Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 River City during CMS and state inspections, most recent first.
Survey results and the plan of correction were not made available for review in the front lobby. Surveyors observed a binder with prior survey results, but it did not include the recent Indiana Department of Health survey results from 2026 other than a Life Safety Code survey. The DON stated the facility had no specific policy for making survey results available and followed state board of health regulations.
Unsafe and Unsanitary Environment in Resident Areas: Surveyors observed marred and soiled walls, baseboards, and door trim throughout multiple unit hallways and resident room areas, along with debris buildup in hallway and nurses station floor corners and around heating/cooling units. Similar debris was also found in both dining rooms, including around baseboards, in corners, and under a wall-mounted TV. The DON later provided the facility policy stating residents are to have a safe, clean, comfortable, and homelike environment.
Missing informed consent for psychotropic meds and drug screening. A resident with diabetes and another resident with chronic pain had psychotropic meds and CBC/BMP/serum drug screen orders without documented consent after the MD noted concern for drug use and ordered testing. Two additional residents also had psychotropic medication orders without consent documentation. The DON confirmed the missing consent records, and a regional nurse stated he forgot to follow up on consent requirements after a regulation change.
The facility failed to treat two residents with dignity and respect when pain medications were reduced after THC-positive drug screens. One resident with diabetes, a left above-knee amputation, osteoarthritis, and polyneuropathy said he was not told the blood draw was for drug testing and that his hydrocodone was lowered, leaving him without pain relief. Another resident with chronic pain syndrome, a right below-knee amputation, and opioid dependence reported his methadone was decreased and was causing nausea and poor appetite; his record also showed THC on drug screen and a later note that methadone was reduced after marijuana was found in his room.
Failure to Document and Resolve Grievance for Missing Resident Property: A resident with encephalopathy and severe cognitive impairment had a cell phone reported missing by family, but the concern was not documented as a grievance or resolved. The family reported no follow-up, and the SS Director stated the facility was still looking for the phone, with no documented investigation or time frame for resolution.
Failure to review and respond to psychotropic medication recommendations for two residents. One resident with depression and cognitive impairment was receiving buspirone and desvenlafaxine, and a pharmacist suggested GDRs that were not documented as completed or signed by the provider. Another resident with MDD was receiving duloxetine, and the DRR called for a dose reduction attempt or a documented reason it was not indicated, but the record lacked provider response or rationale.
Failure to report abuse and theft allegations: One cognitively intact resident dependent on staff for toileting and bathing reported rough, rude incontinence care and later described it as abuse, but the allegation was not reported to the State Survey Agency. Another resident reported $480 missing after a staff member allegedly stole it, but the matter was not reported because it could not be proven. The facility record lacked documentation of the missing money or the investigation.
Lack of Documentation Supporting Schizophrenia Diagnosis: The facility failed to obtain sufficient supporting documentation before assigning schizophrenia as a diagnosis for a resident receiving antipsychotic medication. The record showed Zyprexa orders and a care plan referencing mental disorder, delusional disorder, and schizophrenia, but the chart lacked documentation supporting the diagnosis, why it was given, or any assessment leading to it. A pharmacy MRR noted the diagnosis tied to antipsychotic use had to be an enduring condition, and the Medical Director selected schizophrenia without supporting clinical documentation in the record.
Failure to Provide Scheduled Bathing Assistance: A resident who was dependent on staff for bathing and toileting reported not receiving a shower since admission. Observation noted disheveled hair and a strong odor in the room. Record review showed the resident’s MDS indicated dependence for bathing, and the CNA bathing task documented no complete bed bath or shower over the reviewed period despite a scheduled bathing routine.
Failure to change and assess a wound vac per order. A resident with DM2 and osteomyelitis had a surgical foot wound with wound vac therapy ordered, but staff did not document required wound vac changes or wound assessments, and the resident reported the dressing had not been changed as scheduled. Observations found the saline irrigation bag empty and the wound still covered with foam and an undated clear drape, while an LPN said she was not comfortable changing the wound vac and that the DON handled those changes.
Improper trach suctioning and care were observed for a resident with a tracheostomy, COPD, laryngeal cancer, and a gastrostomy. An LPN entered without PPE despite EBP, suctioned the trach using a catheter from an open package, did so without the inner cannula in place, and then replaced the inner cannula with the speaking valve on. The resident’s orders required trach care each shift and daily inner cannula changes, and the facility policy called for protective equipment and sterile technique during suctioning.
A resident with a history of falls and frequent pain fell and later was found to have a displaced humeral neck fracture. Staff documented ongoing right shoulder, arm, and elbow pain, but the record lacked a clear pain-medication sequence, repeated pain assessments, and documentation of additional pharmacologic or non-pharmacologic pain relief attempts. Acetaminophen was given once and later noted as effective, but when pain continued, pain medication was only offered and not administered, with no documentation that it was refused.
A QMA administered multiple medications to a resident with a PEG tube without checking residual or flushing the tube first, and crushed several medications together with liquid medications before giving them through the PEG. The resident had COPD, laryngeal cancer, a tracheostomy, and a gastrostomy tube, and the observed medication pass resulted in a 19.35% error rate, exceeding the 5% threshold. The resident’s orders required flushing the enteral tube before and after medications and checking residuals, and the facility policy stated crushed medications are not mixed together.
Delayed Radiology Services After Resident Fall and Fracture: A resident with impaired mobility and a history of falls sustained a witnessed fall with a skin tear and right-sided pain. The record lacked documentation of the physician order and ordered X-ray views, the facility could not arrange transport for a STAT CT, and the resident later had a swollen, malformed shoulder with X-ray evidence of a displaced humeral neck fracture before transfer to the ER.
Failure to properly handle confiscated marijuana: An Administrator did not dispose of an illegal substance, report it to law enforcement or the SSA, or follow the facility’s controlled medication disposal policy. A resident with chronic pain syndrome and intact cognition had marijuana found in his room, but the record lacked follow-up documentation. The marijuana was later observed in an open container in an unlocked closet in the Administrator’s office, and the Administrator stated she was unsure what to do and had not reported the incident.
The facility failed to obtain a written contract and lacked documentation of communication for an outside Pain Clinic providing services to a resident with chronic pain syndrome and opioid dependence. The resident was receiving methadone, but the record did not include a physician order for the Pain Clinic or care plan documentation showing the clinic’s role in pain or opioid management, and staff noted the clinic did not communicate well with the facility.
Failure to Follow PPE and Hand Hygiene Requirements: An LPN entered a resident's room without PPE even though the resident was on EBP for a tracheostomy, then suctioned the trach using a catheter from an open package and later replaced the inner cannula with the speaking valve on. In a separate observation, a CNA washed hands for only a few seconds before and after providing personal care to another resident, despite stating hand washing should last 40 seconds; the facility's EBP and hand hygiene policies required gown and glove use for high-contact care and at least 15 seconds of hand rubbing.
A facility failed to ensure staff, including agency LPNs, were trained and competent to provide trach care and wound vac care. An LPN performing trach care did not follow sterile technique or PPE/infection control steps, and the facility had no documented trach-specific training for contractual staff. For another resident with a surgical wound and wound vac, staff could not show documented wound vac training or skills check-offs, an LPN said she was not comfortable changing the wound vac, and the treatment record lacked documentation that the wound vac had been changed as ordered.
Failure to Post Current Nurse Staffing Information: The facility did not post a current Nurse Staffing Information form for 4 of 4 days observed. The form on the main lobby desk was repeatedly outdated, and the DON stated she oversaw the posting process while the weekend night nurse completed it on weekends. The facility policy required the charge nurse or designee to complete and post the staffing information within 2 hours of the start of each shift.
The facility failed to follow physician orders for medication administration and implement fall prevention interventions for two residents. A resident with hypertension received medication without proper blood pressure monitoring, and non-slip strips were not placed in the shower as required. Another resident experienced a fall-related incident without new interventions being documented. The facility's policies on medication administration and care plans were not adhered to.
The facility failed to administer insulin according to professional standards, with insulin given late and by unqualified staff. A QMA administered insulin without certification, and there was a lack of nursing staff to administer insulin on time, leading to delays for several residents. Facility policies on medication administration and staffing were not followed, resulting in these deficiencies.
The facility failed to notify the physician and guardian when two residents left independently. One resident, with a court-appointed guardian, left multiple times without notification, despite a physician's order requiring guardian approval. Another resident, dependent on staff, left without the physician being informed. Facility policies on leave of absence and elopement were not followed, leading to these deficiencies.
A resident admitted with osteomyelitis and multiple wounds did not have necessary physician orders for their PICC line, wound care, and enhanced barrier precautions. A nurse administered vancomycin without donning a gown, and the clinical record lacked orders for saline flushes, PICC line management, and wound vac care. The DON confirmed these orders should have been in place upon admission.
The facility failed to ensure accurate MDS assessments for residents with specific medical conditions and incidents. A resident with PTSD and IV access was inaccurately assessed, and two residents with falls were not properly documented in their MDS assessments. The DON confirmed these omissions, indicating a failure to accurately reflect the residents' conditions and incidents.
A facility failed to establish a baseline care plan for a resident with multiple wounds and a wound vac, essential for infection control. The resident was admitted with osteomyelitis and had wounds on the gluteal folds, coccyx, and left toe, but the clinical record lacked care plans for these wounds. Observations and interviews indicated that care plans were not updated immediately upon admission, contrary to the facility's policy.
The facility failed to update care plans for two residents after significant incidents. One resident experienced multiple falls without care plan revisions, while another was involved in a methamphetamine incident and was at risk of elopement, yet her care plan was not updated. The facility's policies required care plans to be individualized and revised as conditions changed, but this was not followed.
A resident with PTSD and Borderline Personality Disorder did not receive necessary mental health services due to incorrect preadmission screening and billing issues with the contracted provider. Despite expressing a need for mental health support and showing signs of mild depression, the facility failed to arrange alternative services, impacting the resident's quality of life.
A facility failed to adhere to its policy of limiting PRN antianxiety medication to 14 days for a resident with generalized anxiety disorder. The resident was prescribed diazepam without an end date and received it on multiple occasions over a period exceeding 14 days. The facility's policy requires PRN psychotropic medications to have a 14-day stop date and be reviewed by a physician, which was not followed in this case.
The facility failed to properly label and store medications on a medication cart, with loose pills found and multi-dose containers lacking opening dates. The DON incorrectly stated that dating was unnecessary for certain medications, contrary to the facility's policy requiring opened multi-dose vials to be dated and discarded within 28 days.
The facility failed to prepare puree food correctly for two residents on altered diets. A dietary staff member was unsure of recipe conversions, and the Administrator provided incorrect conversions. The staff member used these incorrect measurements, resulting in improperly prepared puree food, which was then stored in a temperature holding area.
The facility failed to maintain complete and accurate documentation for residents, particularly in cases of elopement and falls. A resident with a court-appointed guardian left the facility multiple times without proper documentation, while another resident's leave of absence records lacked necessary details. Additionally, a resident with a history of falls had incomplete neurological checks documented. The facility's policies on documentation were not followed in these instances.
A facility failed to implement enhanced barrier precautions for a resident with a PICC line and multiple wounds, as observed when an RN administered vancomycin without donning a gown. The resident, diagnosed with osteomyelitis, had no orders for EBP in their clinical record, despite the facility's policy requiring PPE to prevent the spread of multi-drug resistant organisms.
The facility did not designate a certified Infection Preventionist (IP) who dedicates at least part-time hours to the role. The DON, responsible for the infection prevention and control program, could only allocate about 8 hours per week to this role while working full-time as the DON. The facility's program required a designated clinical team member to monitor and manage infection control activities.
The facility failed to post accurate nurse staffing information, omitting actual hours worked by RNs, LPNs, and CNAs for three days. Observations showed that the posted sheets did not specify actual shift hours, and the Administrator confirmed the inability to determine actual hours worked. This was contrary to the facility's policy requiring the recording of actual time worked.
Survey Results Not Available for Review
Penalty
Summary
The facility failed to ensure that the most recent standard survey results and plan of correction were available for residents and others to view. On 5/14/26 at 12:15 p.m., surveyors observed a binder in the front lobby containing previous survey results, but it did not include any results from Indiana Department of Health surveys conducted in 2026 other than a Life Safety Code survey. On 5/15/26 at 8:40 a.m., the DON stated the facility did not have a specific policy for making survey results available and that they followed state board of health regulations.
Unsafe and Unsanitary Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for residents on 3 of 3 units observed and in 2 of 2 dining rooms. During observation on 5/14/26 at 8:45 a.m., surveyors found walls in the unit hallways marred and/or soiled, baseboards on the units marred and/or soiled, and door trim around resident rooms marred or chipped. Floors in the hallways and nurses stations had debris built up in corners and around and under all heating/cooling units. In the 100 and 200 dining rooms, floors had debris built up around baseboards and in corners, including on the floor under the wall-mounted television in the 200 unit. The same conditions were observed again on 5/15/26. On 5/16/26 at 9:17 a.m., the DON provided the facility policy on homelike environment, which stated residents are to be provided with a safe, clean, comfortable, and homelike environment and that the facility maintains a clean, sanitary, and orderly environment.
Missing informed consent for psychotropic medications and drug screening
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications and before completing a serum drug screen and related lab work for multiple residents. The record review and resident interviews showed that consent documentation was missing for antipsychotic, antidepressant, and antianxiety medications, as well as for CBC, BMP, and serum drug screen testing ordered in response to concerns about possible drug use. For one resident, who had diagnoses including diabetes mellitus, acquired absence of the left leg above the knee, osteoarthritis, and polyneuropathy, the clinical record showed orders for buspirone, duloxetine, aripiprazole, and mirtazapine, along with CBC, BMP, and serum drug screen testing. A nursing note stated that the Medical Director was in the facility for routine rounds, the resident was assessed, medications were reviewed, and new lab orders were obtained, but the record did not identify the parties notified. An MD note stated the resident would not wake to speak with the physician and that staff reported he left for hours at a time and sometimes all night with concern for drug abuse; the physician ordered a drug test and lab work. The record lacked documentation of informed consent for the medications and the lab work, and the DON confirmed there was no documented consent for the serum drug screen. A second resident, who was cognitively intact and had chronic pain syndrome, acquired absence of the right leg below knee, long-term use of opiate analgesic, and opioid dependence, also had CBC, BMP, and serum drug screen orders after the Medical Director noted concerning behavior for drug use and ordered testing. The record lacked documentation of informed consent for duloxetine and the lab work. A third resident, with major depressive disorder and moderate cognitive impairment, had orders for buspirone, desvenlafaxine, olanzapine, and clonazepam, and the record lacked documentation of informed consent for psychotropic medications. A fourth resident, with vascular dementia, bipolar disorder, and cerebral infarction, had orders for iloperidone and clonazepam, and the record lacked informed consent for psychotropic medications. During interview, the DON stated informed consent could not be found for these residents, and Clinical Regional Nurse 2 stated he forgot to follow up with the facility about informed consents when the regulation changed in July.
Pain Medication Reduced After Marijuana-Positive Drug Screens
Penalty
Summary
The facility failed to treat residents with dignity, respect, and freedom from discrimination when it decreased pain medication after two residents tested positive for marijuana. Resident 21 had diagnoses including diabetes mellitus, acquired absence of the left leg above the knee, osteoarthritis, and polyneuropathy. He was cognitively intact, independent in ADLs, and receiving opioid and PRN pain medication. He reported that the facility obtained a drug test without his consent, told him the blood draw was for diabetes monitoring, and then reduced his pain medication after the marijuana result. He stated he was no longer getting relief for his pain, which he related to his leg amputation and hip pain from sitting in a wheelchair. Resident 21’s record showed that he had been receiving hydrocodone-acetaminophen 7.5-325 mg three times daily for pain related to polyneuropathy and osteoarthritis, then the order was changed to 5-325 mg three times daily for one week and then twice daily. The record contained a lab report showing positive THC and hydrocodone opiates, but it lacked documentation explaining why the hydrocodone-acetaminophen dose was decreased. The DON stated that the medication was decreased because the resident tested positive for marijuana. Resident 3 had diagnoses including chronic pain syndrome, acquired absence of the right leg below the knee, long-term use of opiate analgesic, and opioid dependence. He was cognitively intact, independent in ADLs, and receiving opioid medication. He stated that the facility decreased his methadone and that it was making him nauseous and decreasing his appetite. His record showed a serum drug screen positive for THC and methadone, and later a nursing note documented that the MD and NP were notified after marijuana was found in his room and that the MD ordered methadone to be decreased to wean him off due to illegal activities when outside the facility. The DON indicated the drug screens were ordered during MD rounds and was unsure why Resident 3’s methadone was decreased, but assumed it was related to marijuana use.
Failure to Document and Resolve Grievance for Missing Resident Property
Penalty
Summary
The facility failed to ensure that a grievance was documented and resolved for a resident whose cell phone was reported missing. On 1/4/26, the resident's family member stated that the phone was missing, that the facility had been told about it, that it had not been found, and that there had been no follow-up from the facility. The resident's clinical record showed diagnoses including encephalopathy, and the most recent Quarterly MDS assessment indicated severe cognitive impairment and a need for substantial to maximal assistance with transferring and setup assistance for eating. Care conference notes documented that the resident's phone with the pink case was missing and that the facility was looking for it. A Social Service note also recorded the family member's concern about the missing phone. During interview, the Social Services Director stated that the facility was still looking for the phone, that neither the initial grievance nor the ongoing investigation had been documented anywhere, and that there was no time frame for resolution. The facility later provided a grievance policy stating that concerns should be documented on a Resident Concern form, followed up within 24-48 hours, and resolved with documentation and communication back to the person reporting the concern.
Failure to Review and Respond to Psychotropic Medication Recommendations
Penalty
Summary
The facility failed to ensure pharmacist medication recommendations were reviewed and responded to in a timely manner for 2 of 5 residents reviewed for unnecessary medications. Resident 5 had diagnoses including major depressive disorder, was moderately cognitively impaired, and was dependent on staff for toileting and bathing. The resident was receiving buspirone 15 mg three times daily for anxiety and desvenlafaxine 25 mg daily for depression. A Psychotropic Medication Utilization Report indicated gradual dose reductions were suggested for buspirone and desvenlafaxine, and a Drug Regimen Review dated 11/9/25 showed the desvenlafaxine order was due for review and a gradual dose reduction attempt, but the DRR was not filled out or signed by the provider. Resident 21 had a diagnosis of major depressive disorder, was cognitively intact, and was independent in all ADLs. The resident was receiving duloxetine 60 mg twice daily for major depressive disorder. A Drug Regimen Review dated 7/6/25 indicated the duloxetine order was due for review and dose reduction attempt, with a recommendation to decrease the dose or document why reduction was not indicated, but the DRR was not filled out or signed by the provider. The clinical record lacked documentation that the provider acted on the recommendation or documented a clinical reason that dose reduction was contraindicated. The DON stated she was unable to find signed DRRs for Resident 21 and Resident 5 or documentation explaining why the medications did not have a dose reduction attempt.
Failure to Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse and misappropriation of property were reported to the State Survey Agency or in accordance with State law for 1 of 1 residents reviewed for abuse and 1 of 1 residents reviewed for misappropriation of property. One resident stated that staff were rough during incontinence care, were mumbling hateful words, and that pain medication had to be requested after care was provided. The resident later described the incident as rudeness, roughness, and abuse, and administration was notified of the allegation. The resident’s record showed the resident was cognitively intact and dependent on staff for toileting and bathing, and the medication record lacked documentation that pain medication had been administered since admission. The Administrator stated the abuse allegation was not reported to the State Survey Agency because the resident did not use the word abuse during the interview. A second resident reported that after Thanksgiving, $480 was stolen by a staff member and that the missing money had been reported to an RN, who informed the Administrator and Social Services Director. The resident knew statements were being taken from staff and residents but was unsure whether the matter had been resolved. The clinical record lacked documentation of the missing money or the investigation. The Administrator stated an investigation was completed and the issue was considered resolved because the money could not be located and the resident’s claim could not be substantiated, and she did not report the allegation to the State Survey Agency because it could not be proven. The facility policy stated that all reports of resident abuse, neglect, exploitation, or theft/misappropriation are reported to local, state, and federal agencies and thoroughly investigated.
Lack of Documentation Supporting Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that sufficient supporting documentation was obtained before assigning a diagnosis of schizophrenia to one resident. The resident was admitted with diagnoses that included paranoid schizophrenia, which was added on 4/18/25, and the most recent MDS assessment showed moderate cognitive impairment, dependence on staff for toileting and bathing, and receipt of an antipsychotic medication during the lookback period. Current physician orders included Zyprexa 15 mg at bedtime related to mental disorder and Zyprexa 10 mg daily related to paranoid schizophrenia, and the care plan stated the resident received antipsychotic medications related to delusional disorder, mental disorder, and schizophrenia. A Medication Regimen Review dated 4/14/25 was sent from the pharmacy to the Medical Director and stated that the resident’s current diagnosis of mental disorder was not acceptable per CMS regulation and that the diagnosis associated with antipsychotic use must be an enduring condition. The Medical Director selected schizophrenia as the diagnosis and returned the review to the pharmacy on 4/17/25. However, the clinical record did not contain documentation supporting the schizophrenia diagnosis, why the diagnosis was given, or any assessment that led to the diagnosis, and documentation requested from the DON was not provided.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for bathing received showers or baths. Resident 33, who was cognitively intact and had diagnoses including type 2 diabetes mellitus, stated during interview that she had not received a shower since admission. At the time of observation, her hair was disheveled and there was a strong pungent odor in the room. Record review showed the resident’s MDS indicated she was dependent on staff for toileting and bathing, and the Point of Care bathing task listed a bathing schedule of Monday and Thursday night shift. The bathing task also showed the resident had not received, or had refused, a complete bed bath or shower from 12/26/25 through 1/5/26.
Failure to Change and Assess Wound Vac per Order
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with physician orders and professional standards of practice for a surgical wound. The resident had diagnoses including type 2 diabetes mellitus and osteomyelitis, and the most recent MDS indicated the resident was cognitively intact, dependent on staff for toileting and bathing, and had a foot infection and surgical wound. Physician orders directed wound vac care to the right foot, including cleansing, applying drape and foam, setting the wound vac to 150 mmHg continuous with instillation therapy, and checking placement and function every shift. During observations, the resident stated staff did not change the wound vac the previous day, and the saline irrigation bag was empty on two separate observations. The wound remained covered with foam and a clear, undated drape. Review of the electronic treatment record showed the wound vac due on 1/5/26 was not marked completed, and the record lacked documentation that the wound vac had been changed from 12/24/25 to 12/31/25 or from 1/2/26 to 1/7/26, as well as wound assessments on the days the wound vac was ordered to be changed. An LPN stated she was not comfortable changing the wound vac and that the DON handled wound vac changes. The facility policy required assessment of the wound before dressing selection and documentation of wound status, dressing changes, settings, tolerance, dates, times, and the person performing the procedure.
Improper Tracheostomy Suctioning and Care
Penalty
Summary
Proper tracheal suctioning and oxygen services were not provided according to physician orders for one resident with a tracheostomy. During observation, an LPN entered the resident’s room without donning PPE even though the resident was on Enhanced Barrier Precautions due to the tracheostomy. Before suctioning, the inner cannula was observed sitting on the bedside table with the speaking valve present. The LPN donned clean gloves, took a used suction catheter from an open package near the suction machine, and suctioned the tracheostomy several times without the inner cannula in place. The LPN then replaced the used inner cannula with the speaking valve on. Record review showed the resident had diagnoses including COPD, malignant neoplasm of the larynx, tracheostomy, and gastrostomy. The resident was cognitively intact and dependent on staff for eating, hygiene, dressing, and transferring. Current orders included trach care every shift and PRN, and changing the inner cannula daily. The care plan directed staff to provide trach care and suction as ordered. The facility’s suctioning policy called for a protective mask and eye wear, opening a suction catheter kit, and applying sterile gloves, and the tracheostomy care policy stated tracheostomy care should be provided at least once daily.
Failure to Provide Adequate Pain Management After Fall With Fracture
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident who fell and later was found to have a fractured right shoulder. Resident 7 was cognitively intact, required substantial assistance with toileting and transfers, and had a history of falls with major injury. The resident’s MDS indicated frequent pain in the five days before the most recent assessment, with pain affecting sleep and day-to-day activities and reaching a highest level of 10 on a 1-to-10 scale. Current orders included PRN acetaminophen and PRN morphine, but the clinical record did not direct staff on which pain medication to try first when the resident complained of pain. After the fall, staff documented a skin tear to the right elbow and later noted that the resident complained of right shoulder and right arm pain. The record showed an order for a STAT x-ray of the right shoulder and elbow, but it lacked documentation of the physician’s order details for the x-ray, the x-ray views to obtain, and when the x-ray service was in the facility. The resident continued to complain of pain on multiple occasions, including right arm pain, right elbow pain, and discomfort to the right arm, but the record lacked assessment of the right arm after those complaints and lacked documentation of additional pain relief measures, including non-pharmacological interventions. Acetaminophen was given once after the resident rated pain as 3, and it was later documented as effective. However, when the resident continued to complain of pain, the record did not show additional pain relief attempts. On the day the right shoulder x-ray showed a displaced humeral neck fracture, the resident continued to complain of discomfort, pain medication was offered but not administered, and the record did not document that medication was given or refused. The resident was transferred to the emergency room later that evening for treatment of the right shoulder fracture.
Medication Administration Errors During PEG Tube Pass
Penalty
Summary
The facility failed to ensure it was free of a medication error rate greater than 5 percent for 1 of 6 residents observed during medication pass. During an observation of medication administration, a Qualified Medication Aide prepared medications for a resident with a gastrostomy tube and tracheostomy, and 6 errors were identified in 31 opportunities, resulting in a 19.35 percent medication error rate. The resident was cognitively intact and dependent on staff for eating, hygiene, dressing, and transferring. During the medication pass, the QMA did not check for residual or flush the PEG tube before giving medications. The following medications were crushed together with liquid medications and administered through the PEG at one time: methadone, lorazepam, Norvasc, Senna, Lexapro, and ferrous sulfate. The resident’s orders included flushing the enteral tube with 30 mL of water before and after medications every shift and checking for residual before medications, flushing, and feedings if greater than 100 mL. The facility’s Enteral Tube Medication Administration policy stated that crushed medications are not mixed together.
Delayed Radiology Services After Resident Fall and Fracture
Penalty
Summary
The facility failed to obtain radiology services, or transportation to obtain them, in a timely manner for a resident who fell and later was found to have a fracture. Resident 7 was cognitively intact, required substantial assistance with toileting and transfers, and had a history of falls. After a witnessed fall on the resident’s right side with a skin tear to the right elbow and complaints of right shoulder pain, an X-ray was obtained showing no acute fracture in the elbow but a subtle linear lucency involving the radial head, with clinical and CT correlation recommended. The record lacked documentation of a physician order for the X-ray or the specific views ordered, and also lacked documentation of when the X-ray service was in the facility and obtained the films. The resident continued to complain of right arm pain and had limited use of the arm. A CT scan of the right elbow/forearm was ordered to be completed at a diagnostic center, but the facility was unable to schedule transport for the CT. The resident’s right shoulder later became swollen and malformed, and a two-view shoulder X-ray showed a fracture of the humeral neck with moderate displacement of the distal segment. The resident was then transferred to the emergency room for treatment. The DON stated transportation to the STAT CT was unavailable and was unsure why the correct X-ray view was not ordered, and a regional clinical nurse stated the resident should have been sent to the emergency room when the facility could not complete the ordered CT.
Failure to Properly Handle Confiscated Marijuana
Penalty
Summary
The facility Administrator failed to dispose of confiscated marijuana, report the illegal substance to law enforcement and the State Survey Agency, and follow the Controlled Medication Disposal policy. On 1/5/26, Resident 3 stated that a staff member had taken smoking paraphernalia from his bedside table drawer. The resident’s record showed diagnoses including chronic pain syndrome, and the most recent MDS dated 10/27/25 indicated he was cognitively intact, independent in all ADLs, and had no behaviors. His care plan included risk for complications related to substance abuse and a desire to use tobacco products. A nursing progress note dated 12/31/25 documented that the MD and NP were notified after a bag of marijuana was found in Resident 3’s room, but the record lacked documentation of follow-up regarding the confiscated marijuana. During interviews, the Administrator stated the facility was a non-smoking building, residents could store smoking paraphernalia in their rooms, and if they broke a smoking rule the paraphernalia was held up front. She also stated she was unsure what to do with the marijuana, did not know whether to call police, did not want to get the resident in trouble, and was not sure of the facility’s policy when illegal substances were found. She further stated she did not report the occurrence to the SSA. On 1/7/26, the marijuana was observed in an open tin container in an unlocked closet in the Administrator’s office while the office was unoccupied and unlocked. The Administrator provided the facility’s Controlled Medication Disposal policy and the Unusual Occurrence Policy, and Clinical Regional Nurse 2 stated the disposal policy was to be used for all scheduled drugs, including marijuana, and that the Administrator should have called law enforcement as soon as it was confiscated.
Lack of Contract and Communication With Outside Pain Clinic
Penalty
Summary
The facility failed to obtain a written contract with an outside professional resource and failed to document the services and timeliness of those services for a resident who was being seen by a Pain Clinic. Resident 3 had diagnoses including chronic pain syndrome and opioid dependence, was cognitively intact, independent in ADLs, and was receiving methadone for pain related to opioid dependence and chronic pain syndrome. The clinical record did not contain a physician order for the Pain Clinic, and the care plans did not document that the resident was seeing the Pain Clinic doctor for management of opioid medication and/or pain. Nursing notes showed repeated attempts to contact the Pain Clinic about who was managing the resident’s methadone and to verify the dose, but the record lacked documentation that the clinic returned calls or communicated with the facility about appointments or medication management. The DON stated the Pain Clinic did not communicate well with the facility and that the facility did not have a contract with the Pain Clinic. Clinical Regional Nurse 2 stated the facility did not have a specific policy addressing outside services, but any work done with an outside vendor required a contract.
Failure to Follow PPE and Hand Hygiene Requirements
Penalty
Summary
The facility failed to implement infection prevention measures for two observed residents. For Resident 24, who had diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of the larynx, tracheostomy, and gastrostomy, and who was cognitively intact and dependent on staff for eating, hygiene, dressing, and transferring, an LPN entered the room without donning PPE even though the resident was on Enhanced Barrier Precautions due to a tracheostomy. Before suctioning the tracheostomy, the inner cannula was observed sitting on the bedside table with the speaking valve present. The LPN then donned clean gloves, took a contaminated suction catheter from an open package near the suction machine, suctioned the tracheostomy several times without the inner cannula present, and later replaced the contaminated inner cannula with the speaking valve on. For Resident 33, a CNA entered the room, washed her hands for eight seconds, and put on gloves before providing care. The CNA raised the bed, lowered the covers, removed the resident's gown and brief, and performed perineal care using a washcloth sprayed with peri-wash. After the resident rolled to the left side, the CNA continued cleaning with a wet washcloth and peri-wash spray, then removed her gloves and performed a nine-second hand wash. During interview, the CNA stated hand washing should occur for 40 seconds. The facility's EBP policy stated that gowns and gloves are applied prior to high-contact resident care activities, and the handwashing policy stated hands should be rubbed vigorously for at least 15 seconds.
Lack of documented staff training for trach care and wound vac care
Penalty
Summary
The facility failed to ensure that staff members providing direct care, including contractual staff, were thoroughly trained to provide tracheostomy care for one resident and wound vac care for another resident. During observation, a contractual LPN provided tracheostomy care to a resident with COPD, malignant neoplasm of the larynx, a tracheostomy, and a gastrostomy tube, but did not follow infection control techniques. The LPN did not don PPE before care, used clean gloves with a contaminated suction catheter, did not use sterile gloves for a sterile procedure, and replaced a contaminated inner cannula. The resident’s record showed orders for trach care every shift and PRN, and daily inner cannula changes. The facility policy for suctioning a tracheostomy required mask and eyewear, removal of gloves, use of a sterile suction catheter kit, sterile drape, sterile saline, sterile gloves, and hand hygiene. When in-service education was requested, the DON stated the contractual staff member was from an agency and the facility did not have specific training for contractual staff. The agency stated its staff completed modules for their assigned field, but the content was not recorded and could not support specific training for tracheostomy care. Facility leadership also stated bedside trach training had been done, but there was no documentation of the training. For the second resident, who had type 2 diabetes mellitus, osteomyelitis, a foot infection, and a surgical wound, the record included orders for wound vac care and checks of placement and function every shift. The resident stated staff did not change the wound vac as expected, and observations showed the saline irrigation bag was empty and later undated and empty. The treatment record showed the wound vac change ordered for one date was not completed, and there was no documentation that the wound vac had been changed since the start date listed in the record. An LPN stated she was not comfortable changing the wound vac and that the DON handled wound vac changes. When training records were requested, the facility could not provide documented attendance or skills check-off specific to wound vacs for any staff employed in the facility.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post a current Nurse Staffing Information form for 4 of 4 days during the survey period. On 1/4/26 at 8:53 A.M., a Nurse Staffing Information form on the main lobby desk was dated 1/2/26. On 1/5/26 at 9:24 A.M., the form on the main lobby desk was dated 1/5/25. On 1/6/26 at 3:22 P.M. and again on 1/7/26 at 8:23 A.M., the form on the main lobby desk was still dated 1/5/25. During an interview on 1/7/26 at 8:39 A.M., the DON stated she oversaw the posted nurse staffing form, completed it every morning when she was there, and that on weekends the weekend night nurse would complete it. On 1/7/26 at 2:03 P.M., the Administrator provided a policy dated 8/2024 stating that within two hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff, completes the Nurse Staffing Information form, and posts the staffing information in the designated location.
Failure to Follow Physician Orders and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to follow physician orders for medication administration and implement care plan interventions for residents at risk of falls. Resident D, who was admitted with diagnoses including essential hypertension and orthostatic hypotension, had specific physician orders to hold lisinopril if systolic blood pressure was less than 110. However, the medication was administered without obtaining blood pressure readings on multiple occasions, and it was given even when the systolic blood pressure was below the specified threshold on several dates. Additionally, non-slip strips, which were part of the fall prevention interventions for Resident D, were not observed in the shower room where the resident resided. Resident B, with a history of transient ischemic attack and flaccid hemiplegia, experienced an incident where they were found sliding out of their chair and lowered to the floor. Despite this incident, no new interventions were documented in the clinical record to address the risk of falls. The Director of Nursing acknowledged that a new intervention should have been implemented following the incident. The facility's policies on medication administration and care plans emphasize the importance of administering medications as prescribed and developing comprehensive, person-centered care plans with measurable objectives. However, these policies were not adhered to, as evidenced by the failure to follow blood pressure parameters for medication administration and the lack of implementation of fall prevention interventions for the residents involved.
Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure insulin was administered in accordance with professional standards for five residents with type 2 diabetes mellitus. Insulin was administered late and by unqualified staff. For instance, Resident 18 received insulin from a Qualified Medication Aide (QMA) who was not certified to administer insulin. The Director of Nursing (DON) confirmed that QMAs were not allowed to administer insulin, indicating a breach in protocol. Additionally, there was a lack of nursing staff available to administer insulin at the scheduled times. On a specific day, there were no nurses present from 6:00 A.M. to 9:40 A.M., resulting in delayed administration of insulin for several residents, including Residents 1, 17, 11, and 8. The Registered Nurse (RN) on duty began their shift at 9:40 A.M., which was after the scheduled time for insulin administration. The facility's policies required medications to be administered within one hour of the scheduled time and documented accurately. However, the documentation was inaccurate, as evidenced by the QMA's incorrect documentation of insulin administration. The facility's policies also mandated that licensed nurses be available 24/7, which was not adhered to, leading to the deficiencies observed.
Failure to Notify Physician and Guardian of Resident Elopement
Penalty
Summary
The facility failed to notify the physician and resident representative when two residents left the facility independently, which was a requirement for their care. Resident 22, who had diagnoses including schizophrenia and stimulant dependence, was admitted with a court-appointed guardian. Despite being assessed as low risk for elopement, the resident's clinical record lacked a care plan related to the guardian or elopement risk. The resident signed out of the facility multiple times without the guardian or physician being notified, contrary to the physician's order that required guardian approval for leaving the facility. The Director of Nursing (DON) acknowledged that the former administrator had allowed the resident to leave without proper approval, and there was no documentation of the guardian's changing permissions. Resident 75, who was cognitively intact but dependent on staff for various activities, also left the facility independently without the physician being notified. The resident's clinical record included a physician's order allowing leave of absence with a responsible party as needed, but the order was not modified to reflect the resident's independent departures. The facility's policies required a sign-out log and notification of the physician and legal representative upon the resident's return, but these procedures were not followed. The facility's policies, including those for leave of absence, wandering and elopement, and adult guardianship, were not adhered to, resulting in a lack of proper documentation and notification. The DON and Administrator provided these policies during the survey, but the deficiencies in following them led to the failure to notify the necessary parties when the residents left the facility independently.
Lack of Admission Orders for Resident's PICC Line and Wound Care
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician orders upon admission for the management of their medical needs, including a PICC line, wound care, and enhanced barrier precautions. On observation, a registered nurse was seen administering vancomycin to the resident without donning a gown, despite a sign indicating enhanced barrier precautions. The nurse flushed the resident's PICC line and administered the medication without documented orders for saline flushes or the PICC line itself. Additionally, a wound vac was observed on the resident's coccyx, but there were no orders for its management or for wound care. The resident, who was admitted with a diagnosis of osteomyelitis, had several wounds and a PICC line for intravenous antibiotics. The clinical record lacked essential orders for the resident's immediate care needs, such as saline flushes for the PICC line, wound vac management, and enhanced barrier precautions. The Director of Nursing acknowledged that these orders should have been in place upon admission, as per the facility's policy, which requires immediate care orders to be provided by a physician or other qualified healthcare professional.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents with specific medical conditions and incidents. Resident 21, who was admitted with diagnoses including osteomyelitis and PTSD, was inaccurately assessed in the MDS dated 9/25/24, which failed to reflect the presence of PTSD and intravenous access, despite the care plan indicating IV medication administration. The Director of Nursing (DON) confirmed that the MDS should have included these details. Additionally, the facility did not accurately document falls for two residents. Resident 10, who required substantial assistance for daily activities, experienced an unwitnessed fall resulting in a hospital transfer, which was not recorded in the MDS assessment dated 9/27/24. Similarly, Resident 2, with a history of falls and cognitive impairment, had an unwitnessed fall on 7/19/24 that was not documented in the MDS assessment dated 9/13/24. The DON acknowledged these omissions, indicating a failure to accurately reflect the residents' conditions and incidents in the MDS assessments.
Failure to Establish Baseline Care Plan for Wound Management
Penalty
Summary
The facility failed to ensure that a baseline care plan was in place for a resident with multiple wounds and a wound vac, which is crucial for infection control. The resident, identified as Resident 225, was admitted with a diagnosis of osteomyelitis and had a power injection catheter in the right chest, along with wounds on the left gluteal fold, right gluteal fold, coccyx, and left toe. Despite these conditions, the clinical record lacked baseline care plans for all four documented wounds and the management of the wound vac. Observations and interviews revealed that the care plans were not updated immediately upon admission, as required by the facility's policy for comprehensive, person-centered care plans.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to revise care plans for two residents following significant incidents. Resident 2, who had a history of repeated falls and cognitive impairment, experienced multiple unwitnessed falls on different occasions. Despite these incidents, the care plan was not updated with new interventions to address the falls. The Director of Nursing acknowledged that care plans should be updated after each fall, but this was not done for Resident 2. Resident 22, diagnosed with schizophrenia and stimulant dependence, was involved in an incident where methamphetamine was found in her possession. The care plan was not updated following this incident, nor was it revised to reflect her risk of elopement, despite her inclusion in the facility's elopement binder. The Director of Nursing confirmed that residents at risk of elopement should have corresponding care plans, and the Regional Support noted the absence of a substance abuse policy, which had been retired without replacement. The facility's policies required care plans to be individualized and updated as residents' conditions changed, but this was not adhered to in these cases.
Failure to Provide Mental Health Services for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary social services to address the mental and psychosocial needs of a resident with a history of PTSD and Borderline Personality Disorder. The resident, who was admitted with these diagnoses, expressed anxiety and a desire for mental health services, which were not provided. The facility's Social Service Director acknowledged that the preadmission screening was completed incorrectly by the hospital and should have been reviewed and corrected upon admission. Despite the resident's indication of mild depression on the PHQ-9 Questionnaire, no mental health services were arranged due to billing issues with the contracted behavioral health company. The resident's care plan included a risk for ineffective coping due to past experiences, yet the facility did not take appropriate steps to ensure mental health services were provided. The Social Service Director admitted that the facility would have to cover the cost of services since the contracted provider could not bill the resident's insurance, but no alternative providers were contacted. This oversight resulted in the resident not receiving the necessary mental health support to achieve the highest possible quality of life, as required by the facility's standards.
Failure to Limit PRN Antianxiety Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of PRN antianxiety medication. Resident 18, who was diagnosed with generalized anxiety disorder and had no cognitive impairment, was prescribed diazepam, an antianxiety medication, to be taken as needed every 8 hours. The order, dated 8/28/24, did not include an end date, and the resident received the medication on multiple occasions from 8/28/24 to 10/9/24. The facility's policy, as confirmed by the Director of Nursing, requires that PRN orders for psychotropic medications have a stop date of 14 days and be reviewed by a physician every 14 days for continuance. However, this policy was not followed in the case of Resident 18, leading to the deficiency.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on one of the two medication carts observed. During an observation on the 100 hall medication cart, surveyors found an oblong maroon colored pill and a small round white pill that were loose and not properly stored. Additionally, two dropper bottles of medication were found without patient labels, and two open bottles of multi-dose medications lacked a date indicating when they had been opened. The Director of Nursing (DON) incorrectly stated that multi-dose medications like Miralax did not require the date of opening to be written on them. The facility's Medication Labeling and Storage policy, provided by the Administrator, indicated that multi-dose vials should be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer.
Incorrect Puree Food Preparation for Residents
Penalty
Summary
The facility failed to ensure that food was correctly prepared for two residents who required puree-altered diets. During an observation, a dietary staff member was preparing puree foods but was unsure of the conversion from a recipe designed for 15 servings to 5 servings. The Administrator provided handwritten conversions, which were later found to be incorrect. The dietary staff member proceeded to prepare the puree using these incorrect conversions, resulting in the wrong amounts of ham, apple juice, and food thickener being used. The puree was then stored in a temperature holding area. This incident was noted during an interview with the Administrator, who acknowledged the error in the conversions.
Incomplete Documentation for Resident Elopement and Falls
Penalty
Summary
The facility failed to ensure complete and accurate documentation for residents, particularly in cases of elopement and falls. Resident 22, diagnosed with schizophrenia and stimulant dependence, was identified as being at low risk for elopement but was listed in the elopement binder as at risk. Despite having a court-appointed guardian and a physician order restricting her from leaving the facility without approval, Resident 22 signed herself out multiple times without proper documentation of who she left with, expected return time, instructions provided, or medications sent. The Social Services Director acknowledged that the resident was supposed to check in but failed to document these occurrences. Resident 21, with diagnoses including osteomyelitis and PTSD, was cognitively intact and independent in certain activities. However, the facility's documentation for his leave of absence was incomplete, lacking records of medications sent, return times, and signatures of facility representatives. Additionally, there was no physician order authorizing independent leave of absence, despite the resident being listed in the elopement binder. Resident 2, with a history of repeated falls and mild cognitive impairment, had incomplete neurological checks following falls. The facility's documentation showed missing entries for required neuro checks after two separate falls. The Director of Nursing confirmed that neuro checks should be completed and documented, even if done late. The facility's policies on leave of absence and documentation emphasized the need for complete and accurate records, which were not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to ensure that a resident with a PICC line and multiple wounds was provided with enhanced barrier precautions (EBP) as required for infection control. During an observation, a registered nurse (RN) was seen preparing and administering vancomycin to the resident without donning a gown, despite a sign on the door indicating the need for EBP. The RN flushed the resident's PICC line and connected the medication without using the necessary protective equipment. The resident had a wound vac on the coccyx and was diagnosed with osteomyelitis, indicating a high risk for infection. A review of the resident's clinical record showed no orders for enhanced barrier precautions or transmission-based precautions related to the resident's wounds and PICC line. The care plans included various instructions for managing the resident's venous access device and monitoring for signs of infection, but did not address the need for EBP. The Director of Nursing later confirmed that staff should wear personal protective equipment when providing care to residents, aligning with the facility's policy on enhanced barrier precautions to prevent the spread of multi-drug resistant organisms.
Failure to Designate a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) who dedicates at least part-time hours to the role. The Director of Nursing (DON) was responsible for the infection prevention and control program but was only able to dedicate approximately 8 hours per week to this role, despite working full-time as the DON. The DON held an IP certification dated November 14, 2021. The job description for the Infection Preventionist Nurse indicated that the IP provides assistance to the DON when needed. The facility's Infection Prevention and Control Program, dated August 2022, required a designated clinical team member to monitor the program, perform surveillance, and manage infection control activities.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff responsible for resident care, for three out of four days during the annual survey period. On 10/8/24, an observation revealed that the posted nurse staffing data sheet did not specify the actual hours of shifts for RNs, LPNs, and CNAs. The sheet inaccurately indicated that a CNA worked 4 hours during the evening shift without specifying the actual hours worked. Further review of staffing sheets for 10/8/24, 10/9/24, and 10/10/24 confirmed that none reflected the actual hours worked. The Administrator admitted the facility did not have an evening shift and could not determine the actual hours worked from the posted sheets. The facility's policy, dated 8/2024, required that the actual time worked be recorded, which was not adhered to.
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Illustrative
What surveyors actually found near you
We read the 289 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Woodbridge Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Columbia Healthcare Center | 0.1 mi | ★★★★★ | 9 | 0 |
| Brickyard Healthcare - Brentwood Care Center | 1.5 mi | ★★★★★ | 2 | 0 |
| North Park Nursing Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Parkview Care Center | 1.9 mi | ★★★★★ | 25 | 0 |
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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.