A list of the most recent deficiencies for Envive of Lawrenceburg. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-08-31 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-30 | 2023-04-22 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-04-22 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-30 | 2023-04-22 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-30 | 2023-04-22 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-04-22 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-30 | 2023-04-22 | N |
Establish staff and initial training requirements. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Implement emergency and standby power systems. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Use approved construction type or materials. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-30 | 2023-03-30 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-09 | 2023-02-07 | N |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-09 | 2023-02-07 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-09 | 2023-02-07 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-09 | 2023-02-07 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-01-09 | 2023-02-07 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-09 | 2023-02-07 | N |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-01-09 | 2023-02-07 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-09 | 2023-02-07 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-09 | 2023-02-07 | N |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-09 | 2023-02-07 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-11 | 2022-04-28 | Y |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-11 | 2022-04-28 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-11 | 2022-04-28 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-21 | 2022-04-15 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-21 | 2022-04-15 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-21 | 2022-04-15 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-21 | 2022-04-15 | Y |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-21 | 2022-04-15 | Y |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-12-20 | 2022-03-09 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-12-20 | 2022-03-09 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-12-20 | 2022-03-09 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-20 | 2022-03-09 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-08 | 2022-02-25 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Provide emergency officials' contact information. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Establish staff and initial training requirements. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Conduct testing and exercise requirements. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Implement emergency and standby power systems. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Provide properly protected cooking facilities. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Construct fire resistant interior walls. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Have an externally vented heating system. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-20 | 2022-02-16 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-16 | 2022-01-14 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-16 | 2022-01-14 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-16 | 2022-01-14 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-16 | 2022-01-14 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-16 | 2022-01-14 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-16 | 2022-01-14 | N |
Provide and implement an infection prevention and control program. | Health | 2021-11-16 | 2022-01-14 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-16 | 2021-12-17 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-16 | 2021-12-17 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-16 | 2021-12-17 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-16 | 2021-12-17 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-16 | 2021-12-17 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-16 | 2021-12-17 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-17 | 2021-09-29 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-17 | 2021-09-29 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-17 | 2021-09-29 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-17 | 2021-09-29 | Y |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-06-25 | 2021-07-29 | Y |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-02-10 | 2020-04-30 | N |
Provide properly protected cooking facilities. | Fire Safety | 2020-02-10 | 2020-04-30 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-02-10 | 2020-04-30 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-10 | 2020-04-30 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-10 | 2020-04-30 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-06 | 2019-12-18 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-12-06 | 2019-12-18 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-06 | 2019-12-18 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-06 | 2019-12-18 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-06 | 2019-12-18 | N |