Inspection Report Summary
The most recent inspection on May 20, 2025, identified deficiencies related to discharge from exits, corridor door fire safety features, and electrical equipment testing, all of which had temporary waivers approved until October 31, 2025. Earlier inspections showed a pattern of Life Safety Code and emergency preparedness issues, including corridor obstructions, door latching problems, and electrical system maintenance, as well as medication management and resident care deficiencies. Complaint investigations revealed some substantiated deficiencies, notably related to food storage sanitation, failure to safely transfer a resident causing injury, and incomplete abuse investigations, while most other complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspections show ongoing challenges with fire safety and emergency preparedness, though some issues have been temporarily waived or corrected over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
33.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
693% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
55% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 55
Capacity: 100
Deficiencies: 3
Date: May 20, 2025
Visit Reason
This was a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 04/02/2025, to verify compliance with federal regulations and state licensure requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, except for deficiencies related to discharge from exits, corridor doors, and electrical equipment testing and maintenance, all of which had temporary waivers approved until 10/31/2025.
Deficiencies (3)
Discharge from exits was not maintained free of obstructions and did not provide a hard packed all-weather travel surface.
Corridor doors did not meet requirements for smoke resistance, positive latching hardware, and other fire safety features.
Electrical equipment testing and maintenance requirements were not met, including physical integrity and safety testing of patient-care related electrical equipment.
Report Facts
Certified beds: 100
Census: 55
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 5, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Envive of Lawrenceburg 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: 50
Capacity: 100
Deficiencies: 10
Date: Apr 2, 2025
Visit Reason
The Indiana Department of Health conducted an Annual Survey including Emergency Preparedness and Life Safety Code Recertification to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Emergency Preparedness requirements, Life Safety Code, and other regulatory standards including generator testing, means of egress obstructions, corridor door latching, cooking equipment placement, smoke barrier penetrations, evacuation plans, and electrical equipment maintenance.
Deficiencies (10)
Failed to implement emergency power system inspection, testing, and maintenance requirements.
Failed to ensure 3 of over 4 means of egress were free of obstructions.
Failed to ensure 1 of over 4 exit discharges had a level walking surface and was free of obstructions.
Failed to provide an approved method for returning cooking appliances to approved design location under kitchen hood extinguishing system.
Failed to ensure all corridor doors had no impediment to closing and latching to resist passage of smoke.
Failed to protect penetrations through smoke barrier walls to maintain smoke resistance.
Failed to provide a written fire safety plan addressing all required components including relocation of wheeled equipment during emergencies.
Failed to exercise the emergency generator monthly with proper load documentation for 12 months.
Failed to ensure flexible cord power strips in patient care locations met required UL ratings.
Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE).
Report Facts
Certified beds: 100
Census: 50
Deficiencies cited: 10
Date of Completion: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peninah Wood | Executive Director | Named in relation to exit conference and plan of correction |
| Maintenance Director | Interviewed and acknowledged deficiencies related to maintenance and safety |
Inspection Report
Annual Inspection
Census: 48
Capacity: 48
Deficiencies: 5
Date: Mar 17, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted March 11-17, 2025.
Findings
The facility was found deficient in multiple areas including failure to follow insulin pen manufacturer guidelines, inadequate investigation of an accident hazard, failure to provide physician-ordered nutritional supplements, improper medication storage and labeling, and failure to follow infection control hand hygiene protocols during medication administration.
Deficiencies (5)
Facility failed to follow the manufacturer's guidelines related to insulin pen usage for 1 of 5 residents observed for medication administration (Resident 12).
Facility failed to ensure an accident hazard was thoroughly investigated after a resident acquired a fracture and laceration to her thumb for 1 of 3 residents reviewed for accident hazards (Resident 13).
Facility failed to provide physician ordered nutritional supplements for 1 of 2 residents reviewed for nutrition (Resident 29).
Facility failed to store medications appropriately related to labeling medications, cleanliness of medication carts, loose pills, discontinued medications, and expired medications for 2 of 3 Medication Carts and 1 of 2 Medication Storage areas reviewed.
Facility failed to follow appropriate infection control guidelines during medication administration related to hand hygiene for 2 of 5 residents observed (Residents 28 and 18).
Report Facts
Census Bed Type: 48
Medicare Census: 8
Medicaid Census: 29
Other Payor Census: 11
Deficiencies cited: 5
Discontinued medication counts: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peninah Wood | Executive Director | Signed the report and mentioned in the plan of correction |
| RN 7 | Registered Nurse | Observed insulin administration and interviewed regarding insulin pen usage |
| LPN 2 | Licensed Practical Nurse | Involved in accident investigation for Resident 13 |
| ADON | Assistant Director of Nursing | Provided policies and interviewed regarding accident investigation and nutritional supplement ordering |
| LPN 4 | Licensed Practical Nurse | Observed medication cart issues and interviewed about discontinued medications |
| LPN 5 | Licensed Practical Nurse | Observed medication cart issues on second floor |
| RN 6 | Registered Nurse | Observed medication storage and interviewed about medication labeling and storage |
| QMA 8 | Qualified Medication Aide | Observed medication administration with hand hygiene deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00442330.
Complaint Details
Complaint IN00442330 was investigated and corrected as of October 2, 2024.
Findings
Envive of Lawrenceburg 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: 38
Capacity: 38
Deficiencies: 1
Date: Oct 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442330 related to food storage and sanitation practices in the facility kitchen.
Complaint Details
Complaint IN00442330 was substantiated with a Federal/State deficiency cited at F812 related to food procurement, storage, preparation, and serving sanitary practices.
Findings
The facility failed to store food appropriately during one of two kitchen observations, including undated and expired food items found in refrigerators and dry storage. Immediate corrective actions were taken to discard all unlabeled, outdated, and expired foods, and staff education was provided on proper food storage policies.
Deficiencies (1)
Failed to store food appropriately for 1 of 2 kitchen observations, including undated and expired food items.
Report Facts
Census: 38
Total Capacity: 38
Medicare Census: 5
Medicaid Census: 33
Audit Frequency: 2
Audit Duration: 4
QAPI Review Duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peninah Wood | Executive Director | Named as responsible party for plan of correction and monitoring corrective actions |
| Cook 2 | Interviewed regarding kitchen food storage practices and resident census | |
| Director of Nursing | Director of Nursing | Provided facility policy on kitchen operations and food storage |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 30, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00440606 completed on August 13, 2024.
Complaint Details
Investigation of Complaint IN00440606 completed on August 13, 2024; paper compliance review found facility in compliance.
Findings
Envive of Lawrenceburg 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: 36
Capacity: 36
Deficiencies: 1
Date: Aug 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440606 regarding allegations of abuse at Envive of Lawrenceburg.
Complaint Details
Complaint IN00440606 was substantiated with a deficiency cited at F610. The resident alleged being locked in a closet and room and being choked, but assessments found no injuries. The resident has a history of hallucinations and delusions. The investigation was limited by residents' cognitive impairments and non-interviewability. The facility failed to interview other residents adequately.
Findings
The facility failed to thoroughly investigate a resident's allegation of abuse for 1 of 1 abuse allegations reviewed. The resident alleged physical abuse, but no injuries were found and the investigation concluded the allegations were likely delusions related to the resident's psychiatric history.
Deficiencies (1)
Facility failed to thoroughly investigate a resident's allegation of abuse for 1 of 1 abuse allegations reviewed. (Resident B)
Report Facts
Census: 36
Licensed Capacity: 36
Residents assessed for bruises: 7
Residents not assessed: 13
Interviewable residents not assessed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith McKee | Executive Director | Signed report and involved in investigation oversight |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints numbered IN00437713, IN00438353, IN00438614, IN00439037, IN00439001, and IN00439722.
Complaint Details
Complaints IN00437713, IN00438353, IN00438614, IN00439037, IN00439001, and IN00439722 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 37
Census Payor Type Medicare: 1
Census Payor Type Medicaid: 36
Inspection Report
Re-Inspection
Census: 41
Capacity: 100
Deficiencies: 2
Date: Jun 13, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Life Safety Code Recertification and State Licensure Survey conducted on 03/18/24 and the PSR survey conducted on 05/14/24 by the Indiana Department of Health.
Findings
At this PSR survey, Envive of Lawrenceburg was found in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards. The facility was fully sprinklered except for the detached outdoor oxygen storage area, and had a fire alarm system with smoke detection on all levels. Two deficiencies related to corridors and electrical systems were temporarily waived from 03/18/24 to 12/01/24.
Deficiencies (2)
Corridors - Areas Open to Corridor did not meet requirements under NFPA 101 but this tag is temporarily waived from 03/18/24 to 12/01/24.
Electrical Systems - Other did not meet NFPA 101 requirements but this tag is temporarily waived from 03/18/24 to 12/01/24.
Report Facts
vent unit bed locations: 8
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433226 and IN00434862.
Complaint Details
Complaint IN00433226 and Complaint IN00434862 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00433226 and IN00434862 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 42
Medicare Census: 4
Medicaid Census: 32
Other Payor Census: 6
Inspection Report
Re-Inspection
Census: 40
Capacity: 100
Deficiencies: 1
Date: May 14, 2024
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 03/18/2024, to verify compliance with Emergency Preparedness Requirements and Life Safety Code.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. A deficiency was cited related to the use of an extension cord/power strip as a substitute for fixed wiring in a patient care vicinity.
Deficiencies (1)
Use of an extension cord/power strip as a substitute for fixed wiring in the patient care vicinity in resident sleeping Room 108.
Report Facts
Certified beds: 100
Census: 40
Vent unit bed locations: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith McKee | interim ED | Signed the report |
| Director of Maintenance | Named in deficiency related to power strip use and corrective actions | |
| Executive Director | Educated Director of Maintenance on power strip usage and responsible for audit results presentation |
Inspection Report
Re-Inspection
Census: 44
Capacity: 44
Deficiencies: 0
Date: Mar 28, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on February 9, 2024.
Findings
Envive of Lawrenceburg 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.
Report Facts
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 33
Inspection Report
Annual Inspection
Census: 50
Capacity: 100
Deficiencies: 28
Date: Mar 18, 2024
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness plan deficiencies, fire safety issues, corridor obstructions, door latching problems, sprinkler system maintenance, electrical system deficiencies, and improper storage of oxygen and combustible materials.
Deficiencies (28)
Failed to maintain an emergency preparedness plan reviewed and updated annually.
Failed to maintain an emergency preparedness plan based on all hazards risk assessment.
Failed to develop and implement emergency preparedness policies and procedures reviewed and updated annually.
Failed to develop and maintain an emergency preparedness communication plan reviewed and updated annually.
Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually.
Failed to conduct exercises to test the emergency plan annually and maintain documentation.
Failed to ensure exit door by Therapy Room was not a delayed egress door and signage was incorrect.
Failed to ensure corridor door to second floor nurses station latches properly.
Failed to maintain building construction type as permitted; penetrations in walls and wood framing in kitchen storage room.
Failed to maintain vertical openings enclosure; stairwell doors on third floor did not latch and one-foot opening in concrete block shaft wall.
Failed to separate hazardous areas (Activity Room and Employee Only room) with smoke resistant partitions and self-closing doors.
Failed to ensure cooktop stove/oven in therapy room had a disconnect switch and baffles above cooktop were out of place.
Failed to ensure interior wall and ceiling finishes had flame spread rating of Class A or B; wallpaper observed with no documentation.
Failed to ensure portable fire extinguisher in basement medical record room was mounted properly.
Failed to inspect portable fire extinguishers monthly in lobby, therapy room, and basement medical record room.
Failed to ensure locks on marketing closet and beauty salon bathroom door could be unlocked from inside in case of emergency.
Failed to maintain corridor width of at least 60 inches due to storage of Hoyer lift in third floor corridor.
Failed to ensure corridor doors to resident rooms, medical record room, and mechanical room latched properly.
Failed to ensure corridor door to Therapy Room on first floor had positive latching device; door remained unlocked.
Failed to ensure laundry chute door on third floor self-closed and latched properly.
Failed to conduct quarterly fire drills for all shifts; missing documentation for third quarter second shift fire drill.
Failed to store unattended trash receptacles with capacity greater than 32 gallons in a room protected as a hazardous area.
Failed to ensure cover plates were installed on electrical receptacles in maintenance office and electrical panel room.
Failed to ensure all circuits on life safety branch supply power to circuits essential for life safety; mixed circuits observed.
Failed to ensure all circuits on critical branch supply power to critical branch functions related to patient care; mixed circuits observed.
Failed to ensure power strips in patient care vicinity were not used as substitute for fixed wiring; power strips found in resident rooms.
Failed to ensure indoor oxygen storage area was designed, constructed, and ventilated per NFPA 99; combustible materials stored near oxygen container.
Failed to protect resident sleeping room from use of liquid oxygen containers; room not separated by fire barriers with 1-hour rating.
Report Facts
Certified beds: 100
Census: 50
Vent unit beds: 8
Fire drills missing: 1
Trash receptacle capacity: 64
Liquid oxygen container capacity: 31.6
Emergency generator rating: 100
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 7
Date: Feb 5, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted February 5-9, 2024.
Findings
The facility was found deficient in multiple areas including failure to provide a homelike environment due to loose wires in shower rooms, incomplete care plans for skin impairments and oral health, failure to follow physician orders for insulin administration, inadequate monitoring of dialysis access site, medication transcription errors on admission, improper medication storage and labeling, and an incomplete facility assessment.
Deficiencies (7)
Failed to provide a homelike setting for 7 of 14 residents using shower rooms related to loose wires hanging from walls.
Failed to ensure care plans were in place for residents related to risk for skin impairments, oral health status, and monitoring of seat belt and positioning device use for 3 of 14 residents.
Failed to follow physician's orders for insulin administration and manufacturer's guidelines for insulin pen usage for 2 of 6 residents.
Failed to adequately monitor dialysis access site for 1 of 2 residents receiving dialysis treatments.
Failed to transcribe medication orders on admission for 1 of 5 residents reviewed.
Failed to store medications appropriately in 2 of 3 medication rooms and 2 of 3 medication carts reviewed.
Failed to ensure a complete and accurate facility assessment based on resident population and resources needed for care.
Report Facts
Census: 49
Residents affected by homelike environment deficiency: 7
Residents reviewed for care plans: 14
Residents affected by care plan deficiency: 3
Residents observed for quality of care: 6
Residents affected by insulin administration deficiency: 2
Residents receiving dialysis: 2
Residents affected by dialysis monitoring deficiency: 1
Residents reviewed for pharmacy services: 5
Residents affected by medication transcription deficiency: 1
Medication rooms reviewed: 3
Medication carts reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gary Preece | Executive Director | Signed report and involved in facility assessment correction |
| Director of Nursing | Provided care plans, medication policies, and interviews related to deficiencies | |
| Maintenance Director | Interviewed regarding loose wires in shower rooms | |
| Vice President of Clinical Services | Provided policies and contract information | |
| RN 3 | Interviewed regarding dialysis and medication room observations | |
| RN 5 | Observed medication administration and medication room access | |
| LPN 4 | Interviewed regarding medication transcription error | |
| DNS (Director of Nursing Services) | Provided education and monitoring plans for multiple deficiencies | |
| DHS (Director of Health Services) | Responsible for dialysis and medication monitoring compliance | |
| ADON (Assistant Director of Nursing) | Provided medication storage policies |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00423642.
Complaint Details
Complaint IN00423642 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 relevant regulations.
Report Facts
Medicare census: 4
Medicaid census: 39
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00421152, IN00422285, IN00423391, and IN00423443 at Envive of Lawrenceburg.
Complaint Details
Complaints IN00421152, IN00422285, IN00423391, and IN00423443 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of complaints.
Report Facts
Census SNF/NF: 46
Census Payor Type Medicare: 3
Census Payor Type Medicaid: 39
Census Payor Type Other: 4
Inspection Report
Re-Inspection
Census: 42
Capacity: 42
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00414379 and IN00413989 completed on 2023-08-10.
Complaint Details
This visit was related to the investigation of complaints IN00414379 and IN00413989. Both complaints were corrected.
Findings
Both complaints IN00414379 and IN00413989 were found to be corrected. The facility 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.
Report Facts
Census SNF/NF: 42
Total Capacity: 42
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 39
Census Payor Type Other: 1
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414379 and IN00413989 regarding alleged deficiencies at Envive of Lawrenceburg.
Complaint Details
Complaint IN00414379 and IN00413989 were investigated. Both complaints resulted in federal/state deficiencies cited at F689 related to failure to transfer a resident safely, causing injury.
Findings
The facility failed to safely transfer a resident requiring a full body mechanical lift using the appropriate lift, resulting in a fracture for 1 of 3 residents reviewed for accidents. The full body mechanical lift was not working on the day of the incident, and an alternative standing aid transfer system was used, which was not appropriate for the resident's condition.
Deficiencies (1)
Failed to transfer a resident requiring a full body mechanical lift safely using the appropriate lift, resulting in a fracture.
Report Facts
Census: 46
Residents requiring full body mechanical lift: 14
Medicare residents: 4
Medicaid residents: 34
Other residents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Miller | Chief Nursing Officer | Signed the report and provided facility policy information |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408789.
Complaint Details
Investigation of Complaint IN00408789; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 38
Census Bed Type: 38
Census Payor Type: 38
Inspection Report
Follow-Up
Census: 40
Capacity: 100
Deficiencies: 0
Date: May 1, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Life Safety Code Recertification and State Licensure Survey to verify compliance with previous findings.
Findings
At this PSR survey, Envive of Lawrenceburg was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. The facility was fully sprinklered with a fire alarm system and smoke detection throughout all resident areas.
Report Facts
vent unit bed locations: 8
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406825.
Complaint Details
Complaint IN00406825 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: 40
Medicare residents: 4
Medicaid residents: 32
Other payor residents: 4
Inspection Report
Re-Inspection
Census: 36
Capacity: 100
Deficiencies: 9
Date: Mar 30, 2023
Visit Reason
Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted to verify compliance and correction of previous deficiencies.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements, with multiple deficiencies related to fire safety barriers, fire door inspections, electrical system separations, receptacle counts at vent unit beds, improper use of power strips, and unsecured oxygen storage room.
Deficiencies (9)
Failed to ensure hazardous areas such as fuel fired heater rooms were separated by smoke resistant partitions and doors that self-close and latch.
Failed to ensure openings through ceiling smoke barriers were protected to maintain fire resistance rating.
Failed to ensure annual inspection and testing of all fire door assemblies including oxygen storage room doors.
Failed to ensure all circuits on the life safety branch supply power to circuits essential for life safety were separated from non-life safety circuits.
Failed to ensure all circuits on the critical branch supply power to critical branch functions related to patient care were separated from non-critical circuits.
Failed to ensure equipment branch circuits were connected to equipment in accordance with NFPA 99 and separated from non-equipment branch circuits.
Failed to ensure minimum number of electrical receptacles (14) were installed at vent unit bed locations.
Failed to ensure power strips were not used as a substitute for fixed wiring; a power strip was used for a refrigerator and microwave in Social Services office.
Failed to ensure oxygen storage and transfilling room door was locked to secure against unauthorized entry.
Report Facts
Certified beds: 100
Census: 36
Vent unit bed locations: 8
Receptacles: 10
Receptacles: 8
Receptacles: 12
Receptacles: 8
Receptacles: 12
Receptacles: 6
Emergency generator rating: 100
Power strips: 1
Oxygen containers: 3
Oxygen cylinders: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Miller | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Maintenance Director | Interviewed and involved in observations and corrective actions for multiple deficiencies | |
| Executive Director | Interviewed and involved in exit conference and corrective actions |
Inspection Report
Re-Inspection
Census: 33
Capacity: 33
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on January 9, 2023.
Findings
Envive of Lawrenceburg 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.
Report Facts
Census Bed Type: 33
Census Payor Type: 33
Inspection Report
Routine
Census: 32
Capacity: 100
Deficiencies: 22
Date: Jan 30, 2023
Visit Reason
A routine Emergency Preparedness and Life Safety Code Recertification survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code, and other regulatory standards. Deficiencies included lack of emergency preparedness training documentation, inadequate emergency generator testing and fuel quality testing, improper building construction type, obstructed means of egress, improperly secured fire and smoke doors, electrical safety issues including unsecured electrical panels and improper circuit separation, inadequate fire drills documentation, and improper storage of oxygen containers.
Deficiencies (22)
Failed to ensure emergency preparedness training and testing program includes a training program with documentation and staff knowledge demonstration.
Failed to implement emergency power system inspection, testing, and maintenance requirements including weekly generator inspections and annual fuel quality testing.
Building construction type was not maintained as permitted; wood framing used in basement closet wall changed construction type to Type V (000) which is not allowed for a three story sprinklered building.
Means of egress was obstructed by beds and recycling carts in corridors.
Doors in required means of egress were locked with keypad codes not posted, restricting egress accessibility.
Battery powered emergency lighting failed to illuminate when tested.
Vertical openings in stairwells were not properly fire caulked to maintain fire resistance rating.
Hazardous areas such as laundry, nurse supply, and water heater rooms had doors propped open or failed to self-close and latch.
Fire alarm system circuit breaker disconnecting means was not locked and accessible only to authorized personnel.
Incomplete fire alarm system out-of-service policy lacking procedures for notification and fire watch requirements.
Sprinkler system inspections were not documented monthly for the entire twelve-month period; missing documentation for 8 months.
Sprinkler system deficiencies including obstruction of sprinkler spray pattern by privacy curtains hung less than 18 inches below sprinkler deflectors and missing ceiling tiles in basement delaying sprinkler activation.
Corridor walls had unsealed penetrations allowing smoke passage.
Corridor doors in basement had impediments preventing closing and latching to resist smoke passage.
Smoke barrier doors on first, second, and third floors did not fully self-close to restrict smoke movement.
Electrical panels in corridors were unsecured and accessible to unauthorized personnel.
Electrical outlet box outside Room 205 had a cracked faceplate.
Elevator firefighter's service recall testing was not documented monthly for the most recent twelve-month period.
Electrical circuits for life safety, critical, and equipment branches were not separated as required, mixing circuits for call lights, fire alarm, emergency generator, and others.
Minimum number of electrical receptacles required at vent unit bed locations was not met; use of power strips as substitute for fixed wiring was observed.
Power strips and extension cords were used improperly as substitutes for fixed wiring in patient care vicinities.
Oxygen container was stored in an unsecured room used as office and nursing supply storage instead of a secured oxygen storage room.
Report Facts
Certified beds: 100
Current census: 32
Deficiency count: 22
Weekly generator inspections missing: 12
Vent unit bed locations: 8
Fire drills missing documentation: 2
Fire door inspection missing: 12
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 10
Date: Jan 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00392002.
Complaint Details
Complaint IN00392002 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The facility was cited for multiple deficiencies including failure to develop comprehensive care plans for residents with specialized needs, incomplete discharge summaries, worsening pressure ulcers, failure to follow physician orders for UTI antibiotic administration, inadequate monitoring and dressing changes for PICC lines, failure to provide required RN coverage, and failure to offer influenza, pneumococcal, and COVID-19 vaccines to a resident.
Deficiencies (10)
Failed to develop Care Plans related to a resident having a tracheostomy, an intravenous catheter, and an indwelling urinary catheter for 3 of 17 residents' care plans reviewed.
Failed to complete a discharge summary for 1 of 4 residents reviewed for discharge.
Failed to ensure residents had not acquired in house pressure ulcers and the worsening of pressure ulcers for 3 of 4 residents reviewed for pressure ulcers.
Failed to follow physician orders related to antibiotic use for a UTI for 1 of 2 residents reviewed for UTI's.
Failed to ensure a resident with a PICC line was monitored and dressing changes completed for 1 of 2 residents reviewed for IV medication administration.
Failed to appropriately manage a resident's respiratory needs related to dating equipment for 1 of 5 residents observed for respiratory care.
Failed to provide the required RN on duty for eight hours a day for 4 of the 16 days reviewed.
Failed to demonstrate that ongoing corrective actions were in place to address unresolved quality deficiencies related to pressure ulcers, previously cited on the last annual survey.
Failed to offer a resident influenza and pneumococcal vaccines for 1 of 5 residents reviewed for immunizations.
Failed to offer a resident the COVID-19 vaccine for 1 of 5 residents reviewed for immunizations.
Report Facts
Survey dates: January 3, 4, 5, 6, and 9, 2023
Census: 32
Deficiencies cited: 10
RN coverage days missed: 4
PICC dressing change frequency: 7
Antibiotic administration days: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Miller | Chief Nursing Officer | Signed report |
| RN 2 | Provided multiple interviews regarding Resident 27's PICC line, antibiotic orders, wound care, and respiratory care | |
| ADON | Assistant Director of Nursing | Provided interviews regarding discharge summaries, immunizations, and QAPI activities |
| DON | Director of Nursing | Provided interviews and documentation related to care plans, wound care, immunizations, and staffing |
| RN 3 | Respiratory Therapist who described oxygen tubing change procedures | |
| Administrator | Provided interviews and documentation regarding policies, QAPI, and immunizations | |
| QMA 3 | Qualified Medication Aide | Interviewed about Resident 6 discharge |
| RT 5 | Respiratory Therapist | Interviewed about Resident 26 respiratory status |
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