | Dietary Manager | Provided information on food temperatures and dishwashing issues |
| Administrator | Administrator | Provided policies and investigation documentation |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 141
Deficiencies: 0
Sep 29, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00418135.
Findings
No deficiencies related to the allegations of Complaint IN00418135 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418135 was investigated and no deficiencies related to the allegations were found.
Report Facts
Medicare census: 12
Medicaid census: 96
Other payor census: 33
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 22, 2023
Visit Reason
Paper compliance review of the Investigation of Complaints IN00410491 and IN00413116 completed on August 3, 2023.
Findings
Signature Healthcare of Terre Haute 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 of the investigations.
Inspection Report
Complaint Investigation
Census: 147
Capacity: 147
Deficiencies: 0
Sep 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00416715 and IN00416736 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the allegations in Complaints IN00416715 and IN00416736 were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00416715 and Complaint IN00416736 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census SNF/NF: 147
Total Capacity: 147
Medicare Census: 12
Medicaid Census: 102
Other Payor Census: 33
Inspection Report
Complaint Investigation
Census: 154
Capacity: 154
Deficiencies: 0
Aug 22, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00415373 and IN00415418.
Findings
No deficiencies related to the allegations in complaints IN00415373 and IN00415418 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00415373 and Complaint IN00415418 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 154
Census Payor Type - Medicare: 17
Census Payor Type - Medicaid: 101
Census Payor Type - Other: 36
Inspection Report
Complaint Investigation
Census: 157
Capacity: 157
Deficiencies: 3
Aug 1, 2023
Visit Reason
The visit was conducted for the investigation of multiple complaints (IN00410491, IN00410779, IN00411368, IN00413116, IN00413213, and IN00414409) regarding the facility's compliance with federal and state regulations.
Findings
The investigation found federal/state deficiencies related to complaints IN00410491 and IN00413116, specifically regarding wound assessment documentation and pharmacy services. Other complaints had no deficiencies cited. Additional unrelated deficiencies were also cited, including issues with infection prevention and control practices during medication administration.
Complaint Details
Complaint IN00410491 had federal/state deficiencies related to medication availability. Complaint IN00413116 had federal/state deficiencies related to wound assessment documentation. Other complaints had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure initial wound assessment documentation was completed timely for 2 of 3 residents reviewed for wound documentation. | SS=D |
| Failed to ensure medications were available from the pharmacy for administration for 2 of 3 residents reviewed. | SS=D |
| Failed to ensure proper hand hygiene and equipment sanitation during medication administration for 3 of 4 residents observed. | SS=D |
Report Facts
Census: 157
Total Capacity: 157
Medicare Census: 14
Medicaid Census: 108
Other Payor Census: 35
Survey Dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zachary Wilson | Administrator/CEO | Signed the report |
| Licensed Practical Nurse 7 | LPN | Observed failing to sanitize hands and equipment during medication administration |
| Licensed Practical Nurse 9 | LPN | Interviewed regarding medication reordering and pharmacy communication |
| Licensed Practical Nurse 5 | LPN | Interviewed regarding pharmacy delivery and medication ordering procedures |
| Regional Director of Clinical Operations | Interviewed regarding wound assessment documentation and pharmacy service issues | |
| Director of Nursing | DON | Interviewed and involved in corrective action plans for wound care and medication availability |
| Signature Care Consultant | SCC | Involved in corrective action plans and education for wound care and medication availability |
| Staff Development Coordinator | SDC | Provided education and competency validation for nursing staff |
| Unit Manager | UM | Involved in corrective action plans and audits |
| Vice President of Clinical Operations | VP of Clinical Operations | Provided education and oversight for wound care and medication availability corrective actions |
| Corporate Consultant | Provided policy documents and interviewed regarding infection control and medication administration |
Inspection Report
Complaint Investigation
Census: 150
Capacity: 150
Deficiencies: 1
Jun 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00410070 and IN00410114. Complaint IN00410070 resulted in federal/state deficiencies being cited, while Complaint IN00410114 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a resident (Resident C) was assessed during a significant decline, resulting in delayed treatment before transfer to acute care for acute respiratory distress and sepsis. The deficiency was corrected prior to the survey start date. The facility implemented systemic corrective actions including nursing assessments for changes in condition, staff education, and ongoing monitoring.
Complaint Details
Complaint IN00410070 was substantiated with federal/state deficiencies cited. Complaint IN00410114 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess a resident during significant decline resulting in delayed treatment and transfer to acute care for acute respiratory distress and sepsis. | SS=G |
Report Facts
Census: 150
Total Capacity: 150
Medicare Census: 12
Medicaid Census: 103
Other Payor Census: 35
Lactic Acid Level: 3.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of documentation during resident's decline |
Inspection Report
Follow-Up
Census: 139
Capacity: 139
Deficiencies: 0
May 25, 2023
Visit Reason
This visit was for the Post Survey Revisit to the Investigation of Complaint IN00399290 completed on February 28, 2023, in conjunction with the Investigation of Complaints IN00408044 and IN00409041, and the Post Survey Revisit to the Investigation of Complaint IN00407412 completed on May 01, 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 Post Survey Revisit to the Investigation of Complaint IN00399290. Complaints IN00399290 and IN00407412 were corrected, and no deficiencies related to allegations were cited for complaints IN00408044 and IN00409041.
Complaint Details
Complaint IN00399290 - Corrected. Complaint IN00408044 - No deficiencies related to the allegation are cited. Complaint IN00409041 - No deficiencies related to the allegation are cited. Complaint IN00407412 - Corrected.
Report Facts
Census SNF/NF: 139
Total Capacity: 139
Medicare Census: 10
Medicaid Census: 103
Other Payor Census: 26
Inspection Report
Complaint Investigation
Census: 139
Capacity: 139
Deficiencies: 0
May 25, 2023
Visit Reason
This visit was for the investigation of complaints IN00408044 and IN00409041, in conjunction with post survey revisits to the investigations of complaints IN00399290 and IN00407412.
Findings
No deficiencies related to complaints IN00408044 and IN00409041 were cited. Complaints IN00399290 and IN00407412 were found to be corrected. The facility was found to be in compliance with 42 CFR Part 483 and applicable state regulations.
Complaint Details
Complaint IN00408044 - No deficiencies related to the allegation are cited. Complaint IN00409041 - No deficiencies related to the allegation are cited. Complaint IN00399290 - Corrected. Complaint IN00407412 - Corrected.
Report Facts
Census Bed Type: 139
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 103
Census Payor Type - Other: 26
Inspection Report
Follow-Up
Census: 139
Capacity: 139
Deficiencies: 0
May 25, 2023
Visit Reason
This visit was for the Post Survey Revisit to the Investigation of Complaint IN00407412 completed on May 01, 2023, in conjunction with the Investigation of Complaints IN00408044 and IN00409041, and the Post Survey Revisit to the Investigation of Complaint IN00399290 completed on February 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 Post Survey Revisit to the Investigation of Complaint IN00407412. Complaints IN00407412 and IN00399290 were corrected, and no deficiencies related to allegations were cited for complaints IN00408044 and IN00409041.
Complaint Details
This visit was related to multiple complaints: IN00407412 (corrected), IN00408044 (no deficiencies cited), IN00409041 (no deficiencies cited), and IN00399290 (corrected).
Report Facts
Survey dates: May 23, 24, and 25, 2023
Census SNF/NF: 139
Total licensed capacity: 139
Medicare census: 10
Medicaid census: 103
Other payor census: 26
Inspection Report
Complaint Investigation
Census: 151
Capacity: 151
Deficiencies: 1
May 1, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00404558, IN00404669, IN00405343, IN00404730, and IN00407412) at Signature Healthcare of Terre Haute. The investigation included a Partially Extended Survey due to Substandard Quality of Care with Immediate Jeopardy.
Findings
The facility failed to ensure thorough assessment and timely hospital transfer for a resident (Resident O) with a change of condition, resulting in immediate jeopardy. Resident O was found in distress on 4/21/23 but was not promptly assessed or transferred, leading to septic shock, hospitalization, intubation, and death within 24 hours. The immediate jeopardy was removed after the facility implemented extensive staff education and monitoring protocols.
Complaint Details
Complaint IN00407412 was substantiated with Federal/State deficiencies cited at F684 related to the allegations. Other complaints (IN00404558, IN00404669, IN00405343, IN00404730) had no deficiencies related to the allegations.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure thorough assessment and timely hospital transfer for a resident with a change of condition (Resident O). | SS=J |
Report Facts
Census: 151
Medicare residents: 11
Medicaid residents: 110
Other residents: 30
White Blood Count: 32.7
Hemoglobin: 18.2
Potassium: 5.6
Blood Urea Nitrogen: 126
Glasgow Coma Scale: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathryn Bailey | RN VPCO | Signed the report |
| LPN 11 | Agency nurse who failed to assess Resident O adequately | |
| LPN 12 | Nurse who attempted to assess Resident O and contacted family via text | |
| CNA 9 | Certified Nurse Aide who observed Resident O in distress and notified nursing staff | |
| CNA 10 | Certified Nurse Aide who observed Resident O in distress and notified nursing staff | |
| Vice President of Clinical Operations | VPCO | Provided investigation details and education |
| Unit Manager 4 | Provided information on emergency procedures |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 143
Deficiencies: 0
Mar 21, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403633 and IN00404009.
Findings
No deficiencies related to the allegations in complaints IN00403633 and IN00404009 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00403633 and IN00404009 found no deficiencies related to the allegations.
Report Facts
Census: 143
Total Capacity: 143
Medicare Census: 14
Medicaid Census: 100
Other Payor Census: 29
Inspection Report
Complaint Investigation
Census: 146
Capacity: 146
Deficiencies: 2
Feb 27, 2023
Visit Reason
This visit was for the investigation of complaints IN00398927, IN00399290, IN00400941, and IN00401546 at Signature Healthcare of Terre Haute.
Findings
The facility was found deficient related to complaint IN00399290 involving failure to notify a resident and family of a room change and failure to promptly implement physician-prescribed treatment for stage 4 pressure ulcers for one resident. Other complaints had no deficiencies cited. The facility provided a plan of correction including audits, education, and QAPI meetings.
Complaint Details
Complaint IN00399290 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer treatment delays. Complaints IN00398927, IN00400941, and IN00401546 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify resident and resident representative of a room change as required by facility policy for 1 of 7 residents reviewed (Resident G). | SS=D |
| Failure to promptly implement physician prescribed treatment to promote healing of stage 4 pressure ulcers for 1 of 4 residents reviewed (Resident H). | SS=D |
Report Facts
Census: 146
Total Capacity: 146
Medicare Census: 14
Medicaid Census: 96
Other Payor Census: 36
Inspection Report
Re-Inspection
Census: 147
Capacity: 176
Deficiencies: 0
Feb 1, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the investigation of Complaint Number IN00398367 to verify compliance with previous deficiencies.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Complaint Details
Investigation of Complaint Number IN00398367 conducted on 12/28/22; this PSR survey was to verify compliance.
Report Facts
Facility capacity: 176
Census: 147
Inspection Report
Complaint Investigation
Census: 137
Capacity: 176
Deficiencies: 1
Dec 28, 2022
Visit Reason
An investigation of Complaint Number IN00398367 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The complaint was substantiated but no deficiencies related to the allegation were cited.
Findings
The facility was found not in compliance with Requirements for Participation in Medicare/Medicaid and Life Safety Code related to the sprinkler system impairment policy. Specifically, the facility failed to provide a correct written policy for when the automatic sprinkler system is out of service for 10 hours or more in a 24-hour period, including proper notification procedures to the Indiana Department of Health via the ISDH Gateway.
Complaint Details
Complaint Number IN00398367 was substantiated. No deficiencies related to the allegation were cited.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide 1 of 1 correct written policy in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5 and NFPA 25. | SS=F |
Report Facts
Residents present: 137
Total licensed capacity: 176
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Israel Ray | Administrator | Named in relation to the inspection and findings |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 137
Deficiencies: 1
Dec 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00397747, which was substantiated with state deficiencies cited related to the allegations.
Findings
The facility failed to timely report a fire system disablement caused by busted water pipes, which directly threatened the welfare and safety of all 137 residents. The water was shut off and the fire system disabled on 12/24/22, but the Administrator did not report the incident to the Indiana Department of Health within the required timeframe due to lost access to the reporting system and other issues. The facility implemented emergency procedures to maintain resident care during the water outage.
Complaint Details
Complaint IN00397747 was substantiated. The facility failed to report the fire system disablement and water outage to the Indiana Department of Health within the required 24-hour timeframe, violating state reporting requirements.
Deficiencies (1)
| Description |
|---|
| Failure to timely report when the fire system was disabled due to busted water pipes, threatening the welfare and safety of residents. |
Report Facts
Residents affected: 137
Water jugs observed: 7
Water shut off date: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Israel Ray | Administrator | Named in relation to failure to report the incident to the Indiana Department of Health |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 141
Deficiencies: 0
Nov 29, 2022
Visit Reason
This visit was conducted to investigate Complaints IN00394993 and IN00395120 at Signature Healthcare of Terre Haute.
Findings
Both complaints were found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00394993 - Unsubstantiated due to lack of evidence. Complaint IN00395120 - Unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF beds: 141
Census total residents: 141
Census Medicare residents: 11
Census Medicaid residents: 94
Census other payor residents: 36
Inspection Report
Re-Inspection
Census: 127
Capacity: 176
Deficiencies: 0
Nov 9, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/14/22 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Signature Health Care of Terre Haute was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 176
Census: 127
Inspection Report
Follow-Up
Census: 128
Capacity: 128
Deficiencies: 0
Nov 2, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 16, 2022, including a PSR to multiple complaint investigations completed on September 16, 2022.
Findings
Signature Healthcare of Terre Haute 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 Recertification and State Licensure Survey. Several complaints were corrected, some were substantiated with no deficiencies cited, and others were unsubstantiated due to lack of sufficient evidence.
Complaint Details
The visit included investigations of multiple complaints: IN00387111, IN00387223, IN00387963, IN00388533, IN00390644 were corrected; IN00391316 and IN00392793 were substantiated with no deficiencies cited; IN00391840, IN00391875, and IN00393745 were unsubstantiated due to lack of sufficient evidence.
Report Facts
Census SNF/NF: 128
Total Census: 128
Medicare Census: 9
Medicaid Census: 92
Other Payor Census: 27
Inspection Report
Complaint Investigation
Census: 128
Capacity: 128
Deficiencies: 0
Nov 2, 2022
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00391316, IN00391840, IN00391875, IN00392793, and IN00393745) and included a Post Revisit Survey to the Recertification and State Licensure Survey completed on September 16, 2022.
Findings
The facility was found to be in compliance with relevant regulations regarding the investigated complaints. Some complaints were substantiated but no deficiencies were cited, while others were unsubstantiated due to lack of evidence. Previously cited complaints were corrected.
Complaint Details
Complaint IN00391316 was substantiated with no deficiencies cited. Complaints IN00391840, IN00391875, and IN00393745 were unsubstantiated due to lack of sufficient evidence. Complaint IN00392793 was substantiated with no deficiencies cited. Complaints IN00387111, IN00387223, IN00387963, IN00388533, and IN00390644 were corrected.
Report Facts
Census SNF/NF: 128
Total Capacity: 128
Medicare Census: 9
Medicaid Census: 92
Other Payor Census: 27
Inspection Report
Life Safety
Census: 129
Capacity: 176
Deficiencies: 7
Oct 14, 2022
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related NFPA standards.
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code. Deficiencies included undercharged fire extinguishers, corridor doors that did not latch properly, obstructed smoke barrier doors, missing fire drills documentation, smoking policy enforcement issues, incomplete generator maintenance records, and improper use of extension cords.
Severity Breakdown
SS=E: 2
SS=D: 2
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of at least 5 portable ABC fire extinguishers had pressure gauge readings in the acceptable range. | SS=E |
| Failed to ensure 1 of over 30 resident room corridor doors had a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. | SS=D |
| Failed to ensure 1 of 11 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes due to obstruction. | SS=E |
| Failed to conduct quarterly fire drills for 2 of 4 quarters affecting all staff and residents. | SS=F |
| Failed to enforce smoking policies; cigarette butts found outside non-designated smoking area. | SS=F |
| Failed to maintain written records of weekly generator inspections for 10 of 52 weeks and monthly generator load testing for 4 of 12 months. | SS=F |
| Failed to ensure flexible cords were not used as a substitute for fixed wiring; extension cord and multi-plug adapter used in resident room. | SS=D |
Report Facts
Certified beds: 176
Census: 129
Fire drills missing: 2
Weeks missing generator inspection records: 10
Months missing generator load testing records: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Diaz | CEO | Signed the report |
| Plant Operations Director | Interviewed and involved in observations related to fire extinguishers, doors, smoke barriers, fire drills, smoking policy, generator maintenance, and extension cord use | |
| Maintenance Assistant | Performed corrective actions and audits related to fire extinguishers, doors, smoke barriers, smoking policy, generator maintenance, and extension cords | |
| Facility Administrator | Provided staff in-servicing and monitoring related to fire drills and smoking policy | |
| Regional Director of Maintenance | Educated Maintenance Assistant and interdisciplinary team on door latching, smoke barrier doors, and extension cords |
Inspection Report
Recertification
Census: 136
Capacity: 136
Deficiencies: 16
Sep 8, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of multiple complaints.
Findings
The facility was cited for multiple deficiencies including failure to maintain resident dignity, honor hospice and pharmacy choices, ensure resident rights and care plan meetings, provide adequate staffing, ensure proper transfer documentation, maintain food safety and sanitation, and ensure proper medication management including psychotropic drug use and catheter care.
Complaint Details
This visit included the investigation of complaints IN00388994 (unsubstantiated), IN00387111, IN00387223, IN00387963, IN00388533, and IN00390644 (all substantiated with related deficiencies cited).
Severity Breakdown
D: 7
E: 7
G: 2
Deficiencies (16)
| Description | Severity |
|---|---|
| Resident dignity was compromised by posting an NPO sign on a resident's door. | D |
| Facility failed to honor resident hospice choice resulting in psychosocial harm. | G |
| Facility failed to honor pharmacy and personal care preferences for some residents. | G |
| Facility failed to ensure resident rights and concerns expressed in resident council were addressed. | E |
| Facility failed to communicate with receiving hospitals during resident transfers and failed to provide transfer documentation. | E |
| Facility failed to provide timely and proper notice of transfer/discharge and failed to notify Ombudsman. | E |
| Facility failed to provide bed hold policy to residents or representatives at time of hospital transfer. | E |
| Facility failed to conduct quarterly care plan meetings for some residents. | D |
| Facility failed to provide adequate activities of daily living (ADL) care to dependent residents. | E |
| Facility failed to ensure catheter tubing was kept off the floor and appropriate peri-care was provided. | D |
| Facility failed to assess and monitor residents with significant weight loss. | D |
| Facility failed to maintain sufficient nursing staff to meet resident care needs. | E |
| Facility failed to designate a Dementia Care Director as required for a certified Special Care Unit and failed to develop resident specific dementia care plans. | E |
| Facility failed to follow up on pharmacy recommendations and failed to monitor psychotropic medication use including PRN orders. | D |
| Facility failed to date multi-dose medication vials upon opening. | D |
| Facility kitchen and food storage areas were unsanitary and ice machine drains lacked proper air gap to prevent back siphonage. | E |
Report Facts
Deficiencies cited: 18
Residents present: 136
Staffing levels: 2.2
Weight loss: 16
PRN lorazepam administrations: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings related to resident care, transfer documentation, and medication management. |
| Chief Executive Officer | Chief Executive Officer | Provided policy documents and interviews regarding facility operations and QAPI. |
| Regional Vice President | Regional Vice President | Provided interview regarding dementia care unit oversight and facility policies. |
| Dietary Services Director | Dietary Services Director | Named in findings related to kitchen sanitation and food safety. |
| Unit Manager 19 | Unit Manager | Named in observation and interview regarding medication storage and infection control. |
| Certified Nursing Assistant 12 | Certified Nursing Assistant | Observed providing peri-care with improper glove use. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Observed and commented on peri-care practices. |
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