Signature Healthcare Of Bremen

Based on interview and record review, the facility failed to ensure a care plan related to food allergies was followed for 1 of 3 residents reviewed for dietary needs. (Resident B)Finding includes:On 10/8/25 at 12:12 P.M., Resident B's clinical record was reviewed.

Diagnoses included but were not limited to dementia, feeding difficulties, stroke, gastro-esophageal reflux, chronic obstructive pulmonary disease, anxiety, and atrial fibrillation.Resident B's most recent Face Sheet, dated 10/4/25, indicated the resident had an allergy to Tomatoes.

Physician's orders included but were not limited to, a dietary order dated 2/28/25, that indicated the resident was allergic to tomatoes.Resident B's Care Plans included but were not limited to,1.

Resident B had cognitive loss and dementia with impaired decision-making skills, dated 7/18/23. 2.

Resident had an allergy to tomato, dated 2/20/24, and indicated the resident would not be served tomato at meals. 3.

Resident B was at nutritional risk due to dementia, dated 7/26/23, and indicated the facility would provide his diet as ordered, and notify the physician as needed. A Nursing Progress Notes, dated 8/22/25 at 7:11 P.M., indicated Resident B was accidentally given tomato ketchup for his hotdog sandwich.On 8/24/25 a Grievance Report was filed by Resident B's family member that indicated the resident had received ketchup on his hotdog and that he was allergic to the ketchup.

The grievance investigation by the facility indicated the resident was given ketchup, and that the ketchup came out of the kitchen on the resident's tray.Review of a written statement from CNA (Certified Nursing Assistant) 5, dated 8/24/25, indicated CNA 5 took Resident B his dinner tray and asked if he wanted ketchup and mustard n his hot dog and the resident indicated he did. CNA 5 gave him a few bites of the hotdog with ketchup and then noted his meal ticket indicated an allergy to tomatoes.On 10/10/25 at 1:07 P.M., the Administrator provided the policy titled, Comprehensive Care Plans, dated 4/6/15 and revised on 2/9/24, indicating it was the facilities current policy.

The policy indicated, .The facility will. implement a comprehensive person-centered care plan for each resident This citation relates to Intake 2633300.3.1-35(a)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Bremen

316 Woodies Lane Bremen, IN 46506

SUMMARY STATEMENT OF DEFICIENCIES