Envive Of Beech Grove

Based on observation, interview, and record review the facility failed follow the menus prepared in advance for 1 of 1 dining observations. Findings include: On 12/10/25 at 1:00 p.m., observed posted menu on the wall, outside of the main dining room. The menu indicated scalloped potatoes were to be served on 12/10/25 during lunch time. During a dining observation on 12/10/25 at 1:10 p.m., the following was observed: - Resident 44, Resident 24, Resident 29, and Resident 42's lunch plate was observed to include mashed potatoes, the plate did not include the listed scalloped potatoes as indicated on the posted menu. - At that time, Resident 42's a family member indicated the meals Resident 42 received on his meal tray did not match the posted menu. During an interview on 12/19/25 at 1:00 p.m., the Administrator indicated he was not aware of the discrepancy and indicated the posted menu should match the served meal. On 12/12/25 at 9:12 a.m., the Executive Director provided a policy titled Kitchen operations: Meal Service and Distribution, dated December 2022, and indicated it was the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 1 of 3 kitchen observations. A refrigerator food item was not covered, and a perishable food item was not discarded by the use-by-date. Findings include: During the initial facility tour with the Executive Director (ED) on 12/9/25 at 9:45 a.m., the resident snack pantry, located near the resident dining room area, was observed. The following was observed inside the resident snack pantry refrigerator:-One plastic gallon container of Country Fresh white milk was located on the shelf of the refrigerator door. The milk container contained a grayish colored thick substance that covered the bottom of the container. Similar substances were observed inside the container that was adhered to the sides of the container. Near the top of the milk container, the manufacturer's pre-printed Use By Date: 11/30/25 was observed.-One medium sized plastic pan was observed on the top shelf of the refrigerator unit. The pan was approximately ten percent full of applesauce. The pan was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide special eating utensils for 1 of 2 residents reviewed for restorative services. (Resident 42) Finding included: On 12/10/25 at 1:39 p.m., the clinical record for Resident 42 was reviewed. The diagnoses included, but were not limited to, hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). The current Physician's orders, dated 11/9/25 indicated the following: - Regular diet, pureed texture, nectar/mildly thick consistency fluids. - An Occupational Therapy clarification Order, dated 11/17/25 with no end date, indicated Resident 42 was to use a Kennedy cup (a lightweight, easy to grip adapted drinking cup designed to prevent spills) and scoop plate (a scoop plate is a type of dish specifically designed to help individuals with limited motor skills or disabilities that makes eating challenging) during all meals. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 1 residents with urinary catheters observed. A urinary catheter drainage bag was touching the floor. (Resident 26)Finding includes: On 12/9/2025 from 12:10 p.m., until 12:30 p.m., observed Resident 26 sitting in the dining room. The resident's catheter drainage bag was observed to be hanging from the wheel chair and the drainage bag was touching the floor. During an interview on 12/9/25 at 12:33 p.m., Certified Nursing Assistant (CNA) 2, indicated the catheter drainage bag was not supposed to touch the floor. On 12/9/25 at 12:35 p.m., observed the Assistant Director Nursing adjust the catheter drainage bag so that it was not touching the floor. On 12/12/25 at 8:37 a.m., the Director of Nursing provided a policy titled Catheter Care, dated August, 2024, and indicated it was the current policy being used by the facility. A review of the policy indicated .11. Be sure the catheter tubing and drainage bag are kept off the floor. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure foods were maintained and served in a sanitary and safe manner for 4 of 4 observations. Staff hair was not covered while in the kitchen food preparation and serving area. (Dietary Manager) Findings include: 1. The initial kitchen tour was conducted with the Dietary Manager (DM) on 12/10/24 from 9:00 a.m. to 9:20 a.m. The DM was observed walking through out the kitchen area and near the food preparation table where the noon meal was being prepared. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed to not be covered. 2. During a follow up kitchen observation on 12/10/24 from 11:25 a.m. to 11:45 a.m., the DM was observed at and near the steam table where the noon meal foods were being held. The DM was observed taking and recording the noon meal food temperatures. The DM was observed to have multiple loose facial chin hairs approximately one-fourth inch to one-half inch in length. The chin hairs were observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a physician's ordered skin tear treatment was followed for 1 of 3 residents reviewed for skin integrity. Wound dressings were not dated and initialed and the dressing change was continued beyond the physician's orders.(Resident 6) Findings include: During an observation on 12/10/24 at 10:45 a.m., Resident 6 was observed sitting in her wheelchair in the hall near her room. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches by three inches, was observed covering the mid-shin area. The dressing lacked any documentation that indicated when and who had applied the dressing to the resident's shin area. During an interview at that time, Resident 6 indicated she was unsure when or why the dressing had been applied to her leg. On 12/12/24 at 1:15 p.m., Resident 6 was observed in her room and was sitting in her recliner with both legs elevated. Resident 6's left mid-shin area was observed. A dry and intact tan colored dressing, approximately two inches…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to document the drug dispositions for 1 of 2 residents reviewed for closed records. (Resident 47) Finding includes: On 12/13/24 at 12:36 p.m., Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, hypertension, cerebral infarction (stroke), and hyperlipidemia (high cholesterol). A physician's order summary report of medications, dated for active orders as of 9/17/24, included but were not limited to: - hydralazine HCL 25 milligrams (mg) for hypertension (high blood pressure) - atorvastatin calcium 80 mg for lowering cholesterol - carvedilol 3.125 mg for hypertension - hydrochlorothiazide 12.5 mg for hypertension The Envive Discharge Summary document, was initiated on 9/16/24 in anticipation for Resident 47's planned discharge. A review of the document indicated Resident 47's current medications were to be sent home with the resident on her scheduled discharge date of 9/17/24. The record included Resident 47's current medications; however, it lacked the actual number of pills per…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a soiled utility room lock was repaired for 1 of 1 soiled utility rooms observed. Findings included: On 12/10/24 at 10:00 a.m., observed the door to the Soiled Utility Room between room [ROOM NUMBER] and room [ROOM NUMBER] to be unlocked. An observation of the lock to the door was missing numerical key pads and the door latch was taped to prevent the door from locking when the door closed. In the unlocked room, a barrel labeled trash, three barrels labeled soiled linen, and two barrels containing items in biohazard bags were observed. The door to the Soiled Utility Room had a sign which read, Restricted Area, Authorized Personnel Only. During an interview on 12/10/14 at 10:05 a.m., Qualified Medication Aide (QMA) 2 indicated the door should have been locked, but the lock was broken and there should have been a work order for it. During an interview on 12/10/24 at 10:22 a.m., the Director of Nursing (DON) indicated the door should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Resident's Advanced Directive (code status) preference was implemented and recorded accurately in the clinical record for 1 of 16 residents reviewed for Advanced Directives. (Resident 46) Finding includes: On [DATE] at 2:45 p.m., Resident 46's clinical record was reviewed. Resident 46 was admitted to the facility on [DATE]. The new admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident 46 was severely cognitively impaired. Resident 46's baseline care plan indicated .Focus: [NAME] Care Guide, date initiated: [DATE] and current through [DATE] .Goal: The resident's care will be provided .Interventions: Code status/advanced directive [decision regarding health care intervention]: Full code [meaning a desire for all life sustaining measures were to be implemented] . Resident 46 had an appointed Health Care Power of Attorney (a legal document that grants a trusted person the authority to make healthcare decisions on your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to initiate a baseline care plan for a newly admitted resident for 1 of 2 residents reviewed for baseline careplans. (Resident 27) Finding includes: On 12/12/23 at 1:38 p.m. the clinical record for Resident 27 was reviewed. The diagnoses included, but were not limited to, Diabetes Mellitus and fractured left patella. Resident 27 was admitted on [DATE]. The clinical record lacked a personalized baseline careplan. During an interview 12/14/23 at 2:12 p.m., RN 2 indicated Resident 27 should have had a baseline careplan initiated within 48 hours of admission. On 12/14/23 at 2:30 p.m., the Director of Nursing provided a policy titled Nursing Admission/Return Admission, dated August of 2022, and indicated it was the current policy being used by the facility. A review of the policy indicated .6. After completion of the admission nursing assessment a Baseline care plan will be initiated for all new admissions . 3.1-30(a)