Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was conducted due to complaints IN00448437 and IN00447324 regarding medication administration and fall interventions at the facility.
Complaint Details
This citation relates to Complaint IN00448437 and Complaint IN00447324.
Findings
The facility failed to ensure physician orders were followed for medication administration for 1 of 3 residents reviewed, and care plan interventions for fall prevention were not implemented for 2 of 3 residents reviewed. Blood pressure parameters were not followed, and fall interventions such as non-slip strips were not consistently in place.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions. Physician orders for medication administration were not followed for Resident D, including failure to hold medication when blood pressure was below ordered parameters. Fall interventions were not implemented for Residents B and D, including absence of non-slip strips in shower rooms.
Report Facts
Medication administration dates without blood pressure check: 7
Medication administration dates with systolic BP less than 110: 4
Fall risk score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Indicated there is an order for blood pressure parameters on medication and that blood pressure is recorded on the MAR. | |
| DON | Indicated no intervention was put in place for Resident B after the 11/9/24 incident. | |
| Administrator | Provided current policies on medication administration, care plans, and clinical protocol for falls. |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Oct 11, 2024
Visit Reason
Annual survey inspection of Envive of River City nursing home to assess compliance with regulatory requirements including resident care, medication administration, infection control, and documentation.
Findings
The facility was found deficient in multiple areas including failure to notify physicians and guardians when residents left independently, incomplete and inaccurate Minimum Data Set (MDS) assessments, failure to ensure proper physician orders and care plans for residents with wounds and PICC lines, inaccurate medication administration especially insulin given late or by unqualified staff, incomplete documentation of neurological checks after falls, failure to post accurate nurse staffing hours, failure to provide medically-related social services for mental health needs, failure to limit psychotropic medication PRN orders to 14 days, improper medication labeling and storage, incorrect food preparation for puree diets, incomplete documentation for resident leave of absence, failure to implement enhanced barrier precautions for infection control, and inadequate designation and time dedication of the Infection Preventionist.
Deficiencies (14)
F 0580: The facility failed to notify the physician and resident representative when residents left independently for 2 of 3 residents reviewed for elopement.
F 0635: The facility failed to ensure a resident had physician orders upon admission for PICC line care, wound care, and enhanced barrier precautions for 1 of 1 resident reviewed for infection control.
F 0641: The facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed for residents with PTSD, intravenous access, and falls for 3 residents reviewed.
F 0655: The facility failed to ensure a resident had a baseline care plan related to wounds and wound management for 1 of 1 resident reviewed for infection control.
F 0657: The facility failed to revise care plans after falls, substance misuse, and elopement risk for 2 of 3 residents reviewed.
F 0658: The facility failed to ensure insulin was given in accordance with professional standards for 5 of 5 residents reviewed for insulin; insulin was given late and by unqualified staff.
F 0732: The facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff per shift daily for 3 of 4 days during the survey period.
F 0745: The facility failed to provide medically-related social services to meet a resident's mental and psychosocial needs for 1 of 1 resident reviewed for mood disturbances.
F 0758: The facility failed to ensure residents were free from unnecessary medications; a resident's PRN antianxiety medication was ordered for greater than 14 days without review.
F 0761: The facility failed to ensure medications were labeled, opened multi-dose containers were dated, and medication carts were free of loose pills for 1 of 2 medication carts observed.
F 0805: The facility failed to ensure food was correctly prepared for 2 of 2 residents who received puree altered diets.
F 0842: The facility failed to safeguard resident-identifiable information and maintain complete medical records including neurological checks after falls and documentation for leave of absence for 3 residents reviewed.
F 0880: The facility failed to provide and implement enhanced barrier precautions for a resident with a PICC line and multiple wounds for 1 of 1 resident reviewed for infection control.
F 0882: The facility failed to designate a certified Infection Preventionist who dedicates at least part time to the role for 1 of 1 staff members reviewed.
Report Facts
PRN antianxiety medication days: 43
Wound measurements: 6
Wound measurements: 3
Wound measurements: 1.2
Insulin doses: 8
Insulin doses: 17
Insulin doses: 20
Insulin doses: 16
Insulin doses: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 9 | Registered Nurse | Observed preparing vancomycin and failing to don gown for enhanced barrier precautions for Resident 225. |
| QMA 2 | Qualified Medication Aide | Documented insulin administration without certification. |
| Director of Nursing | Director of Nursing | Provided multiple interviews and policies related to deficiencies and facility practices. |
| Administrator | Facility Administrator | Provided policies and interviews related to staffing and facility procedures. |
| Social Service Director | Social Service Director | Interviewed regarding resident social services and documentation. |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, care plan conferences, nurse staffing, food safety, and quality assurance in the nursing home.
Findings
The facility failed to ensure residents self-administering medications were properly assessed, lacked documented quarterly care plan conferences for multiple residents, failed to maintain RN coverage for 8 consecutive hours on some days, did not post complete nurse staffing sheets daily, served food at unsafe temperatures, improperly stored food items without labeling, and lacked an effective Quality Assurance and Performance Improvement program.
Deficiencies (7)
F 0554: The facility failed to assess and document capability for residents self-administering medications for 2 of 4 residents reviewed.
F 0657: The facility failed to provide quarterly care conferences and update care plans for 13 of 16 residents reviewed.
F 0727: The facility failed to ensure a registered nurse worked 8 consecutive hours on 2 of 14 days reviewed for nurse staffing.
F 0732: The facility failed to post completed nurse staffing sheets daily for 4 of 4 days during the survey.
F 0804: The facility failed to serve food at safe and appetizing temperatures for 1 of 1 meal trays reviewed.
F 0812: The facility failed to ensure food was stored appropriately; food containers were unlabeled and some spices were outdated in the kitchen.
F 0867: The facility failed to complete a Quality Assurance and Performance Improvement Program with sufficient detail to identify and address quality deficiencies.
Report Facts
Falls: 16
Infections: 17
Pressure wounds: 8
Falls: 7
Infections: 14
Pressure wounds: 1
Falls: 15
Infections: 15
Pressure wounds: 14
Falls: 8
Infections: 11
Pressure wounds: 1
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 14, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for nursing home care, including care planning, nursing staffing, infection control, and resident notification of COVID-19 status.
Findings
The facility failed to revise care plans for residents, provide oral care as required, maintain required RN staffing and Director of Nursing qualifications, post accurate nurse staffing information daily, implement proper infection prevention and control practices including COVID-19 protocols, and notify residents of positive COVID-19 staff cases.
Deficiencies (6)
F 0657: The facility failed to revise the care plan for a resident with contractures who refused to wear anti-contracture devices.
F 0677: The facility failed to provide oral care during morning activities of daily living for a resident.
F 0727: The facility failed to provide a Director of Nursing who is a registered nurse and lacked RN coverage for at least 8 hours a day on multiple days.
F 0732: The facility failed to post daily nurse staffing information accurately for 3 of 3 days reviewed.
F 0880: The facility failed to implement infection prevention and control practices properly, including cleaning glucometers, wearing protective eye wear, offering facial coverings, and proper bathing procedures.
F 0885: The facility failed to notify residents of a confirmed positive COVID-19 staff member during Resident Council meetings.
Report Facts
Days lacking RN coverage for at least 8 hours: 10
Days oral care not marked as provided: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in infection control finding for failure to wear gloves and protective eye wear during insulin injection |
| CNA 1 | Certified Nursing Assistant | Named in oral care and infection control findings |
| CNA 2 | Certified Nursing Assistant | Named in infection control findings |
| CNA 3 | Certified Nursing Assistant | Named in infection control findings |
| Acting Director of Nursing | LPN Acting DON | Named in staffing and care plan revision findings |
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