Envive of Indianapolis

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the implementation of adequate and consistent nutritional interventions for a dependent resident (Resident 10) which resulted in actual harm related to significant weight loss and compromised nutritional status for 1 of 2 residents reviewed for tube feeding (TF) and the facility failed to ensure a Resident, (Resident 8) who was at high risk for malnutrition was appropriately monitored for weight loss for 1 of 8 residents reviewed for nutrition monitoring.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents were provided with assistance to maintain their necessary activities of daily living (ADLs) for 5 of 6 residents reviewed for ADLs (Residents 70, 73, 78, 97, and 10).

Inspectors wroteA. Based on observations, interviews, and record reviews, the facility failed to complete a side rail assessment for 4 of 7 residents reviewed for the potential for accidents (Residents 29, 52, 54, and 20). B. Based on observations and interviews, the facility failed to ensure sliding glass doors were appropriately bolted shut in the memory care unit. This deficient practice had the potential to affect 29 of 29 Residents who resided in the memory care unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity during interactions with staff and dining for 2 of 2 residents reviewed for dignity (Resident 87 and 112).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call lights were kept within the residents' reach for 3 of 3 residents reviewed for call lights (Residents 70, 78, and 6).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had orders for desired advance directives for two residents (Residents 75 and 113) and failed to ensure a Physician Order for Scope of Treatment (POST) form was appropriately filled out for a resident (Resident 3) for 3 of 5 residents reviewed for advanced directives.

Inspectors wroteBased on record review and interview, the facility failed to complete a medication disposition for residents' medications when discharged from the facility for 2 of 2 records reviewed for discharge (Residents 120 and 119).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate for 1 of 18 residents' MDS assessments reviewed (Resident 78).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASRR) (a federal Medicaid requirement ensuring individuals with serious mental illness or intellectual disabilities are not inappropriately placed in nursing homes) was re-evaluated when a psychiatric diagnosis was added for 1 of 2 residents reviewed for PASRR (Residents 78 and 11).

Inspectors wroteBased on record review the facility failed to ensure a fall care plan was appropriately revised to reflect new fall interventions to be in place after several falls. This deficient practice had the potential to affect 1 of 7 Residents (Resident 12) reviewed for care plan revision.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure orders were in place and implemented to properly monitor, flush, and secure a resident's G-tube, for 1 of 2 residnets reviewed for tube feeding, (Residnet 95)

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were properly stored and dated on medication carts for 2 of 2 medication carts observed for medication storage (Residents 58, 65, 64, 92, 51, 47, 63, and 83).

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse by a Certified Nursing Assistant (CNA 6) who engaged in a verbal altercation with the resident that included profane language for 1 of 3 residents reviewed for abuse (Resident C). This deficient practice was corrected by 2/16/26 prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of a resident-to-resident allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to obtain timely treatment and assessments of a full thickness burn to a resident's left foot resulting in actual harm when the resident required hospitalization and surgical interventions at an acute care hospital for 1 of 4 reviewed for timely care and treatment (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to protect a resident during care resulting in actual harm when the resident sustained a full thickness burn to his left foot requiring surgical interventions for 1 of 4 reviewed for accidents (Resident B). The deficient practice was corrected on 5/23/25, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was able to appeal a facility initiated discharge and failed to document why the facility was discharging the resident instead of allowing them to return to the facility after a hospital stay for 1 of 3 residents reviewed for discharges (Resident D).

Inspectors wroteBased on interview and record review, the facility failed to follow the policy by not allowing the resident to return to the facility after a hospitalization for 1 of 3 resident reviewed for discharged (Resident D).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Facility Assessment Tool was updated in a timely manner to reflect the specific nursing needs, care and treatments services for the identified resident population. This deficient practice had the potential to affect 102 of 102 residents who resided in and received nursing care, services and treatments in the facility.

Inspectors wroteBased on record review and interview, the facility failed to code Minimum Data Set (MDS) correctly for residents who required a level II according to Pre-admission screening and resident review (PASRR) for 4 of 5 residents reviewed for MDS accuracy (Residents 52, 49, 9, and 14).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who chose to smoke had accurate and current Smoking Safety assessments and interventions; and the facility failed to have clear, concise, and consistent policies and procedures for independent versus supervised smokers, and storage and accountability of smoking materials. These deficient practices had the potential to affect 30 of 56 residents reviewed for smoking (Residents D, E, G, J, K, 1, 6, 8, 13, 14, 19, 21, 28, 35, 44, 46, 49, 52, 56, 62, 66, 76, 78, 80, 81, 88, 92, 103, 264 and 309).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff who were symptomatic with illness were tested and/or wore source control to prevent the potential for spreading infection throughout the community, and the facility failed to ensure staff donned personal protective gear, (PPE) while providing high-contact resident care to those residents who required enhanced barrier precautions (EBP) in order to protect them from the potential of infection, and failed to ensure PPE was readily available outside and/or just inside of the resident's rooms who required EBP. This deficient practice had the potential to affect 11 of 102 resident who required EBP.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had the right to privacy during incontinent care for 1 of 4 residents reviewed for dignity (Resident B).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's advance directive wishes were updated in her medical record for 1 of 3 residents reviewed for advance directive (Resident 53).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of 1 on 1 activities for 1 of 1 residents (Resident 55) reviewed for activities.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident requesting to be sent to the hospital was assessed by a nurse and prepared to be transferred to the hospital for 1 of 3 residents reviewed for hospitalization (Resident E).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident received necessary treatments and services to promote the healing of a pressure ulcer and prevent a new pressure ulcer from developing for 1 of 5 residents reviewed for pressure ulcers (Resident 1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident recieved assistance with toenail care provided by podiatry (a medical specialty that focuses on feet, ankles and legs) for 1 of 3 residents reviewed for ADL care (Resident 66).

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate and address the nutritional status of a resident which resulted in an 11.26 percent (%) weight loss in two months for 1 of 5 residents reviewed for nutrition (Resident 1).

Inspectors wroteBased on record review and interview, the facility failed to complete pre and post dialysis assessments for a resident that received dialysis from an outside facility for 1 of 1 resident reviewed (Resident 79).

Inspectors wroteBased on observation and interview, the facility failed to date medications with time limitations and failed to remove medications from use when they expired for 2 of 3 medication rooms reviewed and 4 of 7 medication carts reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 1 residents (Resident 3) reviewed for medical record accuracy.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure call light devices with a pull cord were installed in the residents' bathrooms for 7 of 60 of the residents' bathrooms without a call light device and 9 of 60 residents' bathrooms without a pull cord on the bathroom call light devices reviewed.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to protect a resident's right to smoke cigarettes which had the potential to affect 1 of 4 residents reviewed for smoking (Resident B).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents from the Wellness unit had the opportunity to attend each Resident Council meeting for 40 of 97 residents who resided on the Secured Wellness unit, and the facility failed to ensure Resident Council requests/suggestions were responded to and/or addressed for 3 of 12 months reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Residents on the Wellness Unit had access and ability to review the most recent state survey results which had the potential to effect 40 of 97 residents who resided on the secured Wellness Unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment for residents who resided on the secured Wellness Unit which had the potential to effect 40 of 97 residents who resided on the secured Wellness Unit.

Inspectors wrote3. On 1/4/24 at 11:56 a.m., Resident 100 was observed to be absent from her room. Her door was wide open. Two medication cups were observed in her room. They were on her over-the-bed table. One medication cup had a pill in it, later to be identified as Eliquis (anti-coagulant). On 1/4/24 at 11:59 a.m., Qualified Medication Aide (QMA) and Certified Nursing Aide (CNA) 8 entered Resident 100's empty room and moved the medication cup with the pill in it so he could put down her lunch tray. He indicated medications should not be left in the resident's room. He left the medication in her room and exited. On 1/4/24 at 12:45 p.m., a white pill was observed on the floor, near the trash can, of Resident 100's room. Resident 100 indicated that was not good. The pill was identified as Tylenol. Resident 100 indicated she did take Tylenol, but did not know if she took it today or not. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure timely charting and documentation was completed by the Nurse Practitioner (NP) who functioned as an authoritative designee under the Medical Director (MD) for routine and acute needs of the residents. This deficient practice had the potential to effeect 4 of 20 residents whose medical records were reviewed, (Residents 36, 51, 56, and 47).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was maintained under generally clean conditions, food was covered as it sat underneath a dirty blowing air vent, and failed to ensure the dishwashing machine was maintained in a neat and clean fashion for 1 of 1 observation of the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received annual influenza and/or pneumococcal vaccinations per their requirements and consent for 5 of 8 residents reviewed for vaccinations (Residents 32, 56, 14, 10, and 35).

Inspectors wroteBased on record review and interview, the facility failed to ensure a notice of transfer/discharge was sent with residents when they left the facility for 2 of 7 residents reviewed for discharges (Resident 99 and 47).

Inspectors wroteBased on record review and interview, the facility failed to send a bed-hold with residents when they left the facility for 2 of 7 residents reviewed bed-hold (Resident 99 and 47).

Inspectors wroteBased on record review and interview, the facility failed to maintain residents Ideal Body Weight (IDW) who had no desire to lose weight for 1 of 5 residents reviewed for weight loss and gain (Resident 14), and failed to montior weight as ordered for 2 of 5 residents reviewed for weight loss and gain (Residents 14 and 16).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received adequate mental health services, interventions and/or therapeutic programming to prevent the potential for a continued resident-to-resident altercations, increasing anxiety and aggressive outburst towards residents and staff and failed to provide the opportunity for age-appropriate past time activities and interests for 1 of 1 resident reviewed for behavioral health ( Resident 80)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin was administer correctly by insulin flex pen for 1 of 1 resident observed for insulin administration (Resident 38).

Inspectors wroteBased on record review and interview, the facility failed to obtain labs as ordered by the physician for 2 of 2 residents (Residents 14 and 61).

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessment was accurately coded for Preadmission Screening and Resident Review (PASRR) for 4 of 4 residents reviewed for accuracy of MDS assessments (Resident 100, 13, 22, and 82).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation procedures of glucometers (instrument for measuring blood glucose concentration), and to ensure glucometers were not shared between residents to prevent possible cross contamination for 7 of 7 residents observed for blood glucose monitoring, to include a HIV (human immunodeficiency virus) positive resident (Residents FF, JJ, QQ, C, RR, SS, and TT).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were available, administered, and documented the disposition of controlled medications accurately for 2 of 11 residents observed for medication administration. (Residents JJ and D).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when staff failed to follow standard nursing principles and facility policy to prepare narcotic medication, and failed to ensure medications were administered on time for 2 of 11 residents observed for medication administration (Resident GG and PP).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly in 1 of 2 medication carts observed on the A hallway (back hallway cart), and medicated patches were destroyed properly for 1 of 1 medication observed being destroyed (Residents B and GG).