Signature Healthcare of Terre Haute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Sep 27, 2024

  Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident residing on the same locked unit for 2 of 3 residents reviewed for abuse (Residents B and C) resulting in an Immediate Jeopardy when the facility failed to keep the residents separated and prevent further abuse. The immediate jeopardy began on 9/22/24 when a cognitive impaired resident (Resident B) was observed by staff touching another cognitively impaired resident (Resident C) in the genital region in the common area after breakfast. Later that same day, Residents B and C were found together in bed with Resident B's hand was on Resident C's bare stomach and legs intertwined. […]

• Immediate jeopardy, isolatedF686Dec 19, 2023

  A. Based on observation, interview, and record review, the facility failed to prevent pressure ulcers for 1 of 6 residents reviewed for pressure ulcers resulting in immediate jeopardy when the resident developed a stage 3 pressure ulcer to the sacrum, a deep tissue injury to the left lateral ankle, and an unstageable to the right thigh (Resident 135). B. Based on observation, interview, and record review, the facility failed to appropriately treat pressure ulcers as ordered for 1 of 6 residents reviewed for pressure ulcers resulting in immediate jeopardy when the stage 3 sacral pressure ulcer worsened to a stage 4, the deep tissue injury to a left lateral ankle worsened to a stage 4, and the unstageable to the right anterior thigh worsened to a stage 3 (Resident 135). C. […]

• Immediate jeopardy, isolatedF684May 1, 2023

  Based on interview and record review, the facility failed to ensure thorough assessment of a resident with a change of condition and failed to timely send the resident with a change of condition out to the hospital for 1 of 3 residents reviewed for emergency transfers due to change of condition (Resident O). The immediate jeopardy began on [DATE] when at 7:30 a.m. Certified Nurse's Aide (CNA) 10 observed Resident O to have not touched her breakfast tray, her face was red in color, she was struggling to breathe, not talking, grabbing at the air, and her eyes were rolling up. Licensed Practical Nurse (LPN) 11 was notified but indicated she did not assess due to Resident O having had tests for a possible urinary tract infection (UTI) earlier in the morning. […]

• Actual harm, isolatedF689May 21, 2026

  Based on record review, and interview, a facility staff member failed to follow a resident's plan-of-care intervention requiring the use of a gait belt for transfers, which resulted in a resident fall with fracture that required a hospital visit and follow-up care for 1 of 3 residents reviewed for accidents (Resident C). The deficient practice was corrected by 5/11/26 after the facility implemented a systemic plan and was therefore Past Noncompliance. Findings include: During an interview on 5/20/26 at 1:09 p.m., Resident C indicated he fell during a transfer when CNA 2 snatched him up by the back of his pants, real quick. She did not use a gait belt as other staff had done. He lost his balance and fell to the floor, landing on his left side. […]

• Actual harm, isolatedF744May 9, 2025

  Based on observation, interview, and record review, the facility failed to ensure resident specific interventions were implemented for a dementia resident who was known to have behaviors upon admitting to the facility and intrusive wandering for 1 of 6 residents reviewed for dementia care (Resident J). This deficient practice resulted in harm when Resident J wandered into Resident F's room unsupervised and then exited with three circular bruises on the right lower arm and scratches with fresh blood on them. […]