Signature Healthcare Of Muncie

F-F880. potential for actual harm 3.1-52(b)(2) Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 155242 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155242 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Muncie 4301 N Walnut St Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 09676 potential for actual harm Based on observation, interview, and record review, the facility failed to develop and implement an infection Residents Affected - Few control program which provided Enhanced Barrier Precautions (EBP) and/or isolation services in order to eliminate or reduce the risk of spread of contagions for 2 of 5 residents reviewed for infection prevention. (Residents 66 and 86)

Findings include:

1. During an observation on 1/15/25 at 11:39 a.m., Resident 66's door had two signs posted. The first sign was a red stop sign posted on pink paper. The second sign was instructions regarding how to correctly apply PPE (personal protective equipment). The door signs did not contain direction regarding what type of isolation the resident was under, what was required to enter the room, when a staff or visitor needed to wear P.P.E.

During an interview on 1/15/25 at 11:42 a.m., QMA 19 indicated Resident 66 was on some type of precautions, however she was unsure of the type and it might be droplet isolation. She left and quickly returned stating the resident was on Enhanced Barrier Precautions (EBP) or contact isolation due to a rash

she used to have. The QMA indicated she thought staff and visitors were supposed to wear P.P.E. when the resident had a rash and the resident did not currently have a rash.

During an observation on 1/16/25 at 10:28 a.m., a third sign had been added to Resident 66's door. The third sign indicated the resident was on Enhanced Barrier Precautions and offered instructions to staff and visitors.

During an observation on 1/17/25 at 10:44 a.m., CNA 21 was speaking to Resident 66 as she assisted her to exit the in room bathroom. CNA 21 removed gloves and threw them away. She then used her bare hands to push the residents wheel chair and assist the residents to don shoes. CNA 21 was not wearing any form of PPE. CNA 21 did not complete hand hygiene. During an interview at this time, CNA 21 indicated she believed she only needed PPE if the resident had a skin rash. She had only used gloves when providing toileting care. CNA 21 reviewed the EBP sign posted on the resident's door and indicated she might be wrong. When the door sign says EBP employees are supposed to wear full PPE during resident care and

she had made an error.

The three signs regarding infection control and prevention remained posted on the resident door during the following dates and times: 1/17/27 at 10:03 a.m., 1/17/25 at 10:44 a.m., 1/21/25 at 3:46 p.m., 1/23/25 at 11:47 a.m.

During an interview on 1/21/25 at 3:48 p.m. LPN 20, indicated, the resident had contact isolation due to a history of skin rashes. The resident did not have to remain in her room. The resident only had to stay in her room if she had a rash. Staff were to follow the directions on the posted signs.

Resident 66's clinical record was reviewed on 1/17/25 at 9:29 a.m. Current diagnoses included candidiasid - unspecified, chronic respiratory failure with hypoxia, and depression.

The resident had current physician's orders which included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 155242 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155242 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Muncie 4301 N Walnut St Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 a. An order which originated, 03/05/2024 for Enhanced Barrier Precautions,

Level of Harm - Minimal harm or b. An order which originated 06/26/2024 for Resident in room without a roommate for isolation, and potential for actual harm c. An order which originated 01/07/2025 forResident receives all meals, medications, activities, and therapy Residents Affected - Few in room.

The resident had a current, 11/20/24, care plan regarding the need for enhanced barrier precautions for the purpose of infection control. An approach to this problem was Personal Protective Equipment as indicated.

The care plan did not indicate when PPE was indicated.

Resident 66 had a 6/25/24 hospital, Facility Infection Control Form which indicated the resident had screened positive for Candida auris on 6/19/24 and had been on enhanced contact precautions while in the hospital.

The resident had a 6/25/24 hospital discharge summary which stated the resident had tested positive for Candida auris. She had been on enhanced contact precautions while in the hospital.

During an interview on 1/23/25 at 11:50 a.m., the Infection Preventionist (IP) indicated Resident 66 should not have orders for both isolation and EBP. If a resident had an order for isolation the order should be clear as to the type of isolation the resident required. If a resident had an order for EBP a sign regarding the precautions should be posted on the resident's door. She did not believe Resident 66 should be on isolation

in her room and she would look into the matter. CNA 21 had informed her she had made an error when she toileted Resident 66. The two had discussed the need for full PPE when caring for the resident.

During an interview on 1/23/25 at 2:06 p.m., the IP indicated Resident 66 should not have had orders for isolation or restrictions to remain in her room. The resident required EBP and staff should wear PPE during care.

42685

2. During an interview at the time of observation on 1/16/25 at 10:22 a.m., Resident 86's door and room lacked any signage for specific precautions. Personal protective equipment (PPE) was not observed readily available in or near the resident's room. During an interview with the resident in her room, she indicated she had a pressure ulcer on the middle-right of her buttock. She was resting on her left side in bed and indicated

she repositioned herself in bed. Her wound vacuum was on during the observation. The facility staff changed her wound vacuum every other day. Staff wore gloves when they changed her dressing, but they never wore

a gown for her wound care.

Resident 86's clinical record was reviewed on 1/17/25 at 10:26 a.m. Diagnoses included pressure ulcer of

the sacral region, unspecified stage. The clinical record lacked any orders for enhanced barrier precautions (EBP).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 155242 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155242 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Muncie 4301 N Walnut St Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A current physician order, dated 12/30/24, included the following: Cleanse the coccyx wound with Hibiclens (antibacterial wound wash) and rinse with normal saline once a day on Mondays, Wednesdays, and Fridays, Level of Harm - Minimal harm or apply skin preparation to the peri area and black foam to the wound cavity, then cover it with the wound potential for actual harm vacuum dressing and set the wound vacuum to run continuously at 150 millimeters of mercury pressure.

Residents Affected - Few A quarterly Minimum Data Set (MDS) assessment, dated 11/16/24, indicated the resident was cognitively intact. She required substantial assistance from the staff for toileting, lower body dressing, personal hygiene and donning and doffing of footwear. The resident was dependent on staff assistance for transfers. She had

a stage 3 pressure ulcer that was not present on admission.

A current care plan, dated 9/2/24, indicated the resident had a pressure ulcer to her sacrum. The care plan lacked any interventions regarding EBP's.

During an observation on 1/17/25 at 11:07 a.m., the resident's door to her room was closed. No signage was noted on the resident's door during the observation.

During an observation on 1/17/25 at 11:50 a.m., CNA 15 indicated the resident was ready to get dressed and get up, and she planned to assist her. She knocked on the resident's door and donned a pair of gloves. The resident consented to the observation of her pressure ulcer wound vacuum before she got dressed. Hand hygiene was not observed. CNA 15 leaned in against the resident's bed with her pants directly against the resident's bed linens. She used her gloved hands to pull down the resident's blanket and unsecured the resident's brief. The resident repositioned herself onto her left side. CNA 15 tucked the brief down under the resident for review of the pressure ulcer wound vacuum. The wound vacuum dressing was on the resident's coccyx, clean, dry, and intact with the wound vacuum turned on. The only PPE noted in the room was gloves. No signage for enhanced barrier precautions was in the resident's room. The resident told CNA 15

she was ready to get assistance with her personal hygiene/dressing. The CNA did not don a gown anytime

during the observation.

Review of a Care Guide 100 Hall-Last Revision 1/20/2025 document, used as a reference guide for the CNA staff, lacked any indication the resident was in enhanced barrier precautions.

During an observation on 1/21/25 at 11:55 a.m., the outside of the resident's door contained an EBP sign that was not present during previous observations. The sign indicated gloves and gowns were required for staff during high contact care activities.

During an interview at the time of observation on 1/21/25 at 6:38 p.m., the resident's door had an EBP sign

on the outside. During an interview at the time of observation, the resident indicated staff placed a new sign

on her door on this date, as she pointed to the EBP sign. She did not know why it was on her door. She indicated staff had to assist her with dressing. She required assistance from two staff members and a lift to transfer into the wheelchair. Staff wore gloves when they assisted her, but they had not worn gowns during

the above-mentioned resident care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 155242 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155242 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Muncie 4301 N Walnut St Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 1/22/25 at 11:34 a.m., CNA 7 indicated the CNAs were able to identify if a resident had EBP due to a sign on the door labeled enhanced barrier precaution. The CNA activity of daily living Level of Harm - Minimal harm or (Care Guide) was also used as a reference to ensure they were aware which residents were in EBP. The potential for actual harm resident's door did not have an EBP sign prior to 1/21/25 even though the resident had a chronic wound prior to that date. She had received new training on 1/20/25 or 1/21/25 when staff were informed of new things Residents Affected - Few going into effect. This included information that residents with wounds and devices such as colostomies and catheters were required to have EBP implemented. Prior to 1/21/25, the 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. Since 1/21/25, a gown, gloves, and masks were required to be worn in the resident's room during dressing, bathing, and assistance with wound care.

During an interview on 1/23/25 at 9:27 a.m., the Infection Preventionist indicated she explained EBP to the staff when it was initiated on each resident. A sign for EBP was also posted on the door, and gowns and gloves were made readily available when it was implemented as well. Prior to 1/21/25, the staff would not have known they should have worn a gown and gloves for the resident's high contact care because EBP had not been implemented for her. She had been trying to get clarification from a corporate staff member and was uncertain about which residents should have been in EBP. As a result, the resident's EBP was not implemented until 1/21/25. She had not reached out to the Indiana Department of Health Infection Preventionist for clarification on EBP. The resident's wound developed before 1/21/25. Any resident with wounds required EBP with a gown and gloves worn during any care that involved touching the resident.

A current facility infection control door sign titled, Enhanced Barrier Precautions, which was provided by the DON on 1/23/25 at 9:30 a.m., indicated:

Everyone Must:

Clean their hands, including before entering and when leaving the room.

Providers and staff must also:

Wear gloves and gown for the following High Contact Resident Care Activities.

Dressing

Bathing/Showering

Transferring

Changing Linens

Providing Hygiene

Changing briefs or assisting with toileting

Device care of use:

central line, urinary catheter, feeding tube, tracheotomy

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 155242 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155242 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Muncie 4301 N Walnut St Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Wound Care: any skin opening requiring a dressing

Level of Harm - Minimal harm or Do not wear the same gown and gloves for the care of more than one person. potential for actual harm

A document, which was identified as a resource used by the facility, Titled Infection Control Guidance: Residents Affected - Few Candida aurius was provided by the IP on 1/23/25 at 2:24 p.m., and identified as the CDC (Center for Disease Control) guidance used to direct care for Resident 66 indicated the following:

Ensuring that all healthcare personnel adhere to infection control is critical to preventing transmission of C aurius .

Practice good hygiene

Use alcohol-based sanitizer as the preferred method of cleaning hands .Wear gowns and gloves using proper donning and doffing techniques .

A current facility policy, last revised 3/25/24, titled Enhanced Barrier Precautions Policy, provided by the Infection Preventionist on 1/23/25 at 10:20 a.m., indicated the following: Policy Statement . This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. GUIDELINE: . 2. Enhanced Barrier Precautions (EBP) are additional measures to attempt to decrease transmission of Multidrug-Resistant Organisms (MDRO) . 3. If a resident is placed on EBP, appropriate signage is placed at

the room entrance so that personnel and visitors are aware of the need for and the type of precautions. a.

The signage informs the staff of instructions for use of PPE, and/or instructions to see a nurse before entering the room . 5. EBP are indicated for residents who have chronic wounds and or indwelling devices regardless of MDRO status

3.1-18(b)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 155242 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155242 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Muncie 4301 N Walnut St Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48146 potential for actual harm Based on record review, observation, and interview, the facility failed to ensure the automated external Residents Affected - Few defibrillator (AED) was maintained in safe operating condition. (Resident F)

Finding includes:

Resident F's clinical record was reviewed on [DATE REDACTED] at 2:23 p.m.

A progress note, dated [DATE REDACTED] at 11:13 a.m., indicated the resident was observed unresponsive without a pulse. Facility staff had called a code (a medical term for cardiac arrest) and begun cardiopulmonary resuscitation (CPR). Emergency services (EMS) were contacted.

A progress note, dated [DATE REDACTED] at 12:11 p.m., indicated the facility staff had transferred CPR and rescue breathing to the EMS, who continued without success. CPR was ceased at 11:28 a.m.

During an interview, on [DATE REDACTED] at 11:51 a.m., RN 29 indicated when a code blue (a medical term for cardiac arrest) was called the staff would get the crash cart from the end of the 700 hall and the AED off the wall, at

the junction of the 800 hallway. He indicated the AED was in working order as it was tested just a few months ago.

During an interview, on [DATE REDACTED] at 12:03 p.m., RN 3 indicated when a resident required CPR, the staff utilized

the crash cart on the 700 hall and obtained the AED from the 800 hallway. She indicated the AED was currently in working order.

During an observation of the 800 hall junction, on [DATE REDACTED] at 12:30 a.m., the white box attached to the wall contained a red AED device. The outside of the box contained no markings to indicate if the device was in working order.

During an observation of the 800 hall junction, on [DATE REDACTED] at 4:15 p.m., the white box attached to the wall was empty. The red AED device was removed from the box. The inside of the box contained no markings or documentation to indicated the device was in working order.

During a telephone interview, on [DATE REDACTED] at 2:56 p.m., RN 27 indicated she was working the hallway where Resident F was staying. On [DATE REDACTED], she and Unit Manager 16 entered the residents room and found the resident was not breathing. The Unit Manager immediately started CPR. The AED was brought in at some time during CPR but was unable to be utilized because the battery was dead.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 155242 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155242 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Signature Healthcare of Muncie 4301 N Walnut St Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During a telephone interview, on [DATE REDACTED] at 7:43 p.m., Unit Manager 16 indicated she was called to help assess Resident F in his room. When she was unable to obtain vital signs, she immediately started CPR. At Level of Harm - Minimal harm or one point, CNA 28 took over chest compressions, so she retrieved the AED that hung at the 800 hall potential for actual harm junction, and called the Code Blue. EMS was called. When she returned to the residents room she opened

the AED, pulled out the cartridges and attached the pads to the residents chest. She pressed the power Residents Affected - Few button and the AED would not turn on. CPR was continued. EMS arrived roughly around 11:10 a.m. and took over CPR. She indicated she was trained in the use of an AED and was under the impression the device had been in working order. After the situation, she contacted the DON and the Maintenance Director to let them know the AED had not worked. She was unaware what staff member was responsible for maintaining the AED in working condition.

During an interview, on [DATE REDACTED] at 2:13 p.m., the DON indicated he was aware a battery had been ordered for the AED on [DATE REDACTED], but it had not arrived yet. He was not aware who ordered the battery or the reason why the battery was ordered. He indicated he was not aware of the battery being dead until Unit Manager 16 told him on the night after the Code Blue. He was not aware of what staff member was responsible for maintaining the AED in working condition. He removed the AED from the box attached to the wall on the 800 hallway on [DATE REDACTED] since it was not in working order. There was not a facility policy related to the AED. The facility did not have a system or practice for routine monitoring and management of the AED.

During an interview, on [DATE REDACTED] at 2:22 p.m., the Administrator indicated she was made aware of the AED not working after the Code Blue. She was aware the Maintenance Director ordered a battery every 6 months as

a part of his duties. The battery was ordered on [DATE REDACTED] but had not arrived. The facility did not have a system or practice for routine monitoring and management of the AED.

During an interview, on [DATE REDACTED] at 2:43 p.m., the Maintenance Director indicated he requested a battery for

the AED every 6 months and had done this since he began working at the facility in 2013. The order is placed through Central Supply and was done on [DATE REDACTED], but the battery had not arrived as it was on back order. He was not aware of which staff member was responsible for maintaining the AED in working condition.

A current AED Owner's Manual, undated, provided by the DON on [DATE REDACTED] at 4:06 p.m., indicated the following: .The AED performs a self-test every day .As long as the green Ready light is blinking, it is not necessary to test . Checks are recommended after each use and periodic checks are limited to checking the green Ready light .Record each periodic check in your inspection log/maintenance booklet .The green Ready light is your guide to knowing the defibrillator is ready for use .If the Ready light is off and the device is emitting a series of single chirps, and the i-button is flashing: a self test has occurred, there is a problem with

the pads or the battery power is low .If the Ready light is off and the device is not chirping and the i-button is not flashing: there is no battery inserted, the battery is depleted, or the device needs repair .

This citation relates to Complaint IN00451569.

3XXX,d+[DATE REDACTED](bb)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 155242