Lakeview Manor

F-F689.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 155077 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155077 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Envive of Indianapolis 45 Beachway Dr Indianapolis, IN 46224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 51296

Residents Affected - Few Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 1 residents (Resident 3) reviewed for medical record accuracy.

Findings include:

On 2/6/25 at 10:46 a.m., Resident 3 was observed in her room yelling out nonsensical things at anyone who walked by her room.

On 2/6/25 at 11:30 a.m., Qualified Medication Aide (QMA) 5 indicated Resident 3 was usually out at the nurses' station because she would often get lonely.

On 2/11/25 at 2:42 p.m., Resident 3's medical record was reviewed. She was a long-term care resident whose diagnoses included but were not limited to, schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder), unsteadiness on feet, and difficulty in walking.

An Interdisciplinary Team (IDT) note, dated 1/8/25 at 10:00 a.m., indicated Resident 3 had a fall on 1/7/25.

The intervention for this fall was to implement 15-minute safety checks for 72 hours to reduce falls and increase resident safety.

A nursing progress note, dated 1/8/25 at 7:20 p.m., indicated the resident had a fall.

On 2/14/25 at 10:45 p.m. the [NAME] President of Clinical Services indicated they could not provide documentation proving 15-minute safety checks were completed for 72 hours for Resident 3.

On 2/14/25 at 2:00 p.m. the administrator provided a copy of a current facility policy titled, Falls and Fall Risk Management, dated 8/2024. The policy indicated . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .

3.1-13(u)

3.1-13(v)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 155077 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155077 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Envive of Indianapolis 45 Beachway Dr Indianapolis, IN 46224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38768 potential for actual harm Based on observations, interviews and record review, the facility failed to ensure staff who were symptomatic Residents Affected - Some with illness were tested and/or wore source control to prevent the potential for spreading infection throughout

the community, and the facility failed to ensure staff donned personal protective gear, (PPE) while providing high-contact resident care to those residents who required enhanced barrier precautions (EBP) in order to protect them from the potential of infection, and failed to ensure PPE was readily available outside and/or just inside of the resident's rooms who required EBP. This deficient practice had the potential to affect 11 of 102 resident who required EBP.

Findings include:

1a. On 2/6/25 shortly after the conclusion of the exit conference, the former Regional Nurse Consultant (RNC) arrived onsite. She apologized for being late, she indicated she did not feel well. Her voice was hoarse, she sniffled and had a rattling cough. She indicated she had not tested for illness, but thought it was just a cold. She intended to stay to help on survey.

On 2/7/25 at 9:27 a.m., the former RNC was observed as she wiped down and cleaned out a medication cart

in the secured memory care unit. The RNC had a rattling cough and runny nose. She coughed and sniffled repeatedly. She sneezed into her elbow several times. She was not observed to wear a mask.

During an interview on 2/7/25 at 9:30 a.m., the RNC indicated, she didn't feel well, I'm sick, she did not know what she had, but it must be whatever was going around.

During an interview on 2/10/25 at 9:06 a.m., the Memory Care Coordinator (MCC) indicated, she did not feel well that morning, but felt better than she had over the weekend. She spent the weekend in bed sick and had experienced chills and diarrhea. She indicated, because she did not have a fever she decided to come into work. She indicated she had not taken any tests to rule out Covid and/or flu, because it was probably whatever was going around. She was not observed to wear a mask throughout the survey period.

On 2/10/25 at 9:46 a.m., the Cooperate Business Office Manager (CBOM) was observed as she coughed several times. Her voice was hoarse as she indicated, she was getting over a bought of bacterial pneumonia.

She was not observed to wear a mask throughout the survey period.

During an interview on 2/10/25 at 9:47 a.m., with the CBOM present, the Director of Nursing Services (DNS) indicated, she still did not feel well and was still getting over an illness. She was not observed to wear a mask throughout the survey period.

During a random observation on 2/10/25 at 11:18 a.m., the MCC spoke with Resident 97. She did not perform hand hygiene before she shook his hand and patted his cheek, then did not perform hand hygiene as she continued to assist other residents with room trays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 155077 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155077 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Envive of Indianapolis 45 Beachway Dr Indianapolis, IN 46224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/10/25 at 10:32 a.m., the [NAME] President of Clinical Services (VPCS) provided a copy of current facility policy titled, Coronavirus Disease (Covid-19) - Work Restrictions and Return to [NAME] Criteria for Level of Harm - Minimal harm or Staff, revised 8/2024. The VPCS indicated, although the policy specifically mentioned Covid-19, it was potential for actual harm applicable for other highly contagious illnesses as well. The policy indicated, Staff who have symptoms of Covid-19 [and/or other highly contagious illness'] or have tested positive for [Covid-19] infection follow CDC Residents Affected - Some guidelines and facility policy for work restrictions and return-to-work-criteria . staff will follow all recommended infection prevention and control practices, including wearing a well-fitted source control, monitoring themselves for fever or symptoms consistent with Covid-19, and not reporting to work when ill or

it testing positively for Covid-19 infection If symptoms recur . these staff will be restricted from work and follow recommended practices to prevent transmission to others (e.g. use of well-fitting source control) until

they again meet criteria to return to work unless an alternative diagnosis is identified.

1b. On 2/7/25 at 10:30 a.m., Resident B was observed from the hallway, through her open door, she was in bed on her left side, faced away from the door, and her privacy curtain was not closed. Registered Nurse (RN) 6 stood at the right side of her bed, and Certified Nursing [NAME] (CNA) 22 was on the left side of her bed. Neither nursing staff was observed to EBP PPE. CNA 22 was observed as she removed a brief from under the resident, rolled it up and placed it in a trash bag. RN 6 stepped toward the head of the resident's bed, so that her bare bottom and several wounds of varying conditions were visible from the hallway. RN 6 continued to provide wound care treatment.

On 2/11/25 at 10:14 a.m., Resident B's door was knocked on with no answer. She was briefly observed through the cracked door, with RN 9 and CNA 23 present, when RN 9 indicated, patient care. Neither nursing staff member had on PPE.

During an interview on 2/11/25 at 10:28 a.m., RN 9 indicated, she did not know if Resident B still required EBP or not. There was a sign on her door, but there had not been any PPE outside of any of the resident's rooms for a long time.

On 2/13/25 at 1:35 p.m., Resident B's medical record was reviewed.

She was a long-term care resident with diagnoses which included, but were not limited to, a history of necrotizing fasciitis, (a rare but life-threatening bacterial infection that rapidly destroys the soft tissues and fascia (connective tissue) beneath the skin), open pressure and arterial wounds, colostomy status, and requirement of an indwelling catheter for neurogenic bladder.

Resident B had a comprehensive care plan dated 10/9/24 which indicated, she required the use of Enhanced Barrier Precautions related to her chronic wounds, indwelling medical devices (an enteral tube and indwelling urinary catheter) to reduce the risk of transmission of multi-drug-resistant organisms (MDROs). Interventions for this plan of care included, but were not limited to, ensure PPE is available, follow CDC guidelines for EBP when performing the following high-contact resident care activities . providing hygiene, changing briefs and wound care . precautions should be in place until discontinuation of the indwelling medical devise . precautions should be in place until resolution of the wound(s)

51296

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 155077 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155077 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Envive of Indianapolis 45 Beachway Dr Indianapolis, IN 46224

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. On 2/6/25 at 10:46 a.m. the room of Resident 1 was observed. Resident 1's room did not have an Enhanced Barrier Precaution sign on the door and there was no Personal Protective Equipment (PPE) Level of Harm - Minimal harm or available. Resident 1 had multiple pressure injuries which require the use of EBP. potential for actual harm

On 2/6/25 at 10:50 a.m. the room of Resident 90 was observed. Resident 90's room did not have an EBP Residents Affected - Some sign on the door and there was no PPE available. Resident 90 had a gastrointestinal tube which requires the use of EBP.

On 2/7/25 11:15 a.m. The Regional Nurse Consultant was observed as she cleaned the medication carts out. At the time she was not wearing a face mask, and she was coughing and sneezing regularly.

46414

3. On 2/11/25 at 2:55 p.m., Resident D's wounds were observed with Licensed Practical Nurse (LPN) 11 and Certified Nursing Assistant (CNA) 16 present. CNA 16 turned Resident D to his side, while LPN 11 removed dressings from Resident's sacrum. LPN 11 and CNA 16 did not wear PPE during the procedure. There was

an orange sign in the top right corer of his door which indicated he was in EBP.

On 2/13/24 at 11:39 a.m., Resident D was observed. CNA 16 was in his room and assisted Resident D, as

he prepared for a shower. CNA 16 did not don PPE.

Throughout the survey week, no PPE was observed to be avilable inside or outside of Resident D's room.

On 2/11/25 at 11:28 a.m., Resident D's medical record was reviewed.

He was a long-term care resident with diangoses which inclucded, but were not limited to, neuromusculare dysfunction of the bladder which required the use of in indwelling urinary catheter, and chronic wounds.

He had current physician's which included, but were not limited to, EBP related to his wounds and the use of

a urinary catheter.

His Comprehenisve Care Plans were reviewed, and included, but were not limite to, a care plan which indicated he required EBP until his wounds resolved and his indwelling medical device was discontinued.

A policy titled Enhanced Barrier Precautions dated 8/24 was provided by the [NAME] President of Clinical Services (VPCS) on 2/7/25 at 1:00 p.m. It indicated, .EBPs are utilized to prevent the spread of multi-drug-resistant organisms (MRDOs) to residents. PPE is available outside of the residents' rooms .

This deficiency relates to Complaint IN00452206.

3.1-18(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 155077