A list of the most recent deficiencies for Envive of Evansville. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-06 | 2024-01-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-06 | 2024-01-01 | 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 | 2023-12-06 | 2024-01-01 | 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 | 2023-12-06 | 2024-01-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-06 | 2024-01-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-06 | 2024-01-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-06 | 2024-01-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-06 | 2024-01-01 | 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 | 2023-12-06 | 2024-01-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-06 | 2024-01-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-06 | 2024-01-01 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-12-06 | 2024-01-01 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-06 | 2024-01-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-06 | 2024-01-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-06 | 2024-01-01 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-11 | 2024-01-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-20 | 2023-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-20 | 2023-08-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-06 | 2022-11-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-19 | 2022-06-24 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-05-19 | 2022-06-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-19 | 2022-06-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-19 | 2022-06-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-31 | 2022-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-21 | 2022-04-11 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-21 | 2022-04-11 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Meet other general requirements. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-18 | 2021-09-27 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-08-10 | 2021-09-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-10 | 2021-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-10 | 2021-09-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-08-20 | 2019-09-19 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-08-20 | 2019-09-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-20 | 2019-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-20 | 2019-09-19 | 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 | 2019-08-20 | 2019-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-20 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-20 | 2019-09-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-20 | 2019-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-20 | 2019-09-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-20 | 2019-09-19 | N |
