Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Envive Of Lawrenceburg during CMS and state inspections, most recent first.
Failure to Follow Medication Hold Parameters: Two residents received ordered meds despite vital signs being outside physician-specified hold parameters. One resident was given midodrine when SBP was above the ordered limit, and another resident received carvedilol when HR was below 60, including one dose with no HR documented. Staff interviews confirmed that vitals should be checked before administration and meds should be withheld when parameters are not met.
Missing transfer/discharge documentation for two residents. One resident was discharged to another LTC facility after a stroke-related hospital stay, but the facility could not provide the transfer/discharge paperwork that should have accompanied the resident. Another cognitively intact resident with cancer and heart failure was sent to the ER at a family member’s request, but the record lacked documentation that a transfer/discharge form was provided. An LPN described expected discharge paperwork, and the DON stated staff often failed to make copies of transfer/discharge records.
Failure to provide a bed hold policy when a resident was transferred to the hospital. A cognitively intact resident with HF was sent to the ER at a family member’s request and later admitted to the hospital, but the clinical record lacked documentation that the resident received the required bed hold notice. The DON stated residents should be given the policy at hospital transfer, and CSS confirmed the bed hold could not be found in the record.
Failure to document ordered daily weights for a resident with metabolic encephalopathy and fluid retention orders. The resident had physician orders for daily AM weights, but the Vitals Record and EMAR lacked multiple weight entries. QMA stated CNAs usually obtained the weights and reported them for EMAR transcription, and CSS stated daily weights should be documented in the clinical record; the facility had no policy for daily weights.
Medication Storage and Labeling Deficiencies: A surveyor found loose pills in a medication cart drawer, with the QMA unable to identify them, and an opened vial of TB serum in a medication refrigerator with no open date or delivery date. An LPN stated the serum should be dated when opened and discarded after 30 days, and the manufacturer insert said vials in use more than 30 days should be discarded.
Failure to use EBP during wound care: An LPN provided wound treatment to a resident with a chronic right buttock wound and recent wound infection while wearing gloves only, with no gown used and no EBP indication posted in or outside the room. The resident had multiple medical conditions, a wound culture positive for MRSA and other organisms, and no EBP order in the chart; the DON stated chronic wounds were among the conditions placed on EBP.
A resident with severe cognitive impairment and multiple medical conditions, who required maximal assistance for transfers, was left sitting unassisted on the side of the bed by a CNA while the wheelchair was retrieved. The resident fell and sustained significant injuries, including orbital fractures and a laceration, due to lack of appropriate supervision and failure to follow established care protocols.
A resident with cognitive intactness and hemiparesis did not have access to a functioning bedside call light for several months. Maintenance staff were aware of the issue, and the resident was given a bell that staff could not hear. When a call light was eventually installed, it did not activate the appropriate signals for staff response, leaving the resident unable to reliably summon assistance.
Multiple areas of the facility, including dining rooms and an activities room, were observed with significant water leakage, ceiling damage, and unsanitary conditions caused by malfunctioning heating and air conditioning units. Staff interviews confirmed the issue had been present for months, affecting all residents and compromising the facility's required standards for a clean and comfortable environment.
Surveyors found that two medication carts and a medication storage area were not maintained according to policy, with issues including unlabeled inhalers and insulin pens, expired and discontinued medications left in carts, loose unidentified pills, and lack of cleanliness. Staff confirmed that medications should be labeled with open dates and discontinued drugs removed, but these procedures were not followed.
A nurse failed to follow the manufacturer's instructions for priming an insulin pen before administering insulin to a resident, holding the pen tip facing the floor instead of upright. The nurse was not trained on the correct priming technique, leading to a deficiency in safe medication administration practices.
A resident with severe cognitive impairment and multiple diagnoses sustained a thumb fracture and laceration, with blood found on her hand and the door frame strike plate. The facility's investigation was incomplete, lacking review of other rooms or interviews with staff and residents, and did not meet policy requirements for thorough accident investigation.
A resident with severe cognitive impairment and malnutrition did not consistently receive physician-ordered Boost Plus supplements due to unavailability, as documented in the EMAR. Staff interviews confirmed that pharmacy delivery issues and inconsistent alternative arrangements led to missed doses, and there was no facility policy on following physician's orders.
A QMA did not consistently perform hand hygiene between medication administration tasks for two residents, handling medication cups, resident items, and equipment without using hand sanitizer or washing hands as required by facility policy. The QMA acknowledged the need for hand hygiene between residents during an interview.
The facility failed to store food appropriately, with several undated or outdated items found in the kitchen. A resident reported being served spoiled food, indicating a pattern of improper food handling. The facility's policy requires proper labeling and storage of leftovers, which was not followed.
A resident alleged abuse, including being locked in a closet and choked, but the facility's investigation was incomplete. The resident, who was severely cognitively impaired, showed no physical signs of abuse. The facility failed to interview other residents on the same floor, despite some being interviewable, and only assessed seven out of twenty residents for signs of abuse, contrary to their policy.
Failure to Follow Hold Parameters for Ordered Medications
Penalty
Summary
The facility failed to follow physician orders for hold parameters on cardiac-related medications for 2 residents reviewed for quality of care. Resident 37 had an order for midodrine 5 mg with meals for hypotension, with instructions to hold the medication if systolic blood pressure was greater than 120. The resident’s EMAR showed the medication was administered on multiple occasions when systolic blood pressure readings were above 120, including readings such as 126/74, 124/78, 134/86, 122/86, 128/82, 129/80, 141/79, and 138/75. Resident 63 had an order for carvedilol 12.5 mg twice daily, with instructions to hold the medication if heart rate was less than 60. The EMAR showed the medication was given on multiple occasions when the resident’s heart rate was below 60, including heart rates of 51, 58, 59, 45, 52, and 55. One administration also had no heart rate documented at the time the medication was given. The resident’s record identified the resident as cognitively intact and diagnosed with hypertension. During interviews, an LPN stated that residents with hold parameters should have vital signs checked before medication administration and that the medication should not be given if the vital signs were outside the physician’s ordered parameters. A QMA also stated that if a resident had hold parameters, she would obtain vital signs before administering the medication and would not give the medication if the vitals were outside the ordered parameters. The facility policy stated that medications shall be administered only upon written order.
Missing transfer/discharge documentation
Penalty
Summary
The facility failed to ensure appropriate transfer or discharge documentation was provided for 2 of 3 residents reviewed for transfer or discharge. For one resident, the clinical record showed admission after a short-term hospital stay for care following a stroke, and a social services note documented acceptance at another LTC facility with pickup arranged by the receiving facility. The resident’s census page showed discharge from the facility, but the facility could not provide the transfer/discharge paperwork that should have accompanied the resident. During interview, an LPN stated that discharge documentation should include a discharge summary, upcoming appointments, prescriptions, and other discharge records sent with the resident, and the DON stated nursing staff had a bad habit of not making copies of transfer/discharge paperwork when residents left the facility. For another resident, the record showed the resident was cognitively intact and had diagnoses including cancer and heart failure. A progress note documented that the resident’s family member requested transfer to the ER, and another note documented admission to the hospital later that evening. The clinical record lacked documentation that the resident was provided a transfer/discharge form. The facility policy titled Transfer or Discharge, Facility-initiated, stated that when a resident is transferred or discharged, the medical record should document that appropriate notice was provided to the resident and/or legal representative.
Failure to Provide Bed Hold Policy at Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold policy for Resident 66 when the resident was sent to the hospital. Resident 66’s quarterly MDS dated 11/13/2025 indicated the resident was cognitively intact, and the resident’s diagnoses included heart failure. On 11/14/2025, the resident’s family member requested that the resident be sent to the emergency room, and the resident was transferred to the local hospital. A later progress note on the same date indicated the resident was admitted to the hospital for heart failure. The clinical record did not contain documentation that the resident received the bed hold policy with the discharge. During interview, the DON stated that residents should be given a bed hold policy when they go to the hospital. Corporate Support Staff 5 stated the resident’s bed hold could not be found and that the resident should have had one in the clinical record when discharged in November. The facility policy titled Bed Holds and Returns stated that residents or representatives are to be provided written information regarding bed-hold policies, including at the time of transfer or within 24 hours if the transfer is an emergency, and that multiple attempts to notify the resident representative should be documented if staff cannot reach them timely.
Failure to Document Ordered Daily Weights
Penalty
Summary
The facility failed to follow physician orders for daily weights for Resident 52, who was cognitively intact and had a diagnosis that included metabolic encephalopathy. An admission MDS dated 01/12/2026 documented the resident’s condition, and a physician order from 01/31/2026 through 02/11/2026 directed that the resident be weighed daily in the morning for fluid retention. A subsequent open-ended order starting 02/12/2026 also directed daily weights for fluid retention. Review of the Vitals Record and February 2026 EMAR showed missing documented weights on multiple dates, including 02/02/2026 through 02/09/2026, 02/12/2026, 02/13/2026, 02/15/2026, 02/16/2026, 02/18/2026, and 02/19/2026. During interviews, QMA 2 stated that CNAs usually obtained daily weights and reported them to nursing staff for transcription into the EMAR, and that refusals would also be documented. CSS 5 stated that daily weights should be documented in the resident’s clinical record. The facility did not have a policy related to daily weights.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medications appropriately in 1 of 4 medication carts and 1 of 3 medication rooms reviewed. On the South Medication Cart on the third floor, a surveyor observed a small round white pill lying loose in the bottom of the second drawer with dust and paper debris, and another small round white pill lying loose in the bottom of the third drawer with dust and several pieces of paper debris. During the observation, the QMA stated she did not know what the pills were or who they belonged to and said there should not be any loose pills in the medication cart. The facility policy stated that medications and biologicals are to be stored in the packaging, containers, or other dispensing systems in which they arrived. In the third-floor medication room, the medication refrigerator contained an opened vial of TB serum with no date showing when it was opened, and the vial was half full. An LPN stated the TB serum should be dated when opened and discarded after 30 days, and there was no delivery date on the serum bottle. The LPN was unsure when it was last used. The manufacturer’s insert stated that vials in use more than 30 days should be discarded.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow infection control guidelines related to Enhanced Barrier Precautions for 1 of 16 residents reviewed for infection control. During observation, an LPN entered the resident’s room, sanitized her hands, donned gloves, and provided wound treatment care, but did not don a gown before or during the wound care. There was also no indication outside or inside the room that the resident was on EBP. The resident was cognitively intact and had diagnoses including anemia, hypertension, renal insufficiency, diabetes, anxiety, depression, cirrhosis of the liver, and liver transplant status. The resident had a chronic wound to the right buttock with moderate serosanguineous drainage, and a wound culture showed sparse growth of Proteus mirabilis, very sparse growth of Enterococcus faecalis, and sparse growth of MRSA. The resident also had a recent physician order for Amoxicillin for a wound infection, but the physician’s orders lacked an order for EBP. The DON stated residents were placed on EBP for conditions including chronic wounds and that staff should wear a gown, gloves, and face mask when residents were on EBP, but the resident was not on EBP because the wound was considered clean and not draining.
Failure to Provide Adequate Supervision and Assistance Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate assistance to prevent an avoidable accident for a resident with severe cognitive impairment and multiple medical diagnoses, including heart failure, asthma, and respiratory failure. The resident required maximal assistance for transfers and had a care plan indicating the need for close monitoring and interventions to prevent falls. Despite these documented needs, a certified nursing assistant left the resident sitting unassisted on the side of the bed while retrieving a wheelchair from across the room. During this time, the resident fell, resulting in significant injuries including right medial and posterior orbital fractures, a laceration, and broken dentures. Interviews with staff revealed that the resident had been declining and required maximal assistance, with therapy staff indicating that two staff members were needed for transfers and that the resident was unable to follow directions. The facility's policies on fall risk management and safe lifting emphasized the need for individualized interventions and appropriate techniques to ensure resident safety. However, these protocols were not followed, leading to the resident being left unsupervised and sustaining serious injuries.
Failure to Provide Functioning Bedside Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system at the bedside for a resident who used a wheelchair and required moderate assistance with lower body dressing. The resident reported that upon moving into the room, maintenance staff informed him there was no place to hook up a call light, and he never received one during his stay. Instead, the facility provided a bell, which the resident could not always locate and which staff could not hear due to the room's location at the end of the hallway. On at least one occasion, the resident was unable to get out of bed and had to yell for help because no call light was available. Observations confirmed there was no call light plugged in above the bed, and the resident and staff both confirmed that a call light had never been provided at the bedside. Further investigation revealed that the maintenance supervisor was aware of the missing call light and attributed it to the room's previous configuration as a single room. Email documentation showed delays in ordering and receiving the necessary call light equipment, with no evidence of follow-up between July and September. When a call light was eventually installed, it did not function properly: pressing the button did not activate the light above the resident's door or produce a sound at the nurses' station, and the alternative bell system remained ineffective. Facility policy required that call lights be plugged in, functioning, and accessible to residents at all times, but this was not followed in this case.
Failure to Maintain Sanitary and Homelike Environment Due to Water Leakage
Penalty
Summary
The facility failed to maintain a functional, sanitary, and comfortable homelike environment due to ongoing issues with dripping and pooling water in multiple areas. Observations revealed a large area of the first-floor dining room ceiling covered with a black spotted substance, brown staining, visible moisture, and a concaved, bowed ceiling. Brown liquid was observed dripping from the ceiling, leaving stains on the floor, and water was pooling on the windowsill and dripping into the air conditioning unit below. The issue extended to the second-floor dining room, where a heating and air conditioning unit was leaking and pooling water on the floor, and to the basement activities room, where water damage and pooling were also noted. Staff interviews indicated that the problem had been noticed as early as April or May, but the cause was only recently identified as a drainage issue with the second-floor unit, which had been replaced in April. The deficiency had the potential to affect all 49 residents in the facility, including nine residents currently living on the first floor, six of whom were independently mobile. The activities room in the basement, which is used by 12-15 residents for activities and up to 50 people for events, was also impacted by water leakage from above. Facility policy requires a safe, clean, and comfortable environment, but the observed conditions did not meet these standards, as evidenced by the persistent water damage, staining, and unsanitary conditions in resident and public areas.
Improper Medication Storage, Labeling, and Cleanliness
Penalty
Summary
Surveyors observed multiple failures in the proper storage and labeling of medications across two medication carts and one medication storage area. On the third floor, the South Medication Cart contained an Albuterol inhaler without an open date, a drawer with a shiny film indicating lack of cleanliness, two loose unidentified pills, and several cards of discontinued medications for a resident, including antibiotics and an anticoagulant that had been discontinued months prior. The LPN confirmed that discontinued medications should not have been present in the cart and should have been returned to the pharmacy or destroyed. Physician orders confirmed the discontinuation dates of these medications, some of which had been discontinued for several months. On the second floor, the North Medication Cart was found to have an Admelog insulin pen without an open date, a Basaglar/Lantus insulin pen with an open date exceeding the recommended 28-day use period, and two loose unidentified pills. Additionally, on the first floor, a locked refrigerator contained an open vial of flu vaccine with no open date, and staff indicated it was used for incoming residents. Interviews with nursing staff confirmed that medications should be labeled with open dates and discontinued medications should be removed from carts. The facility's policy requires proper labeling, removal of discontinued or expired medications, and cleanliness of medication storage areas, all of which were not followed as observed.
Failure to Follow Manufacturer's Guidelines for Insulin Pen Administration
Penalty
Summary
A nurse was observed preparing and administering insulin to a resident using an insulin pen. The nurse primed the insulin pen by turning the dose selector to two units and expelling the insulin with the pen tip facing the floor, rather than holding the pen upright as specified in the manufacturer's instructions. The nurse stated she was not trained on the correct position for priming the pen and believed that holding it upright was only necessary for syringes, not pens. The manufacturer's instructions for the Novolog insulin pen, provided by the Director of Nursing, clearly state that the pen should be held with the needle pointing up during priming to allow air bubbles to rise and be expelled. The facility's policy requires medications to be administered safely and as prescribed. The resident involved had no critical blood sugar values prior to the incident. The failure to follow the manufacturer's guidelines for insulin pen usage constituted a deficiency in medication administration practices.
Failure to Thoroughly Investigate Accident Hazard After Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an accident hazard after a resident, who was severely cognitively impaired and had diagnoses including a left ilium fracture, seizure disorder, anxiety, and severe intellectual disabilities, sustained a fracture and laceration to her thumb. The resident was found with a laceration and discoloration to her left thumb, and blood was observed on her hand and on the door frame next to the strike plate in her room. The resident was able to get in and out of her wheelchair and would crawl on the floor, but was only able to say a few simple words, making it difficult to ascertain exactly how the injury occurred. The LPN on duty cleaned the wound, notified the ADON and NP, and the resident was sent to the emergency room for evaluation. Documentation included a progress note, an incident report, an X-ray, and a follow-up orthopedic visit. Despite these actions, the facility's accident investigation folder lacked a comprehensive investigation into the cause of the injury. There was no evidence that other resident room strike plates were reviewed or that staff and cognitively intact residents were interviewed to determine if similar hazards existed elsewhere. The facility's policy required all accidents and incidents to be thoroughly investigated and reported, including any corrective actions taken, but the documentation and investigation were incomplete and did not meet these requirements.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
A resident with a diagnosis of malnutrition, severe cognitive impairment, and other medical conditions was admitted to the facility and placed on a physician-ordered weight gain program, which included the administration of Boost Plus nutritional supplements three times daily. The resident's care plan and nutritional risk assessment both documented the need for these supplements due to her underweight status and risk for malnutrition. Despite these orders, the resident did not receive the prescribed supplement on multiple occasions, as documented in the Electronic Medication Administration Record (EMAR), due to the supplement not being available. Interviews with facility staff revealed that the pharmacy did not deliver the required dietary supplements, and alternative arrangements, such as ordering from other companies or local stores, were sometimes made. However, these measures were not consistently effective in ensuring the resident received the supplements as ordered. Additionally, the facility did not have a policy related to following physician's orders, as confirmed by Corporate Clinical Support. The failure to provide the ordered nutritional supplements as prescribed constituted a deficiency in meeting the resident's nutritional needs.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
A Qualified Medication Aide (QMA) failed to follow proper infection control guidelines during medication administration for two residents. During observation, the QMA prepared and administered medications, handled medication cups, water cups, and assisted residents without consistently performing hand hygiene between tasks and residents. The QMA touched various surfaces, including the medication cart, computer keyboard, mouse, and resident items, and did not use hand sanitizer or wash hands between these contacts as required by facility policy. The QMA was observed donning gloves to administer eye drops, removing gloves, and then handling medication and resident items without performing hand hygiene. The QMA continued to prepare and administer medications to another resident, again without using hand sanitizer or washing hands between residents, despite the facility's policies requiring hand hygiene after contact with the resident's environment and during medication administration. The QMA acknowledged in an interview that hand hygiene should be performed between residents and when hands are soiled.
Improper Food Storage and Handling
Penalty
Summary
The facility failed to store food appropriately, as observed during a kitchen inspection. Several food items in the kitchen refrigerators and dry storage were found to be undated or outdated. These included a sealed bag of cooked ham, a sealed bag of cooked taco meat, a container of country gravy with incorrect preparation and discard dates, a resident's leftover pizza box, an opened gallon of mustard past its best-by date, and two gallons of milk past their best-by date. Additionally, a dented can of mandarin oranges was found in the dry storage area. During interviews, it was revealed that the kitchen serves 34 to 36 residents, and the undated or outdated food items were to be discarded. The facility's policy on food storage, revised in January 2023, requires that leftover foods be labeled with the name, preparation date, and discard date, and stored at 41 degrees Fahrenheit or less for no more than three days. However, the policy was not followed, as evidenced by the undated and outdated items found. A resident reported having been served spoiled meat, sour broccoli, and spoiled milk and juices in the past, indicating a pattern of improper food storage and handling. The deficiency was related to a complaint investigation, highlighting the facility's failure to adhere to its food storage policies.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse made by a resident, identified as Resident B. During a meeting, Resident B alleged physical abuse, including being locked in a closet and room, and being choked at night, claiming to have a bruise above her eye. However, upon assessment, no bruising or injuries were found, and it was noted that the resident's room did not have locks. The resident was severely cognitively impaired with a history of alcohol abuse, psychotic disorder with hallucinations, anxiety, depression, and seizure disorder. The Social Services Director (SSD) initially followed up with the resident for 72 hours but did not interview other residents. The Administrator reported the incident to the State Department of Health, and the Director of Nursing (DON) conducted a head-to-toe assessment of Resident B with no findings. The investigation was incomplete as the facility did not interview other residents on the same floor, despite some being cognitively intact and interviewable. The DON assessed only seven residents for physical signs of abuse, leaving thirteen others unassessed, including six who were interviewable. The facility's policy required thorough investigation of all incidents, but this was not adhered to, as evidenced by the lack of interviews and assessments of all potentially affected residents. This deficiency was related to Complaint IN00440606.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 570 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lawrenceburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgewood Health Campus | 0.3 mi | ★★★★★ | 0 | 0 |
| Shady Nook Care Center | 0.3 mi | ★★★★★ | 14 | 0 |
| Shawneespring Health Care Center | 10.1 mi | ★★★★★ | 7 | 1 |
| Three Rivers Healthcare Center | 10.4 mi | ★★★★★ | 2 | 0 |
| Waters Of Dillsboro-ross Manor, The | 11.5 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Envive Of Lawrenceburg.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.