Envive of Evansville

In the surveyor’s words

From the most serious findings on record at Envive of Evansville, in the surveyor’s own words.

• Actual harm, isolatedF689May 14, 2024

  Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to Resident C, an aggressive resident, to protect Resident B, a cognitively impaired resident, from being pushed to the floor for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident B falling and requiring hospitalization for surgical repair of a right femur fracture. (Resident B, Resident C) Finding includes: On 5/13/24 at 9:33 a.m., during interview, Resident B indicated a man got mad, pushed, and threw her, reached down, and grabbed her hair. Resident B indicated it happened in [name of city]. On 5/13/24 at 10:01 a.m., Resident B's clinical record was reviewed. […]

• Actual harm, isolatedF689Dec 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices to each resident to prevent accidents for 4 of 8 residents reviewed for falls. Care plans were not updated following each fall, and the clinical record lacked information related to falls resulting in a hip fracture. This deficient practice led to a fall with a fracture requiring hospitalization . (Resident P, Resident Y, Resident F, Resident T) Findings include: 1. On 12/1/23 at 1:31 P.M., Resident P's clinical record was reviewed. admitted was 8/31/23. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anxiety. […]

• Actual harm, isolatedF684Jul 20, 2023

  Based on interview, and record review, the facility failed to ensure a resident was provided medication as ordered, notification of medication change to family, and notification of medication ordered between specialty physicians and primary physicians, resulting in loss of blood flow to right lower leg, and ischemia due to clots in the lower extremities for 1 of 3 residents (Resident D) reviewed for quality of care. Findings include: The clinical record was reviewed for Resident D on [DATE] at 6:51 A.M. Diagnoses included, but were not limited to, presence of cardiac pacemaker, atrial flutter, atrial fibrillation, and long term use of anticoagulants. […]

• No harm, potential for more than minimal, widespreadF838Dec 6, 2023

  Based on observation, record review, and interview, the facility failed to provide an accurate updated Facility Assessment. The Facility Assessment lacked specific services for residents with Intellectual Disabilities, feeding tubes, tracheotomies and dialysis, and staffing numbers for all departments. Finding includes: On 11/28/23 at 8:14 A.M., the current [name of facility] Facility Assessment, dated 9/12/23, was reviewed. The document indicated staffing numbers varied, and it lacked specific resident population services for residents with Intellectual Disabilities, feeding tubes, dialysis, tracheotomies, and feeding tubes. […]

• No harm, potential for more than minimal, widespreadF851Dec 6, 2023

  Based on interview and record review, the facility failed to submit direct care staffing information to CMS (Centers for Medicare and Medicaid Services) for 1 of 1 quarters reviewed. (April, May, June, 2023) Finding includes: Failed to Submit Data for the Quarter and 1 Star Staffing Rating was triggered on the CMS PBJ (Payroll Based Journal) Data Report for Quarter 3 (April 1 - June 30, 2023). On 11/30/23 at 1:58 P.M., the Administrator indicated that she was aware that staffing information had not been submitted for the third quarter because the facility changed ownership in July and the information did not get submitted. […]