A list of the most recent deficiencies for Envive of Indianapolis. 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Meet other general requirements. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-30 | 2024-02-29 | 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 | 2024-01-30 | 2024-02-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-11 | 2024-02-19 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-01-11 | 2024-02-19 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-11 | 2024-02-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-11 | 2024-02-19 | 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 | 2024-01-11 | 2024-02-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-11 | 2024-02-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-02-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-11 | 2024-02-19 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-01-11 | 2024-02-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-11 | 2024-02-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-11 | 2024-02-19 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-01-11 | 2024-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-02-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-11 | 2024-02-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-01 | 2023-12-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-01 | 2023-12-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-01 | 2023-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-12-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2023-06-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-02 | 2023-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-04-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-01-06 | 2023-02-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-06 | 2023-02-04 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-01-06 | 2023-02-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-06 | 2023-02-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-06 | 2023-02-04 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-02 | 2022-12-15 | 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 | 2022-11-02 | 2022-12-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-20 | 2022-11-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-20 | 2022-10-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-20 | 2022-10-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-20 | 2022-10-21 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-20 | 2022-10-21 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-09-20 | 2022-10-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-20 | 2022-10-21 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-09-20 | 2022-10-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-20 | 2022-10-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-20 | 2022-10-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-20 | 2022-10-21 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-09-20 | 2022-10-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-20 | 2022-10-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-20 | 2022-10-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-20 | 2022-10-21 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-09-20 | 2022-10-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-20 | 2022-10-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-20 | 2022-10-21 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-28 | 2022-03-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-28 | 2022-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-03-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-05 | 2022-03-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-07 | 2022-03-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2022-03-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-07 | 2022-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-05 | 2022-03-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-28 | 2022-02-28 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-01-07 | 2022-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-05 | 2022-02-18 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-07 | 2022-02-18 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-13 | 2021-12-31 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-13 | 2021-12-31 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-03 | 2021-12-17 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-12-03 | 2021-12-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-05 | 2021-11-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-07 | 2021-11-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-07 | 2021-11-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-07 | 2021-11-05 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-29 | 2021-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-29 | 2021-10-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-29 | 2021-10-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-29 | 2021-10-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-29 | 2021-10-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Meet other general requirements. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-29 | 2021-09-20 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-07-16 | 2021-08-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-16 | 2021-08-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-16 | 2021-08-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-16 | 2021-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-16 | 2021-08-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-26 | 2021-04-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-26 | 2021-04-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-26 | 2021-04-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-03-26 | 2021-04-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-26 | 2021-04-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-26 | 2021-04-12 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-03-26 | 2021-04-12 | Y |
