Signature Healthcare of Muncie: Wound Care Gaps - IN
Inspectors cited the facility on October 1, 2025, after reviewing the resident's clinical record and interviewing staff. What they found was a pattern of gaps that the facility's own director of nursing confirmed, one by one, on the day of the inspection.
The director of nursing told inspectors she could not locate wound measurements for the right elbow pressure injury in the electronic record beyond what was taken on admission. She could not locate measurements for the other pressure injuries either. She could not find a specific treatment order for the right elbow wound. She could not find a specific order for the coccyx injury.
Three things she could not find. All in the same resident's chart.
The right elbow wound was classified as a stage 2 pressure injury. The facility's approach was to leave it open to air and rely on turning and repositioning. The resident had a private caregiver who kept them repositioned and propped with pillows, and the facility had ordered a pressure-relieving mattress. But there was no physician's order directing a specific treatment for the wound itself.
For the coccyx injury, nursing aides routinely applied moisture barrier cream during incontinence care. The director of nursing noted that this type of application was not typically ordered by a physician. No specific treatment order existed for that wound either.
The resident's heels were a separate matter. Both were documented as deep tissue injuries, and heel protectors were the treatment being used. The director of nursing confirmed this was the approach for the right and left heel wounds.
Weekly skin assessments were conducted on September 9, September 16, and September 23. Each one was signed off with the notation "existing skin impairment." The special instructions field on the treatment administration record directed staff to open an appropriate event for newly identified skin issues. No additional documentation appeared beyond that. The assessments were completed. The box was checked. The wounds continued.
A care plan addressing the pressure injuries was not put into place until September 25, more than three weeks into what the record reflects as an ongoing wound situation. Before that date, the only care plan entries were those listed in the initial baseline plan completed at admission.
The facility's own skin integrity policy, revised as recently as January 31, 2025, spelled out what was supposed to happen. Licensed nurses were to complete a skin check at admission and obtain physician orders for any area of impaired skin integrity. The wound nurse practitioner was to document all impaired skin integrity areas in the electronic medical record on an ongoing basis until the wounds closed or the resident was discharged.
A registered nurse interviewed by inspectors that morning described the standard process: pressure injuries were measured and entered into a skin event in the system, and if a pressure injury had no treatment order, the director of nursing and the nurse practitioner were to be informed so an order could be obtained. The wound nurse practitioner assessed pressure injuries weekly and evaluated the skin of all new admissions.
That process, as described, did not produce measurements in the electronic record for this resident's wounds. It did not produce treatment orders for the elbow or the coccyx. It did not produce a care plan until the final week of September.
The citation was tagged at a level of minimal harm or potential for actual harm, affecting a few residents. It was tied to a complaint investigation.
The resident had people looking after them. A private caregiver kept them repositioned. The mattress was in place. The aides applied cream during incontinence care. But the documentation that would show a facility actively monitoring, measuring, and directing treatment for known open wounds was not there. And when inspectors asked the director of nursing where it was, she could not find it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Muncie from 2025-10-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
SIGNATURE HEALTHCARE OF MUNCIE in MUNCIE, IN was cited for violations during a health inspection on October 1, 2025.
Inspectors cited the facility on October 1, 2025, after reviewing the resident's clinical record and interviewing staff.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.