Inspection Reports for Envive of Anderson
1821 LINDBERG RD, ANDERSON, IN, 46012
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2025, found the facility in compliance based on a paper review of a complaint investigation. Prior inspections showed a pattern of deficiencies related mainly to resident rights, medication management, and safety, including issues with resident access to outdoor areas, narcotic handling, insulin administration, and wound care. Several complaint investigations were substantiated, involving failure to prevent staff-to-resident abuse, timely reporting of abuse allegations, and inadequate wound and medication care, while many other complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with recent inspections indicating correction of previously cited deficiencies and compliance in key areas.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
28.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
574% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Routine
Deficiencies: 4
Date: Jul 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notifications for transfers and hospitalizations, wound care and pressure ulcer management, and dietary sanitation practices.
Findings
The facility failed to provide required documentation and notifications related to resident transfers and hospitalizations, failed to follow physician orders for wound care including use of heel boots, failed to provide adequate wound assessments and infection control for a stage IV pressure ulcer, and failed to ensure dietary staff competency in dishwasher sanitation testing.
Deficiencies (4)
Failed to provide bed hold policy and transfer/discharge notifications to residents/representatives and failed to notify Long-Term Care Ombudsman for hospitalizations.
Failed to follow physician's orders regarding placement of heel boots for a resident with skin conditions.
Failed to provide wound assessments/monitoring and wound treatments in a manner to promote healing of a stage IV pressure ulcer, including failure to perform hand hygiene and glove changes during wound care.
Failed to ensure dietary employees were competent in dishwasher sanitation testing, using improper test strips and lacking knowledge of sanitizer levels.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 57
Pressure ulcer measurements: 9.5
Pressure ulcer measurements: 10.5
Pressure ulcer measurements: 3.3
Pressure ulcer undermining: 3.8
Pressure ulcer measurements: 14
Pressure ulcer measurements: 14
Pressure ulcer depth: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Interviewed regarding transfer/discharge notifications and observed providing wound care without proper hand hygiene | |
| LPN 4 | Interviewed regarding transfer/discharge notifications and wound care observations | |
| Director of Nursing | DON | Interviewed regarding transfer/discharge notifications, wound care policies, and dietary sanitation |
| Corporate Nurse Consultant | Provided facility policies and interviewed regarding wound care and transfer/discharge notifications | |
| Dietary Manager | Interviewed regarding dishwasher sanitation testing and use of test strips | |
| Social Service Director | SSD | Interviewed regarding submission of transfer/discharge notifications to State Ombudsman |
| Corporate President of Life Enrichment | Interviewed regarding incomplete transfer/discharge notifications sent to State Ombudsman |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00456647 completed on May 22, 2025.
Complaint Details
Investigation of Complaint IN00456647 completed on May 22, 2025; facility found in compliance.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: May 22, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00456647) regarding the facility's failure to ensure residents were afforded the opportunity to go outside per their preference, weather permitting.
Complaint Details
This citation relates to complaint IN00456647.
Findings
The facility failed to allow 4 of 4 residents reviewed to go outside without supervision despite their preference, potentially impacting 17 of 59 residents. Interviews with residents and staff revealed that residents who could not sign themselves out required staff supervision to go outside, and on weekends, staff availability was limited. A list of residents allowed to sign themselves out and those at risk for elopement was maintained.
Deficiencies (1)
Failed to ensure residents were afforded the opportunity to go outside per their preference, weather permitting, for 4 of 4 residents reviewed for resident rights.
Report Facts
Residents affected: 17
Residents reviewed: 4
Total residents present: 59
Residents allowed to sign themselves out: 42
Residents at risk for elopement: 6
Residents with guardians: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Indicated residents who could sign themselves out could sit outside; those who could not sign out needed supervision | |
| LPN 3 | Indicated residents could not go outside if no staff was available to watch them | |
| RN 1 | Indicated residents who smoke could go out for smoke breaks and described supervision arrangements | |
| Activity Director | Indicated smoking residents went out three times a day and described supervision and resident sign-out procedures | |
| DON | Provided the facility list of residents allowed to sign themselves out |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 1
Date: May 22, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00459082 and IN00456647. Complaint IN00456647 resulted in a federal/state deficiency citation related to resident rights, while complaint IN00459082 had no deficiencies cited.
Complaint Details
Complaint IN00456647 was substantiated with a federal/state deficiency cited at F550 related to resident rights. Complaint IN00459082 was not substantiated with any deficiencies.
Findings
The facility failed to ensure residents were afforded the opportunity to go outside per their preference, weather permitting, for 4 of 4 residents reviewed. This deficient practice had the potential to impact 17 of 59 residents who were unable to go outside without supervision.
Deficiencies (1)
Facility failed to ensure residents were afforded the opportunity to go outside per their preference, weather permitting, for 4 of 4 residents reviewed.
Report Facts
Residents impacted: 17
Residents reviewed: 4
Total census: 59
Residents allowed to sign out: 42
Residents at risk for elopement: 6
Residents with guardians: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Kinzie | Executive Director | Signed the report |
| LPN 2 | Provided information about residents signing themselves out and supervision | |
| LPN 3 | Indicated residents could not go outside if no staff was available to watch them | |
| RN 1 | Provided information about smoke breaks and resident outdoor access | |
| Activity Director | Described resident outdoor activities and supervision | |
| Director of Nursing | Provided the resident sign-out sheet and instructions for outdoor access |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453821 and IN00454578.
Complaint Details
Complaint IN00453821 and Complaint IN00454578 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00453821 and IN00454578 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 1
Medicaid Census: 49
Other Payor Census: 9
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00447984 completed on December 3, 2024.
Complaint Details
Investigation of Complaint IN00447984 completed on December 3, 2024; facility found in compliance.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 1
Date: Dec 3, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00447984, IN00447337, and IN00446745). Only complaint IN00447984 resulted in a federal/state deficiency citation.
Complaint Details
Complaint IN00447984 was substantiated with a federal/state deficiency cited at F755. Complaints IN00447337 and IN00446745 were not substantiated with any deficiencies.
Findings
The facility failed to ensure medications were received from the pharmacy in accordance with policy to ensure the safe handling of narcotics. Specifically, a 30-pill card of tramadol was left unsecured and subsequently went missing. The facility conducted a full narcotic reconciliation with no discrepancies found and implemented corrective actions including staff re-education and disciplinary action.
Deficiencies (1)
Failed to ensure medications were received from pharmacy in accordance with policy to ensure the safe handling of narcotics, resulting in a missing 30-pill card of tramadol.
Report Facts
Census: 55
Total Capacity: 55
Medicare residents: 2
Medicaid residents: 49
Other payor residents: 4
Medication card pills missing: 30
Medication reconciliation frequency: 3
Medication reconciliation duration: 3
Compliance target: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Kinzie | Executive Director | Signed the report |
| LPN 1 | Named in medication handling deficiency; received disciplinary action and in-service education | |
| LPN 2 | Interviewed regarding medication receipt and handling procedures | |
| Director of Nursing | DON | Interviewed about medication handling policies and the incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 3, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00447984) regarding the facility's handling and receipt of medications, specifically narcotics.
Complaint Details
This citation relates to Complaint IN00447984.
Findings
The facility failed to ensure medications, specifically a 30-pill card of tramadol, were properly secured immediately upon receipt from the pharmacy, resulting in the medication becoming missing. Interviews revealed that the medication was left unsupervised at the nurses' station contrary to policy.
Deficiencies (1)
Failed to ensure medications were received from pharmacy in accordance with policy to ensure the safe handling of narcotics, resulting in a 30 pill card of tramadol becoming missing.
Report Facts
Pills missing: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Named in medication handling deficiency; failed to secure narcotic medication properly |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication receipt and handling procedures |
| DON | Director of Nursing | Interviewed regarding medication handling policies and incident details |
Inspection Report
Re-Inspection
Census: 52
Capacity: 97
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440738.
Complaint Details
Complaint IN00440738 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 52
Total Capacity: 52
Medicare Census: 3
Medicaid Census: 45
Other Payor Census: 4
Inspection Report
Life Safety
Census: 49
Capacity: 97
Deficiencies: 11
Date: Aug 13, 2024
Visit Reason
Life Safety Code Recertification and Emergency Preparedness Survey conducted by the Indiana Department of Health on August 13, 2024.
Findings
The facility was found not in compliance with several Life Safety Code requirements including maintenance of smoke barriers, exit discharge door functionality, corridor door self-closing devices, exit discharge walking surface, egress lighting, sprinkler coverage and maintenance, corridor door latching, smoking area maintenance, power strip UL rating compliance, and oxygen storage security.
Deficiencies (11)
Failed to maintain one-hour ceiling smoke barrier between attic and living areas to ensure fire resistance.
One exit discharge door required excessive force to open, impeding full instant use in case of fire.
Corridor doors to hazardous area enclosures were not self-closing and kept closed.
Exit discharge walkway was uneven, had holes, and weeds, not providing an unobstructed level walking surface.
Exit discharge sidewalks from 600 and 500 halls lacked egress lighting.
One kitchen alcove was not completely covered by sprinkler protection.
Seven sprinklers showed signs of corrosion.
Two corridor doors on southwest 300 hall did not latch due to tape over strike plate.
Two smoking areas lacked metal or noncombustible containers with self-closing covers for cigarette butts disposal.
Power strip in patient care area did not meet required UL rating of 1363A or 60601-1.
Outside oxygen storage area gate was not locked and lacked required precautionary signage.
Report Facts
Residents affected by smoke barrier deficiency: 30
Residents affected by exit door deficiency: 15
Residents affected by hazardous area corridor doors: 30
Residents affected by exit discharge walkway deficiency: 20
Residents affected by egress lighting deficiency: 35
Residents affected by sprinkler coverage deficiency: 20
Sprinklers with corrosion: 7
Residents affected by corridor door latching deficiency: 13
Residents affected by smoking area deficiency: 10
Residents affected by power strip deficiency: 2
Residents affected by oxygen storage deficiency: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Kinzie | Executive Director | Signed the report. |
| Maintenance Director | Involved in observations and corrective actions for multiple deficiencies including smoke barrier, exit doors, sprinkler system, corridor doors, smoking areas, power strips, and oxygen storage. | |
| Administrator | Participated in observations and exit conference. | |
| Regional VP | Participated in observations and exit conference. |
Inspection Report
Deficiencies: 1
Date: Jul 26, 2024
Visit Reason
The inspection was conducted to assess the facility's implementation of corrective and preventive actions related to systemic issues involving resident funds, medication labeling, and medication expiration, as part of ongoing quality assessment and performance improvement efforts.
Findings
The facility failed to implement effective corrective and preventive actions to address systemic issues with resident funds management, medication labeling, and expired medications. The Quality Assessment and Performance Improvement (QAPI) plan was in place but lacked full execution, with incomplete audits and unresolved concerns regarding resident funds accounting.
Deficiencies (1)
Failed to implement corrective and preventive actions to ensure systemic issues related to resident funds, medication labeling, and medication expiration were identified and addressed.
Report Facts
Audit months: 3
QAPI meeting last met date: QAPI team last met on 6/28/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided QAPI action plan and facility policy | |
| Chief Operating Officer | Provided audit tools and indicated inability to provide audits related to resident funds | |
| Director of Nursing (DON) | Responsible for medication room and medication cart audits as per action plan |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 26, 2024
Visit Reason
The inspection was conducted to investigate complaints related to the management of resident funds, medication labeling, medication expiration, and infection control practices.
Complaint Details
The complaint investigation revealed issues with resident fund management, medication labeling, expired medication disposal, and infection control related to PICC line dressings. The facility had not adequately addressed these issues through their QAPI process.
Findings
The facility failed to properly manage resident funds for one resident, failed to ensure PICC line dressings were changed as ordered for infection control, failed to label insulin pens with resident identifiers, failed to dispose of expired vaccines timely, and failed to implement effective quality assurance and performance improvement plans to prevent recurrence of these deficiencies.
Deficiencies (5)
Failed to manage Resident Funds in accordance with acceptable accounting principles for 1 of 4 residents reviewed (Resident 29).
Failed to ensure protective PICC dressings were intact and changed as ordered for 1 of 6 residents reviewed for infection control (Resident 151).
Failed to ensure insulin pens were labeled with appropriate resident identifier information on 1 of 3 carts reviewed for medication storage.
Failed to ensure expired vaccinations were disposed of timely for 1 of 1 medication rooms reviewed for medication storage.
Failed to implement corrective and preventive actions to ensure systemic issues related to resident funds, medication labeling, and medication expiration were identified and quality assessment and performance improvement (QAPI) plans were implemented.
Report Facts
Residents with managed personal funds: 37
Negative balance in Resident 29 account B: 2911.47
Negative balance in Resident 29 account C: 15.16
Insulin pens without resident identifiers: 4
Expired influenza vaccine syringes: 10
Residents reviewed for infection control: 6
Residents reviewed for resident funds management: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Registered Nurse | Accompanied medication storage observations and provided interview regarding insulin pens and expired vaccines |
| Corporate Business Office Consultant | Interviewed regarding Resident 29's returned check and account management | |
| Business Office Manager | Provided Resident Funds Trial Balance sheet and interviewed about resident funds management | |
| DON | Director of Nursing | Interviewed regarding PICC line dressing change policies and infection control concerns |
| Administrator | Provided QAPI action plan and interviewed about QAPI team meetings and audit processes | |
| Chief Operating Officer | Interviewed regarding audits related to resident funds management |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 49
Capacity: 49
Deficiencies: 5
Date: Jul 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including Investigation of Complaints IN00433083 and IN00434056.
Complaint Details
Complaint IN00433083 and IN00434056 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in managing resident funds according to acceptable accounting principles, ensuring PICC line dressings were intact and changed as ordered, proper labeling and storage of medications including removal of expired vaccines, and failure to implement effective QAPI plans to address systemic issues.
Deficiencies (5)
Failed to manage Resident Funds in accordance with acceptable accounting principles for 1 of 4 residents reviewed (Resident 29).
Failed to ensure protective PICC dressings were intact and changed as ordered for 1 of 6 residents reviewed for infection control (Resident 151).
Failed to ensure insulin pens were labeled with appropriate resident identifier information on 1 of 3 medication carts reviewed.
Failed to ensure expired vaccinations were disposed of timely in 1 medication room reviewed.
Failed to implement corrective and preventive actions to ensure systemic issues related to resident funds, medication labeling, and medication expiration were identified and addressed through QAPI.
Report Facts
Census: 49
Total Capacity: 49
Residents with personal funds managed: 37
Negative balance: 2911.47
Negative balance: 15.16
Insulin pens unlabeled: 4
Expired vaccine doses: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Kinzie | Executive Director | Signed the report |
| Corporate Business Office Consultant | Interviewed regarding resident funds management and billing issues | |
| Business Office Manager | Interviewed regarding resident funds management and billing issues | |
| RN 6 | Registered Nurse | Observed medication storage and PICC dressing issues |
| DON | Director of Nursing | Provided information on PICC dressing policies and infection control |
| Administrator | Provided QAPI action plan and interview | |
| Chief Operating Officer | Interviewed regarding audits and resident funds management |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 16, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00430011 completed on March 15, 2024.
Complaint Details
Investigation of Complaint IN00430011 completed on March 15, 2024; facility found in compliance.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 15, 2024
Visit Reason
The inspection was conducted due to a complaint alleging that a staff member physically struck a resident (Resident D) on the face, and the facility failed to report and thoroughly investigate the allegation in a timely manner.
Complaint Details
This citation relates to Complaint IN00430011. The allegation involved Resident D being struck on the face by a staff member. The allegation was determined unsubstantiated due to inconsistent resident statements, but the investigation was incomplete and delayed.
Findings
The facility failed to report the allegation of abuse to the State Agency within the required timeframe and did not complete a thorough investigation. The clinical record lacked documentation of the incident and pain assessment. The Administrator was unaware of the investigation outcome, and the facility was unable to access surveillance footage. Interviews confirmed delays and incomplete investigation processes.
Deficiencies (1)
Failed to report an allegation of abuse to the State Agency in the required timeframe and failed to complete a thorough investigation of the allegation of abuse for 1 of 3 residents reviewed.
Report Facts
Residents affected: 1
Dates: Mar 1, 2024
Dates: Mar 6, 2024
Dates: Mar 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Completed witness statement and involved in reporting the allegation |
| Administrator | Contacted regarding the allegation, unaware of investigation outcome, unable to access surveillance footage | |
| QMA 2 | Qualified Medication Aide | Heard LPN 3 talking with the Administrator about the allegation |
| DON | Director of Nursing | Reported delay in abuse report submission and failure to review staff statements |
| Corporate Nurse Consultant | Indicated facility was unable to access surveillance footage |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
This visit was conducted for the investigation of four complaints (IN00425213, IN00425817, IN00430011, and IN00430437) regarding alleged abuse and other concerns at Envive of Anderson.
Complaint Details
Complaint IN00430011 was substantiated with deficiencies related to failure to timely report and thoroughly investigate an abuse allegation involving Resident D. Complaints IN00425213, IN00425817, and IN00430437 had no deficiencies related to the allegations cited.
Findings
The facility failed to report an allegation of abuse to the State Agency within the required timeframe and did not complete a thorough investigation of the abuse allegation for one resident (Resident D). The allegation was ultimately found to be unsubstantiated. No deficiencies were cited for the other complaints.
Deficiencies (1)
Failed to report an allegation of abuse to the State Agency in the required timeframe and failed to complete a thorough investigation of the allegation of abuse for 1 of 3 residents reviewed for abuse (Resident D).
Report Facts
Census: 48
Total Capacity: 48
Complaint IDs: 4
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00418074, IN00419086, and IN00419288.
Complaint Details
Complaints IN00418074, IN00419086, and IN00419288 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census SNF/NF beds: 54
Total census: 54
Medicare census: 7
Medicaid census: 44
Other payor census: 3
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00417217 and IN00417071. Complaint IN00417071 resulted in a federal/state deficiency related to the allegations, while Complaint IN00417217 had no deficiencies cited.
Complaint Details
Complaint IN00417071 was substantiated with a federal/state deficiency cited at F600. Complaint IN00417217 was not substantiated with no deficiencies cited.
Findings
The facility failed to prevent staff to resident abuse involving one resident (Resident C) and one CNA (CNA 1). The resident was transported to the shower room wearing only a bra without any covering, despite telling the CNA to stop. The CNA admitted to a lapse in judgment. The facility took immediate corrective actions including relieving the CNA of duties, notifying administration, and implementing ongoing training and monitoring.
Deficiencies (1)
Failed to prevent staff to resident abuse for 1 of 3 residents reviewed, where a CNA transported a resident to the shower room with exposed body parts despite the resident's request to stop.
Report Facts
Census: 48
Licensed Capacity: 48
Medicare Residents: 6
Medicaid Residents: 40
Other Payor Residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eileen Thomas | Executive Director | Signed the report |
| CNA 1 | Named in abuse finding for transporting resident without covering | |
| Activity Director | Intervened during the abuse incident and reported to Director of Nursing | |
| Director of Nursing | DON | Responded to incident, reported to Administrator |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 19, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00417071 completed on September 19, 2023.
Complaint Details
Investigation of Complaint IN00417071 completed on September 19, 2023; paper compliance review found the facility in compliance.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00417071) regarding alleged staff to resident abuse involving CNA 1 and Resident C.
Complaint Details
This Federal tag relates to Complaint IN00417071. The complaint involved allegations of staff to resident abuse by CNA 1 towards Resident C, which was substantiated based on interviews and record review.
Findings
The facility failed to prevent staff to resident abuse when CNA 1 transported Resident C to the shower room while she was only wearing a bra and did not provide any covering despite the resident's request to stop. The resident was visibly upset and crying. CNA 1 admitted to a lapse in judgment.
Deficiencies (1)
Failed to protect Resident C from staff to resident abuse by transporting her without covering and ignoring her request to stop.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in abuse finding for transporting Resident C without covering and ignoring her request to stop. |
| Activity Director | Witnessed and reported the incident involving Resident C and CNA 1. | |
| Director of Nursing | Director of Nursing | Responded to the incident, interviewed Resident C and CNA 1, and reported to the Administrator. |
Inspection Report
Re-Inspection
Census: 48
Capacity: 97
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/01/23.
Findings
At this Post Survey Revisit, Envive of Anderson was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Re-Inspection
Census: 49
Capacity: 49
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Investigation of Complaint IN00412464 completed on July 14, 2023.
Complaint Details
Complaint IN00412464 was investigated and found to be corrected.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and Investigation of Complaint IN00412464.
Report Facts
Census SNF/NF beds: 49
Census total residents: 49
Census Medicare residents: 4
Census Medicaid residents: 35
Census Other payor residents: 10
Inspection Report
Routine
Census: 47
Capacity: 97
Deficiencies: 17
Date: Aug 1, 2023
Visit Reason
Routine Emergency Preparedness and Life Safety Code survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with Emergency Preparedness requirements and Life Safety Code standards, including deficiencies in emergency preparedness plan content, emergency exercises, fire safety features, and maintenance of safety equipment.
Deficiencies (17)
Emergency preparedness plan failed to address resident population, services in emergencies, and continuity of operations including delegations of authority and succession plans.
Failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills.
Smoke barrier doors to 300 Hall and Therapy room failed to close and latch properly.
Exit discharge surfaces were uneven, cracked, broken, and obstructed by tree limbs, creating trip hazards.
Corridor doors to laundry and oxygen storage rooms lacked self-closing devices that properly latched.
Staff in kitchen were not instructed on proper use of UL 300 hood fire extinguishing system.
Fire alarm control panel displayed incorrect date and time after power outage.
Annual fire alarm system maintenance report showed broken pull station and smoke detectors covered with tape; no documentation of repairs.
Sprinkler head by room 210 was painted, violating maintenance standards.
Three portable fire extinguishers lacked documented monthly inspections.
Corridor door to wound supply room would not close due to tape covering latch opening.
Two electrical receptacles within 3 feet of sinks lacked required GFCI protection.
Two employee smoking areas had cigarette butts disposed on ground instead of in metal containers with self-closing covers.
Trash and soiled linen cart in 100-hall corridor exceeded allowed capacity and was unattended.
Non-hospital grade electrical receptacles in resident sleeping rooms lacked documented annual testing.
Power strip used as substitute for fixed wiring to supply high current draw equipment in housekeeping supervisor office.
Liquid oxygen container stored unsecured in 100 Hall corridor.
Report Facts
Facility capacity: 97
Census: 47
Deficiencies cited: 16
Fire extinguishers inspected: 15
Fire extinguishers not inspected monthly: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation (complaint IN00412464) regarding the facility's management of residents' personal funds, specifically concerning reconciliation of withdrawals with receipts and provision of quarterly statements.
Complaint Details
This finding relates to complaint IN00412464.
Findings
The facility failed to properly manage Resident Funds for 4 residents by not reconciling withdrawals with receipts and failing to provide quarterly statements to residents or their representatives. Multiple withdrawals lacked corresponding receipts, and quarterly statements were not documented for the previous two quarters.
Deficiencies (1)
Failure to manage Resident Funds in accordance with acceptable accounting principles, including lack of receipts for withdrawals and failure to provide quarterly statements for Residents B, C, D, and E.
Report Facts
Residents with managed personal funds: 40
Withdrawal amount: 500
Withdrawal amount: 100
Withdrawal amount: 300
Withdrawal amount: 100
Withdrawal amount: 2000
Withdrawal amount: 10
Withdrawal amount: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Business Office Manager (C-BOM) | Provided information about resident funds and interviews regarding fund management and lack of quarterly statements. | |
| Activity Director | Indicated she cashed a $500 check for Resident B and gave the cash to the previous Business Office Manager. | |
| Previous Business Office Manager (BOM) | Terminated on 7/3/23 due to poor job performance; responsible for managing resident funds and failing to provide quarterly statements. |
Inspection Report
Routine
Deficiencies: 9
Date: Jul 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, resident funds management, facility cleanliness, nutrition, respiratory care, medication management, and infection control.
Complaint Details
This finding relates to complaint IN00412464 regarding resident funds management.
Findings
The facility was found deficient in multiple areas including failure to resolve resident concerns about laundry and housekeeping, improper management of resident funds including lack of receipts and quarterly statements, failure to notify residents about Medicaid resource limits, poor environmental cleanliness across multiple units, failure to complete significant change assessments for weight loss, lack of physician orders for oxygen administration, incomplete narcotic reconciliation logs, unsecured medication and supply storage, and inadequate infection prevention and control practices including lack of transmission-based precautions and absence of a water-borne pathogen prevention plan.
Deficiencies (9)
Failed to resolve Resident Council concerns related to laundry services and housekeeping services.
Failed to manage Resident Funds in accordance with acceptable accounting principles including lack of receipts and quarterly statements for 4 residents.
Failed to notify residents and/or their representatives when resident funds exceeded Medicaid resource limits.
Failed to maintain a safe, clean, comfortable, and homelike environment in 4 of 6 nursing units and common areas.
Failed to complete a significant change assessment after significant weight loss for 1 resident.
Failed to obtain a physician's order related to oxygen administration for 1 resident.
Failed to ensure narcotic reconciliation counts were completed and acknowledged for 2 medication carts.
Failed to securely and hygienically store drugs, biologicals, and nursing supplies on multiple nursing units.
Failed to implement a water-borne pathogen prevention plan and failed to utilize infection prevention and control strategies for a resident with antibiotic-resistant infection.
Report Facts
Resident Funds balance: 2222.61
Resident Funds balance: 1984.39
Resident Funds balance: 2143.75
Weight loss percentage: 12.7
Weight loss percentage: 11.3
Weight loss percentage: 4.4
Medication carts reviewed: 3
Residents affected: 31
Residents in facility: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laundry Aide 16 | Interviewed regarding laundry services and missing items | |
| Administrator | Provided grievance log and facility policies; commented on management turnover and facility cleanliness | |
| Activity Director | Interviewed regarding resident funds cashing and Medicaid spend down | |
| Corporate Business Office Manager | C-BOM | Provided information on resident funds management and facility policies |
| Housekeeper 15 | Interviewed regarding cleaning standards and observations | |
| Certified Nurse's Aide 9 | CNA 9 | Delivered meal tray and commented on floor cleanliness |
| Certified Nurse's Aide 5 | CNA 5 | Interviewed regarding infection control practices on 600 Unit |
| Qualified Medication Aide 8 | QMA 8 | Interviewed regarding narcotic count and medication cart observations |
| Registered Nurse 7 | RN 7 | Interviewed regarding narcotic count and medication cart observations |
| Licensed Practical Nurse 6 | LPN 6 | Interviewed regarding medication storage room cleanliness and facility environment |
| Certified Nurse's Aide 18 | CNA 18 | Interviewed regarding facility cleanliness |
| Certified Nurse's Aide 19 | CNA 19 | Interviewed regarding floor and toilet cleanliness concerns |
| Qualified Medication Aide 4 | QMA 4 | Interviewed regarding infection control practices on 600 Unit |
| Maintenance Supervisor | Interviewed regarding water system maintenance and pathogen prevention plan | |
| Director of Nursing | DON | Interviewed regarding nutrition assessments, medication logs, infection control, and facility cleanliness |
| Assistant Vice President of Clinical Services | AVP | Interviewed regarding infection control and water testing |
Inspection Report
Recertification
Census: 49
Capacity: 49
Deficiencies: 10
Date: Jul 14, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00412464.
Complaint Details
Complaint IN00412464 was investigated during this survey. Federal/State deficiencies related to the allegations were cited at F568.
Findings
The facility was found deficient in multiple areas including failure to resolve resident council concerns related to laundry and housekeeping services, failure to manage resident funds properly, failure to notify residents of Medicaid resource limits, failure to maintain a clean and homelike environment, failure to complete significant change assessments after weight loss, failure to obtain physician orders for oxygen therapy, failure to complete narcotic reconciliation counts, failure to securely store medications and supplies, failure to implement infection control measures including water-borne pathogen prevention and transmission-based precautions, and failure to maintain complete personnel records.
Deficiencies (10)
Failure to resolve Resident Council concerns related to laundry and housekeeping services.
Failure to manage Resident Funds in accordance with acceptable accounting principles including reconciliation and quarterly statements.
Failure to notify residents and/or their representative when resident funds approached Medicaid resource limits.
Failure to maintain a safe, clean, comfortable, and homelike environment including cleanliness of floors, bathrooms, and common areas.
Failure to complete a significant change assessment after significant weight loss.
Failure to obtain physician order for oxygen administration for a resident receiving oxygen therapy.
Failure to ensure narcotic reconciliation counts were completed and acknowledged for medication carts.
Failure to securely and hygienically store drugs, biologicals, and nursing supplies on nursing units.
Failure to implement a water-borne pathogen prevention plan and failure to utilize infection prevention and control strategies for a resident with antibiotic-resistant infection.
Failure to maintain complete personnel records including reference checks, resident rights training, orientation, physicals, and TB testing.
Report Facts
Survey dates: 2023-07-10 to 2023-07-14
Census: 49
Total Capacity: 49
Residents reviewed for Resident Funds: 4
Residents reviewed for nutrition: 4
Residents reviewed for respiratory care: 2
Residents reviewed for infection control: 6
Employees reviewed for personnel records: 10
Residents in facility: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eileen Thomas | Executive Director | Signed the report |
| QMA 8 | Qualified Medication Aide | Named in narcotic reconciliation deficiency |
| RN 7 | Registered Nurse | Named in narcotic reconciliation deficiency |
| CNA 10 | Certified Nurse Aide | Named in infection control and environmental cleanliness findings |
| Housekeeper 15 | Housekeeper | Named in environmental cleanliness findings |
| DON | Director of Nursing | Named in multiple findings including infection control, environmental cleanliness, and narcotic reconciliation |
| AVP of Clinical Services | Assistant Vice President of Clinical Services | Named in infection control and water-borne pathogen prevention findings |
| Corporate Business Office Manager | Corporate Business Office Manager | Named in resident funds and personnel records findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 30, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00407090 and IN00407500 completed on May 12, 2023.
Complaint Details
This visit was related to complaint investigations IN00407090 and IN00407500. The facility was found in compliance.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 24, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00400512 completed on March 20, 2023.
Complaint Details
Investigation of Complaint IN00400512 completed on March 20, 2023, with findings of compliance.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding delayed and untimely administration of insulin medication to residents at the facility.
Complaint Details
The investigation was triggered by complaints IN00407090 and IN00407500 regarding delayed insulin administration and lack of proper medication documentation. Some residents reported not receiving insulin, and staff acknowledged ongoing issues with timely medication passes and documentation.
Findings
The facility failed to ensure insulin was administered timely according to physician orders for 3 of 4 residents reviewed. Multiple interviews and record reviews revealed repeated delays in insulin administration, lack of proper documentation, and failure to act on high blood glucose readings. Staff reported delays due to medication cart key access and understaffing, and some residents reported not receiving insulin as ordered.
Deficiencies (1)
Failure to ensure insulin was administered timely according to physician orders for 3 of 4 residents reviewed.
Report Facts
Dates of missed insulin administration: 30
Number of residents reviewed for medication administration: 4
Number of residents affected by deficiency: 3
Insulin administration delay frequency: 3
Number of shifts QMA 8 worked with LPN 4: 5
Number of residents for whom LPN 3 administered medications late: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 9 | Registered Nurse | Interviewed regarding medication pass timing and delays due to insulin administration responsibilities. |
| QMA 8 | Qualified Medication Aide | Reported delays in medication administration and worked shifts with LPN 4. |
| DON | Director of Nursing | Provided information on insulin storage, acknowledged resident complaints, and administered insulin during observation. |
| ADON | Assistant Director of Nursing | Acknowledged resident complaints about late insulin administration and lack of documentation. |
| LPN 4 | Licensed Practical Nurse | Regularly administered insulin late and discussed medication administration concerns with management. |
| LPN 3 | Licensed Practical Nurse | Reported delayed medication administration for multiple residents and lack of proper documentation. |
| RN 10 | Registered Nurse | Monitored medication administration documentation and reported concerns regarding lack of insulin administration. |
| Corporate RN 10 | Corporate Registered Nurse | Was made aware of insulin administration concerns but issues persisted. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Date: May 11, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407090 and IN00407500 regarding medication administration and quality of care concerns.
Complaint Details
Complaints IN00407090 and IN00407500 triggered the investigation. Both complaints cited federal/state deficiencies related to insulin administration delays and quality of care issues.
Findings
The facility failed to ensure timely administration of insulin according to physician orders for 3 of 4 residents reviewed (Residents C, D, and E). Multiple interviews and record reviews confirmed delays in insulin administration, lack of documentation, and failure to report blood glucose results outside parameters. The facility acknowledged these issues and implemented corrective actions including staff education and increased monitoring.
Deficiencies (1)
Failure to ensure insulin was administered timely according to physician orders for 3 of 4 residents reviewed for medication administration (Residents C, D, and E).
Report Facts
Residents reviewed for medication administration: 4
Facility census: 49
Licensed capacity: 49
Insulin administration delays: 3
Dates insulin not administered: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Miller | Chief Nursing Officer | Signed the report |
| LPN 4 | Named in findings related to delayed insulin administration and lack of documentation | |
| RN 9 | Interviewed regarding medication pass delays | |
| QMA 8 | Interviewed regarding insulin administration delays | |
| DON | Director of Nursing | Interviewed regarding insulin storage and administration issues |
| Corporate RN 10 | Named in interviews as aware of insulin administration concerns | |
| LPN 3 | Interviewed regarding medication administration delays and resident complaints |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404695 and IN00405540.
Complaint Details
Complaint IN00404695 and Complaint IN00405540 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00404695 and IN00405540 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 50
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 45
Census Payor Type - Other: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00399265, IN00399287, and IN00399788 completed on January 24, 2023.
Complaint Details
The visit was related to complaint investigations IN00399265, IN00399287, and IN00399788. The facility was found to be in compliance.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 55
Capacity: 55
Deficiencies: 2
Date: Mar 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00400512 and IN00404198. Complaint IN00400512 had no deficiencies related to the allegations, while Complaint IN00404198 resulted in federal/state deficiencies being cited.
Complaint Details
Complaint IN00404198 was substantiated with federal/state deficiencies cited at F685 and F687. Complaint IN00400512 had no deficiencies related to the allegations.
Findings
The facility failed to ensure that a resident (Resident B) received proper vision, hearing, and foot care services as ordered. Specifically, the resident did not receive timely optometry, ENT, and podiatry services despite physician orders and requests, and there was misinformation about insurance coverage. The facility lacked documentation of attempts to schedule these services.
Deficiencies (2)
Failed to ensure a resident who wore glasses and had a history of ear wax build-up received optometry and ENT services as ordered.
Failed to ensure a resident with diabetes had foot care needs addressed, including podiatry services.
Report Facts
Census: 55
Total Capacity: 55
Medicare Census: 5
Medicaid Census: 40
Other Payor Census: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Miller | Chief Nursing Officer | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 20, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00404198) regarding the facility's failure to ensure a resident (Resident B) received appropriate vision, hearing, and podiatry services as ordered by physicians.
Complaint Details
This finding relates to Complaint IN00404198. The complaint involved failure to provide ordered ENT, optometry, and podiatry services to Resident B, with no documentation of appointments or scheduling attempts, and confusion regarding insurance coverage.
Findings
The facility failed to ensure Resident B received ENT and optometry services as ordered, and there was no documentation of attempts to schedule these appointments. Additionally, the facility did not ensure appropriate foot care for the diabetic resident, with no record of podiatry visits or scheduling attempts. The Social Services Director had left without notice, and relevant insurance coverage information was not found.
Deficiencies (2)
Failed to assist a resident in gaining access to vision and hearing services as ordered.
Failed to provide appropriate foot care for a diabetic resident, including failure to ensure podiatry services were provided.
Report Facts
Residents reviewed for vision and hearing services: 3
Residents reviewed for podiatry services: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding lack of records for Resident B's ENT, optometry, and podiatry visits. |
| Social Services Director | Social Services Director | Mentioned as having told Resident B that insurance would not cover certain services; left without notice and facility could not locate information obtained by this person. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Jan 23, 2023
Visit Reason
This visit was for the investigation of three substantiated complaints (IN00399265, IN00399287, IN00399788) concerning resident care, pharmacy services, and kitchen sanitation.
Complaint Details
Complaint IN00399265 - Substantiated with deficiencies related to insulin administration and blood sugar monitoring. Complaint IN00399287 - Substantiated with deficiencies related to linens cleanliness and condition. Complaint IN00399788 - Substantiated with deficiencies related to kitchen sanitation.
Findings
The facility was found deficient in maintaining clean and good condition linens, ensuring proper monitoring and administration of insulin for residents, and maintaining the kitchen in a sanitary manner. Multiple residents' clinical records showed missing documentation of blood sugar monitoring and insulin administration. The kitchen had visible debris and unsanitary conditions during observations.
Deficiencies (3)
Facility failed to ensure linens were kept clean and in good condition.
Facility failed to ensure resident's blood sugars were monitored and insulin was administered per order for 5 of 5 residents reviewed.
Facility failed to ensure the kitchen was maintained in a sanitary manner during two observations.
Report Facts
Census: 51
Insulin dependent residents: 19
Residents reviewed for insulin administration: 5
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Nordhoff | Laboratory Director or Provider/Supplier Representative | Signed the report |
Inspection Report
Life Safety
Census: 53
Capacity: 97
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
A Post Survey Revisit to the PSR conducted on 11/15/22 to the Life Safety Code Recertification and State Licensure Survey conducted on 09/23/22 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Envive of Anderson was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for one detached garage.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
This visit was conducted for the investigation of three complaints: IN00395503, IN00393590, and IN00393602.
Complaint Details
Complaint IN00395503 - Unsubstantiated due to lack of evidence. Complaint IN00393590 - Unsubstantiated due to lack of evidence. Complaint IN00393602 - Unsubstantiated due to lack of evidence.
Findings
All three complaints were found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 54
Census Payor Type: 5
Census Payor Type: 49
Inspection Report
Re-Inspection
Census: 52
Capacity: 97
Deficiencies: 3
Date: Nov 15, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code surveys conducted on 09/23/22 to verify correction of cited deficiencies.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to deficiencies related to sprinkler system installation, corridor door functionality, and electrical light fixture safety. Plans of correction were required to address these issues.
Deficiencies (3)
Failed to maintain ceiling sprinkler head escutcheons in accordance with NFPA 13; sprinkler heads were missing escutcheons and some were hanging down leaving gaps.
One corridor double door set on the 400 hall failed to close and latch properly, impeding smoke resistance.
Seven electrical light fixtures in the corridor next to the dining room were maintained in unsafe condition with exposed wiring and temporary receptacles dangling from the ceiling.
Report Facts
Certified beds: 97
Census: 52
Light fixtures: 7
Affected staff: 6
Affected residents: 15
Affected residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Ngene | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| Administrator | Acknowledged deficiencies during observations and interviews. | |
| Maintenance Supervisor | Acknowledged deficiencies and provided explanations during observations and interviews. |
Inspection Report
Re-Inspection
Census: 47
Capacity: 47
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2022-08-30, including a PSR to the Investigation of Complaint IN00388147 completed on 2022-08-30.
Complaint Details
Complaint IN00388147 was investigated and found to be corrected.
Findings
Envive of Anderson was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00388147.
Report Facts
Census SNF/NF beds: 47
Census Medicare residents: 2
Census Medicaid residents: 45
Inspection Report
Routine
Census: 44
Capacity: 97
Deficiencies: 19
Date: Sep 23, 2022
Visit Reason
A routine Emergency Preparedness and Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to life safety, fire safety, emergency preparedness communication, corridor obstructions, exit access, fire door maintenance, fire alarm system security and testing, sprinkler system maintenance, smoking regulations, electrical safety, and use of portable heaters.
Deficiencies (19)
Failed to ensure emergency preparedness plan includes a method for sharing information with residents and families.
Failed to maintain latching hardware on 2 of 2 smoke barrier doors.
Failed to maintain means of egress free of obstructions; gas grill blocking exit discharge sidewalk.
Failed to ensure means of egress through 3 of 8 exits was readily accessible; exit door codes not posted visibly.
Failed to maintain corridor means of egress free of obstructions; pallet and beds obstructing 600 hall.
Failed to ensure exit discharge passageways had level walking surface free of obstructions; blacktop pathways cracked and uneven.
Failed to document annual testing for all battery backup emergency lights and failed to ensure exterior emergency lighting connected to generator.
Failed to ensure propane tanks stored properly away from ignition sources; gas grill removed.
Failed to ensure corridor doors to hazardous rooms were equipped with self-closing devices.
Failed to ensure staff were instructed in the use of UL 300 hood system in kitchen; dietary manager unaware of proper fire response.
Failed to ensure fire alarm control panel was locked to prevent unauthorized use.
Failed to ensure fire alarm system was continuously in proper operating condition; smoke detectors taped closed during construction.
Failed to ensure sprinkler heads in kitchen cooler were not loaded or covered with foreign material.
Failed to provide complete written policy for sprinkler system impairment and fire watch notification procedures.
Failed to ensure corridor doors had no impediment to closing and latching to resist passage of smoke.
Failed to ensure smoking materials were deposited into ashtrays and metal containers with self-closing covers in outdoor smoking areas.
Failed to ensure portable space heaters were not used in the facility.
Failed to ensure electrical panels in corridors were secured from non-authorized personnel.
Failed to ensure power strips were not used as substitute for fixed wiring for high current draw equipment.
Report Facts
Certified beds: 97
Census: 44
Deficiency completion date: Sep 30, 2022
Deficiency completion date: Oct 30, 2022
Deficiency completion date: Apr 30, 2023
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 10
Date: Aug 30, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaint IN00388147.
Complaint Details
Complaint IN00388147 was substantiated with federal/state deficiencies cited at F684.
Findings
The facility was found deficient in multiple areas including failure to ensure accurate advanced directives documentation, failure to provide transfer/discharge notices, incomplete Minimum Data Set assessments, failure to complete PASRR assessments, quality of care issues including insulin administration errors and wound care, failure to assess elopement risk and smoking status, inadequate dialysis care documentation, lack of staff competency in wound vac management, failure to monitor and reduce antipsychotic medications appropriately, and medication administration errors.
Deficiencies (10)
Failed to ensure a resident's clinical record, care plan, and orders accurately reflected his chosen advanced directive/code status.
Failed to provide written transfer and discharge notice and notify the Ombudsman for 4 residents.
Failed to ensure Minimum Data Set (MDS) assessments were completely and accurately completed for 2 residents.
Failed to ensure PASRR assessments were completed for 1 of 3 residents reviewed.
Failed to clarify insulin order, administer insulin, monitor blood sugar, maintain wound vac, and obtain weights as ordered, resulting in harm.
Failed to assess a newly admitted resident for elopement risk and failed to complete smoking assessments for a resident who smoked.
Failed to provide pre- and post-dialysis nursing services and maintain dialysis communication for 2 residents.
Failed to ensure staff was trained to properly manage a physician prescribed wound vacuum for 1 resident.
Failed to identify and monitor targeted behaviors or develop non-chemical interventions for reduction or elimination of antipsychotic medications for 1 resident.
Failed to administer medications according to manufacturers guidelines and physician orders resulting in an 8.33% medication error rate.
Report Facts
Survey dates: 7
Census: 45
Total capacity: 45
Medication error rate: 8.33
Weight gain: 37.7
Blood sugar reading: 560
Days without insulin: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in wound vac malfunction and insulin administration findings |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including advanced directives, transfer notices, MDS, dialysis, wound care, and behavior monitoring |
| QMA 9 | Qualified Medication Aide | Named in medication administration observation for nasal spray |
| Nurse Consultant | Provided multiple facility policies and interviewed regarding deficiencies |
Inspection Report
Re-Inspection
Census: 45
Capacity: 45
Deficiencies: 0
Date: Aug 19, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigations of Complaints IN00385994, IN00383702, and IN00380088 to verify correction of previously identified deficiencies.
Complaint Details
This visit was related to complaint investigations IN00385994, IN00383702, and IN00380088. All complaints were found to be corrected.
Findings
The facility was found to be in compliance with relevant regulations, and all three complaints were corrected as of the survey dates.
Report Facts
Census SNF/NF beds: 45
Census Medicare residents: 5
Census Medicaid residents: 40
Inspection Report
Re-Inspection
Census: 45
Capacity: 45
Deficiencies: 0
Date: Aug 19, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigations of Complaints IN00380088, IN00383702, and IN00385994, to verify correction of previously identified deficiencies.
Complaint Details
This visit was related to complaint investigations IN00380088, IN00383702, and IN00385994. All complaints were corrected as of this visit.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSRs to the investigations of the complaints. All three complaints were corrected.
Report Facts
Census Bed Type: 45
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 40
Inspection Report
Re-Inspection
Census: 45
Capacity: 45
Deficiencies: 0
Date: Aug 19, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigations of Complaints IN00383702, IN00385994, and IN00380088 to verify correction of previous deficiencies.
Complaint Details
This visit was related to complaint investigations IN00383702, IN00385994, and IN00380088. All complaints were corrected as of this visit.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSRs to the investigations of the complaints. All cited complaints were corrected.
Report Facts
Census SNF/NF beds: 45
Census Medicare residents: 5
Census Medicaid residents: 40
Total census: 45
Total capacity: 45
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 1
Date: Jul 26, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00385994 and IN00386469, including a COVID-19 Focused Infection Control Survey. Complaint IN00385994 was substantiated, while Complaint IN00386469 was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00385994 was substantiated with federal/state deficiencies cited at F686. Complaint IN00386469 was unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure wound treatments were provided per physician orders for 2 of 4 residents reviewed for wound care (Resident B and Resident D). Multiple instances of missing documentation for wound care treatments were noted, and the Director of Nursing acknowledged treatments should have been given and documented as ordered.
Deficiencies (1)
Failed to ensure wound treatments were provided per physician order for 2 of 4 residents reviewed for wound care (Resident B and Resident D).
Report Facts
Census: 46
Total Capacity: 46
Medicare Census: 18
Medicaid Census: 28
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