Envive of Lawrenceburg

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 22, 2025

  Based on record review and interview the facility failed to provide appropriate assistance to prevent an avoidable accident for 1 of 3 residents reviewed for accidents hazards. This deficient practice resulted in the resident acquiring right medial and right posterior orbital fractures. (Resident D) Findings include:The clinical record for Resident D was reviewed on 9/22/2025 at 3:15 P.M. An admission Minimum Data Set (MDS) assessment, dated 9/3/2025, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, heart failure, asthma, and respiratory failure. […]

• Actual harm, isolatedF689Aug 10, 2023

  Based on observation, interview, and record review, the facility failed to transfer a resident, that required a full body mechanical lift, safely using the appropriate lift resulting in a fracture for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: On 8/9/23 at 11:08 a.m., the Director of Nursing (DON) indicated on 7/27/23 Resident C was being assisted into bed with a lift. The resident yelled out in pain and was sent out to the emergency room (ER). The resident had a fractured left fibula and a follow up appointment with Orthopedics. During an observation and interview on 8/9/23 at 1:57 p.m., Resident C was lying in her bed, her left leg was wrapped and elevated on a pillow. She indicated she required a full body mechanical lift for transfers. […]

• Actual harm, isolatedF686Jan 9, 2023

  Based on observation, interview, and record review, the facility 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. This deficient practice resulted in two residents' pressure ulcers worsening to a Stage 4 and Stage 3 and one residents' wound identified as a deep tissue injury. (Residents 25, 9, and 13) Findings include: 1. During an interview and observation on 01/03/23 at 12:04 P.M., Resident 25's right elbow was in a padded heel protector. The resident indicated he had an open wound on his right elbow. The clinical record for Resident 25 was reviewed on 01/05/23 at 12:17 P.M. […]

• Actual harm, isolatedF686Apr 11, 2022

  Based on observation, interview, and record review, the facility failed to prevent and follow appropriate treatment orders related to skin breakdown for 4 of 5 residents reviewed for pressure ulcers. This deficient practice resulted in Resident B acquiring and worsening (an increase of wound size) of a Stage 3 pressure ulcer. (Resident B, C, D, and E) Findings include: 1. During an observation on 04/07/22 at 3:49 P.M., LPN (Licensed Practical Nurse) 4 was at the treatment cart in the hallway obtaining supplies for Resident B's wound dressing change. She had a non-adherent pad outside of the package and two pieces of tape hanging off the medication cart with one of them having her initials and date on it. […]

• Actual harm, isolatedF697Nov 16, 2021

  Based on record review, interview, and observation, the facility failed to adequately provide [MEDICATION(S)] for 2 of 3 residents reviewed for pain. (Resident 1 and 189) Findings include: 1. The clinical record for Resident 1 was reviewed on [DATE] at 2:35 P.M. The MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She required the assistance of one or two staff members for ADLs (Activities of Daily Living). The resident had frequent severe pain during the assessment, making it hard to sleep at night. The pain had limited her day-to-day activities. An undated incident report indicated the resident had fallen on [DATE] at 6:30 A.M. […]