INDIANAPOLIS, IN - Federal inspectors documented serious infection control violations at Envive of Indianapolis during a February 2025 inspection, including staff working while visibly ill without protective equipment and nurses providing wound care without proper safety protocols.
Staff Worked While Symptomatic Without Testing or Masks
The most concerning findings involved multiple facility staff members working while experiencing symptoms of illness, potentially exposing the facility's 102 residents to infectious diseases.
A Regional Nurse Consultant arrived at the facility during the inspection with a hoarse voice, sniffling, and "rattling cough." She admitted to inspectors that "she did not feel well" and had not tested for any illness, believing it was "just a cold." Despite her symptoms, she was observed cleaning medication carts in the memory care unit without wearing a mask, coughing and sneezing repeatedly.
The Memory Care Coordinator reported working despite feeling ill, having "spent the weekend in bed sick" with chills and diarrhea. She told inspectors she came to work because she didn't have a fever and hadn't tested for COVID-19 or flu, assuming it was "whatever was going around." She worked without wearing a mask throughout the inspection period.
Additional staff members, including the Corporate Business Office Manager and Director of Nursing Services, were documented working while recovering from illness without wearing masks.
Critical Gaps in Wound Care Safety Protocols
Inspectors observed serious breaches in infection control during wound care for residents requiring Enhanced Barrier Precautions (EBP). These protocols are essential for residents with chronic wounds or indwelling medical devices to prevent the spread of multi-drug resistant organisms.
During one observation, a registered nurse and certified nursing assistant provided wound care to a resident with a history of necrotizing fasciitis - a life-threatening bacterial infection - without wearing any protective equipment. The resident required EBP due to chronic wounds and indwelling medical devices, yet staff exposed themselves and other residents to potential infection.
Medical Significance of These Violations
Necrotizing fasciitis spreads rapidly through soft tissue and can be fatal without immediate treatment. When healthcare workers fail to use protective equipment while treating such conditions, they create pathways for dangerous bacteria to spread to other vulnerable residents.
Enhanced Barrier Precautions exist specifically to contain multi-drug resistant organisms that don't respond to standard antibiotics. These "superbugs" pose extreme risks in nursing home settings where residents often have compromised immune systems, chronic conditions, and multiple medical devices.
Missing Safety Equipment and Documentation
Inspectors found protective equipment was not readily available in resident rooms requiring EBP, despite facility policies mandating its presence. Multiple residents with chronic wounds and indwelling catheters lacked proper signage and available protective equipment outside their rooms.
The facility also failed to maintain required documentation. When a resident with schizoaffective disorder experienced a fall, the interdisciplinary team ordered 15-minute safety checks for 72 hours. However, facility leadership could not provide documentation proving these safety checks were completed, violating federal requirements for accurate medical records.
Industry Standards for Infection Prevention
Federal regulations require nursing homes to maintain comprehensive infection prevention programs. Staff experiencing respiratory symptoms should be tested for infectious diseases and wear appropriate source control measures when present in the facility.
The Centers for Disease Control and Prevention recommends that healthcare workers with symptoms consistent with respiratory illness should not work with patients unless they test negative for infectious diseases or receive medical clearance. When they must work, proper source control including well-fitted masks is essential.
Enhanced Barrier Precautions represent a targeted approach to preventing transmission of resistant organisms. These protocols require staff to use gloves and gowns during high-contact care activities including wound care, hygiene assistance, and device management.
Facility's Own Policies Violated
The inspection revealed the facility had appropriate policies in place but failed to implement them. Their COVID-19 work restriction policy, applicable to "other highly contagious illnesses," clearly stated that symptomatic staff should "follow CDC guidelines" and wear "well-fitted source control" while monitoring for symptoms.
The facility's Enhanced Barrier Precautions policy specified that "PPE is available outside of the residents' rooms" to prevent spread of multi-drug resistant organisms, yet this equipment was consistently absent during the inspection.
Risk to Vulnerable Population
The violations occurred in a facility caring for residents with complex medical needs, including those with chronic wounds, indwelling catheters, and compromised immune systems. These residents face elevated risks from infectious diseases due to their underlying health conditions and the healthcare setting environment.
Respiratory infections can be particularly dangerous for elderly residents with chronic conditions. When staff work while symptomatic without protective measures, they create unnecessary exposure risks that can lead to serious complications or death among vulnerable residents.
The failure to maintain proper wound care protocols poses additional risks for residents with existing infections or compromised healing capacity. Cross-contamination between residents can occur when staff move between rooms without appropriate protective equipment.
Regulatory Response and Oversight
The inspection was conducted by federal surveyors as part of routine oversight of nursing home compliance with Medicare and Medicaid participation requirements. The violations were categorized as having "minimal harm or potential for actual harm," though the scope affected multiple residents requiring enhanced safety measures.
Federal regulations require nursing homes to maintain infection prevention programs that protect residents from acquiring and transmitting infectious diseases. Facilities that fail to meet these standards risk losing their ability to participate in federal healthcare programs.
The documented violations at Envive of Indianapolis highlight ongoing challenges in nursing home infection control, particularly ensuring staff adherence to established safety protocols during routine care activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeview Manor from 2025-02-14 including all violations, facility responses, and corrective action plans.
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