Inspection Reports for
Signature Healthcare of Terre Haute

The complaint investigation was related to Intake 2641934 concerning failure to develop a baseline care plan and complete admission assessments for Resident B. The complaint was substantiated based on record review and interviews.

The facility failed to timely develop and implement a baseline care plan and complete nursing admission assessments, including vital signs, skin assessment, catheter assessment, and medication orders for one resident. Documentation was missing or delayed, and the resident was sent to an acute care hospital due to respiratory distress shortly after admission.

The facility failed to promptly revise the comprehensive care plan for a resident who lost smoking privileges after a behavioral incident. The resident's care plan and profile were not updated to reflect the revocation of smoking privileges as required.

The facility had deficiencies in informed consent for psychotropic medications, failure to notify physicians of elevated blood sugars, inaccurate Minimum Data Set (MDS) assessments, inadequate fall prevention interventions, unsafe transport practices on the facility bus, incomplete pharmacy medication reviews, medication administration errors, and lapses in infection control practices.

This citation relates to Complaint 1385466 and was substantiated based on observation and interview.

A dietary staff member was observed failing to wear gloves while handling sandwich bread during food preparation, which posed a potential risk to residents. The sandwiches prepared without gloves were discarded, and facility policy requires proper hand hygiene and glove use.

This citation relates to Complaint IN00460686. The complaint involved failure to administer scheduled comfort medications as ordered, which was substantiated by record review and interviews.

The facility failed to administer scheduled doses of comfort medication per physician orders for one resident, Resident B, without proper nursing assessment or physician notification. The deficient practice was corrected prior to the survey start date.

This visit was related to the investigation of three complaints: IN00458972 (corrected), IN00459393 (no deficiencies cited), and IN00460686 (deficiencies cited at F760).

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 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.

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.

This investigation relates to Complaint IN00458972. The complaint involved allegations of resident-to-resident abuse resulting in injury and death of Resident F. The facility initially did not report the incident as abuse due to family member statements and internal decisions. Police and Attorney General's office became involved, and an investigation was conducted. Resident J had a history of aggressive behaviors and prior altercations. The facility failed to implement adequate monitoring and interventions.

The facility failed to timely report an allegation of suspected resident-to-resident abuse and failed to implement appropriate interventions for a dementia resident with known aggressive behaviors. Resident J wandered into Resident F's room unsupervised, causing injuries to Resident F including a clavicle fracture and subdural hematoma. Resident F was found on the floor with injuries and later died. The facility did not update care plans to address Resident J's behaviors adequately and allowed Resident J to wander freely on the secured memory care unit.

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.

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.

The complaint alleged the facility failed to provide a 30-day notice of discharge and failed to ensure a safe discharge for Resident B, who had significant clinical needs and payor source issues. The resident was discharged to a motel despite safety concerns and lack of home health care acceptance. The resident and family were not properly informed or educated about discharge plans or appeal rights.

The facility failed to issue a 30-day notice of discharge prior to a planned discharge for one resident and failed to plan for and ensure the resident was prepared for a safe discharge, including education and arrangements for catheter care, oxygen use, and wound care. The resident was discharged to a motel despite safety concerns and lack of home health care acceptance.

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.

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.

The investigation was triggered by complaints IN00454858 and IN00454449 regarding verbal abuse of Resident E by a contract nurse. The abuse was substantiated, and the nurse was removed from the facility. The facility initially reported the abuse inaccurately but corrected the report after investigation.

The facility failed to protect Resident E from verbal abuse by a contract nurse who used derogatory language. The incident was substantiated, the nurse was removed, and the facility implemented corrective actions including staff education and ongoing monitoring. Additionally, the facility initially failed to accurately report the incident to the Indiana Department of Health but corrected this after investigation.

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.

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.

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.

Complaint IN00449795 was investigated with no deficiencies related to the allegations cited.

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.

The facility was found deficient in multiple areas including medication administration and physician notification, transfer/discharge documentation, pressure ulcer care, hydration, respiratory care, psychotropic medication monitoring, and medication storage and labeling.

This inspection relates to Complaint IN00446733 regarding post-fall assessment failures and Complaint IN00446006 regarding failure to assist with transportation.

The facility failed to ensure post-fall assessments including skin assessment, vital signs, and pain assessment were completed for 72 hours post-fall for one resident. The facility also failed to assist one resident with transportation to a scheduled physician appointment, resulting in missed appointments and hospital transfer.

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.

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.

This citation relates to Complaint IN00443846. The complaint involved allegations of sexual abuse between two cognitively impaired residents, Resident B and Resident C, occurring on 9/22/2024. The facility initially failed to report the incident timely and failed to properly investigate and document the abuse and interventions.

The facility failed to protect residents from sexual abuse by another resident, resulting in an Immediate Jeopardy that was removed after systemic corrective actions. The facility also failed to timely report and properly investigate the abuse allegations, and failed to document interventions and family notifications adequately.

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.

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.

This citation relates to Complaint IN00438294.

The facility failed to implement personalized, person-centered care and interventions to prevent repeated resident-to-resident altercations involving Resident F and other cognitively impaired residents. Multiple incidents were documented without adequate follow-up interventions or care plan updates to prevent further events.

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.

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.

The inspection relates to complaints IN00431251 and IN00426829 concerning respiratory care and medication administration issues.

The facility failed to ensure proper respiratory care by not dating, timing, and signing oxygen nebulizer equipment for one resident. Additionally, the facility failed to administer medications per physician orders and did not notify the physician when medications were unavailable for another resident.

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.

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.

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.

The inspection relates to complaints IN00417987, IN00421358, and IN00420745 concerning resident shower preferences, elopement risk, and food service hygiene respectively. The elopement incident was substantiated and corrected prior to the survey.

The facility was found deficient in honoring resident shower preferences, preventing resident elopement, and ensuring proper sanitation of dishware and hand hygiene during resident feeding. Deficiencies were cited with minimal harm and affected few to some residents.

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.

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.

This inspection relates to multiple complaints including IN00417987, IN00421358, IN00420745, and IN00420145. Complaints involved issues such as failure to provide resident choice, pressure ulcer care, elopement, catheter care, respiratory care, medication management, food service, sanitation, and environmental safety.

The facility was found deficient in multiple areas including failure to honor resident choice for bathing, incomplete care planning, immediate jeopardy related to pressure ulcer prevention and treatment, failure to prevent elopement, improper catheter care, improper oxygen tubing handling, medication storage and labeling issues, inadequate food temperature and palatability, poor sanitation of dishware and failure to perform hand hygiene during feeding, and failure to maintain a safe and comfortable environment for residents.

This Federal tag relates to Complaint IN00413116 for wound care and Complaint IN00410491 for pharmacy services.

The facility failed to ensure timely wound assessment documentation for residents with pressure ulcers and failed to ensure medications were consistently available for administration. Additionally, improper hand hygiene and equipment sanitation were observed during medication administration.

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.

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.

This Federal tag relates to Complaint IN00410070. The complaint was substantiated as the facility failed to assess and respond to a resident's change in condition, resulting in actual harm.

The facility failed to ensure timely assessment and treatment of Resident C who experienced a significant decline resulting in unresponsiveness and transfer to acute care with diagnoses of acute respiratory distress and sepsis. The deficiency was corrected prior to the survey by implementing systemic changes including staff education and monitoring.

Complaint IN00410070 was substantiated with federal/state deficiencies cited. Complaint IN00410114 was not substantiated with no deficiencies cited.

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.

This Federal tag is related to Complaint IN00407412. The complaint involved failure to assess and timely transfer a resident with a change of condition, resulting in death.

The facility failed to ensure a thorough assessment and timely hospital transfer for a resident with a change of condition, resulting in immediate jeopardy to resident health and safety. The resident was found in distress, not properly assessed by nursing staff, and was eventually sent to the hospital where she died within 24 hours. The immediate jeopardy was removed after education and corrective actions, but noncompliance remained at a lower severity level.

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.

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 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.

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 Number IN00398367 was substantiated. No deficiencies related to the allegation were cited.

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 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.

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.

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.

This visit included the investigation of complaints IN00388994 (unsubstantiated), IN00387111, IN00387223, IN00387963, IN00388533, and IN00390644 (all substantiated with related deficiencies cited).

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.