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Deficiency Records for Envive of Lawrenceburg
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.
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 waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2024-03-18 | 2024-12-01 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-18 | 2024-12-01 | N |
| Respond appropriately to all alleged violations. | Health | 2024-08-13 | 2024-08-21 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-18 | 2024-05-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Develop a communication plan. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Meet other general requirements. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Use approved construction type or materials. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Meet other general requirements. | Fire Safety | 2024-03-18 | 2024-05-14 | 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 | 2024-03-18 | 2024-05-14 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-03-18 | 2024-05-14 | 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 | 2024-03-18 | 2024-05-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-03-18 | 2024-05-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-18 | 2024-05-14 | 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 | 2024-02-09 | 2024-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-09 | 2024-03-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-09 | 2024-03-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-09 | 2024-03-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-09 | 2024-03-22 | 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 | 2024-02-09 | 2024-03-22 | 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 | 2024-02-09 | 2024-03-22 | N |
| 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 |
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