Signature Healthcare of Bremen

In the surveyor’s words

From the most serious findings on record at Signature Healthcare of Bremen, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 21, 2026

  Based on observation, interview and record review, the facility failed to ensure a staff nurse performed CPR correctly for 1 of 3 residents reviewed for death. (Resident B) In addition, the facility failed to ensure nursing staff who received online Cardiopulmonary Resuscitation (CPR) training completed a hands on component led by an in- person or virtual instructor for 13 of 16 nursing staff members reviewed (Registered Nurses 2, 4, 5 & 6, Licensed Practical Nurses 7, 8, 9, 10, 11, 12 & 13, the Director of Nursing and the Assistant Director of Nursing). […]

• Immediate jeopardy, isolatedF600Jun 29, 2022

  Based on observation, interview and record review, the facility failed to ensure 1 of 5 residents reviewed were free from sexual and mental abuse. (Resident B) This deficient practice had the potential/likelihood of a negative psychosocial outcome, for Resident B, resulting from the facility's noncompliance to protect a resident, who had mild to moderate cognitive deficits from sexual abuse and from the perpetrator attempting to contact her, after he was instructed not to do so, for 1 of 5 residents reviewed for abuse resulting in the resident (Resident B) The immediate jeopardy began on 6/3/22 when Resident B reported the incidents of sexual abuse to a Certified Nurse Aide (CNA). The Administrator was notified of the immediate jeopardy at 2:30 P.M. on 6/27/22. […]

• Actual harm, isolatedF689Jun 29, 2022

  Based on observation, interview and record review, the facility failed to implement interventions to ensure 2 of 3 residents were free from falls, which resulted in a fracture for both residents and the demise of Resident E. (Resident G and Resident E) Findings include: 1.On 6/28/22 at 2:24 P.M., a review of the clinical record for Resident G was conducted. The resident's diagnoses included, but were not limited to: Alzheimer's disease, repeated falls, history of falls, cognitive communication deficits and delusions. A Quarterly Minimum Data (MDS) Assessment, dated 3/11/22, indicated the Brief Interview for Mental Status (BIMS) score was 6 (score of 0-7 severe cognitive deficit), required extensive assistance of 2 persons with transfers, bed mobility and toileting. […]

• No harm, potential for more than minimal, widespreadF880Feb 17, 2025

  Based on observation and interview, the facility failed to follow infection control procedures during a medication pass for 2 of 4 residents observed. (Resident 8 & 20) Finding includes: During an observation of a medication pass, on 2/12/2025 at 8:01 A.M., LPN 6 prepared Resident 8's medications. LPN 6, with her bare hands, broke 2 potassium chloride tablets in half. She indicated this was the only way she could break the tablets in half and she had sanitized her hands prior to starting the preparation of medication. During an observation, on 2/12/2025 at 8:08 A.M, LPN 6 was at the medication cart and coughed into her bare hand. During an observation, on 2/12/2025 at 8:10 A.M., LPN 6 prepared Resident 20's insulin injection. […]

• No harm, potential for more than minimal, patternF812Feb 17, 2025

  Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions in 1 of 1 kitchens and 2 of 2 resident nutrition pantries. This deficient practice had the potential to affect 59 of 61 residents who received meals out of the kitchen. (main kitchen, north unit nutrition pantry & south unit nutrition pantry). Findings include: 1. During the initial tour of the kitchen, on [DATE] at 10: 26 A.M., with the Dietary Manager the following was observed: In the walk in freezer: - there was an opened bag of chicken pieces not sealed. - the floor had pieces of food and other debris. 2. […]