MUNCIE, IN - Federal inspectors found that Signature Healthcare of Muncie failed to properly implement infection prevention and control programs, placing residents at risk of exposure to dangerous pathogens including a drug-resistant fungal infection. The January 2025 inspection also revealed that life-saving equipment was not maintained in working condition during a medical emergency.
Infection Control Failures Put Vulnerable Residents at Risk
The most significant violations centered on the facility's inadequate implementation of Enhanced Barrier Precautions (EBP), a critical infection control measure designed to prevent the spread of multidrug-resistant organisms and other dangerous pathogens among nursing home residents.
Inspectors documented serious deficiencies in the care of a resident who had tested positive for Candida auris, a potentially deadly fungal infection that is resistant to multiple antifungal medications. This organism is considered a serious global health threat by the Centers for Disease Control and Prevention because it spreads easily in healthcare settings and can cause severe infections with high mortality rates.
The resident had been placed on Enhanced Barrier Precautions since March 2024, yet facility staff demonstrated confusion about proper protocols nearly a year later. During the inspection, nursing staff were observed providing care without appropriate personal protective equipment. A certified nursing assistant was seen assisting the resident with bathroom care, removing gloves, then using bare hands to push the resident's wheelchair and help with shoes without completing proper hand hygiene or wearing required protective equipment.
When questioned, the nursing assistant stated she believed protective equipment was only necessary when the resident had a visible skin rash, demonstrating a fundamental misunderstanding of infection control principles for drug-resistant organisms. This type of pathogen can be transmitted even when symptoms are not visible, making consistent protective measures essential.
Medical Significance of Candida auris Infections
Candida auris represents one of the most serious emerging threats in healthcare settings. Unlike common yeast infections, this organism is often resistant to multiple classes of antifungal medications, making treatment extremely difficult. The fungus can survive on surfaces for weeks and spreads rapidly between patients, particularly in nursing homes where residents have compromised immune systems and require frequent personal care.
The CDC estimates that more than 1 in 3 patients with invasive Candida auris infections die, though death is often due to other serious underlying conditions rather than the infection itself. However, the organism can cause serious bloodstream, wound, and ear infections that significantly complicate medical care and recovery.
For nursing home residents, who often have multiple chronic conditions and weakened immune systems, exposure to Candida auris can be particularly dangerous. The organism can colonize the skin without causing immediate symptoms, allowing infected individuals to unknowingly spread it to others through contaminated hands, equipment, or surfaces.
Confusion Over Precaution Requirements
The inspection revealed systemic confusion about infection control requirements that persisted for months. The affected resident's door displayed conflicting signage, including general stop signs and protective equipment instructions, but lacked clear information about the specific type of precautions required or when staff needed to use protective equipment.
Multiple signs were eventually posted on the resident's door, creating further confusion among staff about which protocols to follow. Different nursing staff provided contradictory information about the resident's status, with some believing precautions were only necessary during active symptoms and others uncertain about requirements altogether.
The facility's Infection Preventionist acknowledged that the resident should not have had conflicting orders for both isolation and Enhanced Barrier Precautions, indicating systematic problems with infection control protocols. The preventionist also revealed she had been seeking clarification from corporate staff about which residents required Enhanced Barrier Precautions but had not reached out to state health department specialists for guidance.
Inadequate Wound Care Protocols
A second resident with a stage 3 pressure ulcer also received inadequate infection control measures. Despite having a chronic wound requiring daily care with specialized vacuum therapy, the resident's room initially lacked any signage indicating Enhanced Barrier Precautions were needed.
Nursing staff were observed providing wound care wearing only gloves, without the gowns required for high-contact care activities involving wounds. The staff member was seen leaning against the resident's bed linens with her clothing during wound assessment, creating additional contamination risks.
According to federal guidelines, any resident with chronic wounds requires Enhanced Barrier Precautions regardless of whether drug-resistant organisms have been identified. Wounds provide direct access for pathogens to enter the bloodstream and can serve as reservoirs for dangerous bacteria and fungi that can spread to other residents.
The resident reported that "staff placed a new sign on her door" during the inspection period, indicating that proper precautions were only implemented after inspectors arrived, despite the wound existing for months prior.
Life-Saving Equipment Failure During Emergency
In a separate but equally serious violation, the facility's automated external defibrillator (AED) failed to function during a cardiac arrest emergency. When staff attempted to use the device during CPR efforts on a resident, "the AED would not turn on" due to a dead battery.
The Unit Manager who responded to the emergency reported that "she opened the AED, pulled out the cartridges and attached the pads to the residents chest. She pressed the power button and the AED would not turn on." CPR continued until emergency medical services arrived, but the equipment failure represented a critical gap in emergency response capabilities.
AEDs are designed to analyze heart rhythms during cardiac arrest and deliver electrical shocks when appropriate, significantly improving survival chances when used quickly. The devices perform daily self-tests and display clear visual indicators when batteries need replacement or other maintenance is required.
Investigation revealed that while maintenance staff ordered replacement batteries every six months, the facility lacked formal policies or procedures for AED maintenance and monitoring. No staff member was specifically assigned responsibility for ensuring the device remained operational, and the facility had no inspection log or maintenance documentation system.
Systemic Training and Policy Deficiencies
The violations revealed broader systemic issues with infection control training and policy implementation. Staff reported receiving updated training about Enhanced Barrier Precautions only during the inspection period, nearly a year after some residents had been placed on these precautions.
A certified nursing assistant indicated that prior to January 21, 2025, "staff were only required to wear gloves in the resident's room during high contact care because EBP were not in place at that time." This statement demonstrates that proper infection control measures were not being implemented despite physician orders and clinical indications.
The facility's own policies clearly stated that Enhanced Barrier Precautions are indicated for residents with chronic wounds and indwelling devices regardless of whether drug-resistant organisms have been identified. However, implementation of these policies was inconsistent and inadequate.
Additional Issues Identified
Beyond the major infection control and equipment failures, inspectors identified other concerning issues. The facility's Care Guide reference document used by nursing assistants lacked information about which residents required Enhanced Barrier Precautions, creating gaps in communication about essential safety protocols.
Documentation revealed that some residents had conflicting physician orders for different types of isolation precautions, adding to staff confusion about proper procedures. The facility's infection control program lacked clear communication channels with state health department specialists who could provide guidance on complex cases.
Equipment storage and availability also posed challenges, with personal protective equipment not readily accessible in resident rooms where Enhanced Barrier Precautions were required, potentially discouraging consistent compliance with safety protocols.
These violations represent serious departures from accepted standards of care that put vulnerable nursing home residents at unnecessary risk of infection and inadequate emergency response. Proper infection control and equipment maintenance are fundamental responsibilities that require systematic policies, adequate training, and consistent oversight to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Muncie from 2025-01-23 including all violations, facility responses, and corrective action plans.
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