Signature Healthcare Of Muncie
SIGNATURE HEALTHCARE OF MUNCIE in MUNCIE, IN — inspection on October 1, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview, on 10/1/25 at 10:52 a.m., RN 4 indicated when a resident was admitted a skin assessment was performed.
Pressure injuries were measured and put into a skin event. If the pressure injury did not have a treatment, the DON and the NP would be informed to get an order to treat the area.
The wound NP assessed the pressure injuries each week and assessed the skin of all new admissions.
During an interview, on 10/1/25 at 11:52 a.m., the DON indicated she was unable to locate wound measurements in the electronic record for the resident's right elbow pressure injury other than on admission or wound measurements for the other pressure injuries in the resident's clinical record.
She indicated the heel protectors were the treatment utilized for the right and left heel DTIs.
The right elbow stage 2 pressure injury was left open to air and utilized turning and repositioning for bony prominences per nursing measures.
The resident had a private caregiver who kept the resident repositioned and propped with pillows.
The resident had an order for a pressure relieving/redistribution mattress as well.
She was unable to locate a specific treatment order for the right elbow.
For the coccyx pressure injury, the CNAs routinely applied moisture barrier creams to the resident with incontinence care as a nursing measure.
The application of moisture barrier cream was not typically a physician's order.
She was unable to locate a specific order for treatment for the coccyx pressure injury. A care plan for the pressure injuries was not implemented until 9/25/25 other than those listed in the initial baseline care plan.
Review of a treatment administration record for 9/8/25 through 10/1/25, provided by the DON on 10/1/25 at 2:51 p.m., indicated a weekly skin assessment was performed on 9/9/25, 9/16/25, and 9/23/25.
The assessment was signed off as existing skin impairment.
The special instructions indicated Open an appropriate event for newly identified skin issues. No additional documentation was listed. A facility policy, revised 1/31/25, provided by the DON on 10/1/25 at 2:51 p.m., titled Skin Integrity, indicated the following: .A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing.Upon admission, the licensed nurse shall complete the initial skin check and obtain orders from the physician/practitioner for any area of impaired skin integrity that may not have orders in place when the resident is admitted to the facility from other healthcare settings or home.The Nurse Leader/Wound Nurse shall document all impaired skin integrity areas such as: pressure, stasis, surgical incision, or diabetic ulcers in the EMR [electronic medical record] on an ongoing basis or until closed or the resident has been discharge.
This citation relates to Intake 2621648. 3.1-40(a)(2)
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