Envive Of Muncie
ENVIVE OF MUNCIE in MUNCIE, IN — inspection on March 31, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
provide transport to the ER.A progress note, dated 3/11/26 4:00 a.m., indicated Resident 45 was
representative.
During an interview, on 3/30/26 at 1:30 p.m., the Social Services Director (SSD)
his own representative; however, the facility usually notified his wife if he went to the hospital.
Notice of Transfer forms and bed hold policies were not mailed out or given directly to residents or their family members.
Forms were only sent to the ER at the time of the transfer.
During an interview on 3/30/26 at 1:30 p.m., the DON indicated bed hold paperwork was sent to the hospital in a packet given to the EMTs at the time of the transfer.
During an interview, on 3/31/26 at 9:43 a.m., RN 2 indicated if a resident had a change in their condition and needed to be sent out for an evaluation, the nurse was to notify the provider to get an order.
The DON and family were to be notified of the transfer.
All notifications were to be documented.
The nurse was to complete a change in condition assessment, which consisted of step-by-step instructions and indicated what documentation needed to be completed. A progress note was to be entered, and a transfer form was to be completed.
Upon notification of the EMS, report was to be called to the receiving facility.
Paperwork was usually sent with EMTs and included the face sheet, medication list, the resident's code status, and a bed hold policy.
The packet was sent with EMTs. No paperwork was given to residents.
The bed hold was for the hospital to know the facility would take the resident back when discharged from the hospital.
During an interview, on 3/31/26 at 1:45 p.m., the SSD indicated the nursing staff filled out a bed hold policy at the time of a resident's transfer to the hospital and she was given a copy.
She then typed it out to make it more legible and placed it in a binder.
She believed all bed holds went with the resident to the hospital and upon the family notifying the family of resident's transfer, they would tell them that the bed hold was sent to the hospital.
During an interview, on 3/31/26 at 1:59 p.m., the DON indicated a transfer form was to be completed when a resident was transferred to the hospital.
There was no documentation of what information, including the Notice of Transfer rights and bed hold policy, was sent to the hospital at the times of Resident 4, 27, and 45's hospitalizations.
There was no documentation of Resident 4, 27, and 45 representatives having received the Notice of Transfer rights and bed hold policy at the time of each hospitalization. A current facility policy, dated 8/2024, titled Transfer or Discharge, Facility -Initiated, provided by the DON on 3/31/26 at 2:39 p.m., indicated the following: .20.
Notice of Facility Bed-Hold and Return policies are provided to the residents and representatives within 24 hours of emergency transfer. 21.
Notices are provided in a form and manner that the resident can understand, taking into account the resident's education level, language, communication barriers, and physical or mental impairments.Documentation of Facility-Initiated Transfer or Discharge. 1.
When a resident is transferred or discharged from the facility the following information is documented in the medical record: 1.b.
That an appropriate notice was provided to the resident and/or legal representative.410 IAC (Indiana Administrative Code) 16.2-3.1-3.1-12(a)(25)410 IAC 16.2-3.1-3.1-12(a)(26)
155549 03/31/2026
Envive of Muncie 7524 E Jackson Street Muncie, IN 47302
being admitted
record review and interview, the facility failed to ensure a resident and/or the resident representative
for care plans. (Resident 8) Finding includes:Resident 8's clinical record was reviewed on 3/30/26 at 10:30 a.m.Census information indicated the resident was admitted to the facility on [DATE].The clinical record lacked documentation that the resident and/or the resident's representative was provided with a copy of the baseline care plan.
During an interview, on 3/30/26 at 1:30 p.m., the Social Services Director (SSD) indicated she had not completed a baseline care plan conference review note for Resident 8 due to him not having had a care plan conference since his admission. As a result, no baseline care plan information was provided to Resident 8 or to his resident representative.During an interview, on 3/31/26 at 1:28 p.m., the SSD indicated baseline care plan information was to be conveyed to residents or their representative within 72 hours after a resident's admission to the facility.
Baseline care plan information was permitted to be relayed over the phone. No phone contact was made with Resident 8's representative regarding baseline care plan information. Resident 8's cognitive status was intact, but cognitive functions fluctuated at times.
She did not provide base line care plan information, verbally or written, to Resident 8. A current policy, dated 8/2024, titled Care Plans, Baseline, provided by the DON, on 3/31/26 at 2:39 p.m., indicated the following: Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.
Policy Interpretation and Implementation.4.
The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a.
The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c.
Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d.
Any updated information based on the details of the comprehensive care plan as necessary. 5.
Provision of the summary to the resident and/or resident representatives is documented in the medical record.410 IAC (Indiana Administrative Code)16.2-3.1-30(a)
155549 03/31/2026
Envive of Muncie 7524 E Jackson Street Muncie, IN 47302
During an interview, on 3/30/26 at 1:30 p.m., the DON indicated she was unable to locate current pneumococcal vaccination forms for Resident 27 and 45.
The facility did not administer any vaccinations, and an off-site company was utilized to administer vaccinations to the residents.
She was aware that another vaccine clinic needed to be scheduled but had not done it yet.During an interview, on 3/31/26 at 2:06 p.m., the DON indicated pneumonia vaccinations were offered per guidelines.
During an interview, on 3/31/26 at 2:24 p.m., the Infection Preventionist indicated residents were offered pneumococcal vaccinations.The Center for Disease and Control (CDC) website, accessed on 4/1/26 at 2:30 PM, indicated the following: Pneumococcal Vaccine Recommendations.Adults 50 years or older.
Routine vaccination recommendations: Administer PCV (pneumococcal conjugate vaccines) 15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccine history is unknown.
PCV15: Additional vaccination recommended. If PCV15 is used, administer a dose of PPSV23 one year later.
Only one dose of PPSV (pneumococcal polysaccharide vaccine) 23 is indicated. If PPSV23 was previously administered, another dose isn't needed.
The patient's pneumococcal vaccinations are complete. PCV20 or PCV21: Additional vaccination not recommended. If PCV20 or PCV21 is used, a dose of PPSV23 isn't indicated.
Regardless of which vaccine is used (PCV20 or PCV21), the patient's pneumococcal vaccinations are complete.
Recommendation for shared clinical decision-making.
Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines.
They can get PCV20 or PCV21 if they have received both PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old.A current facility policy, dated 8/2024, titled Pneumococcal Vaccine, provided by the DON on 3/31/26 at 2:39 p.m., indicated the following: Policy Statement: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.
Policy Interpretation and Implementation: 1.
Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and when indicated are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident was completed the current recommended vaccine series. 2.
Assessments of pneumococcal vaccination status are conducted within five (5) working days of their resident's admission if not conducted prior to admission.7.
Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(5)
155549 03/31/2026
Envive of Muncie 7524 E Jackson Street Muncie, IN 47302
Based on record review and interview, the facility failed to administer the appropriate COVID-19
infection control. (Resident 45)Finding includes:Resident 45's clinical record was reviewed on 3/27/26 at 3:15 p.m.
Diagnoses included aortic valve insufficiency, heart disease, and muscle weakness.A quarterly Minimum Data Set (MDS) assessment, dated 3/9/26, indicated the resident's cognitive status was moderately impaired.A COVID-19 vaccine consent and a COVID-19 booster consent was signed by Resident 45's representative on 12/6/24.A review of the resident's vaccinations indicated the resident had not received a COVID-19 vaccination and the family representative had refused the vaccination in December 2024.The record lacked an updated or yearly COVID-19 vaccination consent or declination.
During an interview, on 3/30/26 at 1:30 p.m., the DON indicated she was unable to locate current COVID-19 vaccination forms for Resident 45.
The facility did not administer any vaccinations, and an off-site company was utilized to administer vaccinations to the residents.
She was aware that another vaccine clinic needed to be scheduled but had not done it yet.
During an interview, on 3/31/26 at 2:06 p.m., the DON indicated COVID-19 vaccinations were to be offered yearly.
During an interview, on 3/31/26 at 2:24 p.m., the Infection Preventionist indicated residents were offered COVID-19 vaccinations.The Center for Disease and Control (CDC) website, accessed on 4/1/26 at 2:30 PM, indicated the following: COVID-19 Vaccination for Long-term Care Residents.Vaccine recommendations: CDC recommends an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) settings, get 1 dose of an updated COVID-19 vaccine. CDC recommends everyone ages 65 and older including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart.Reminder: People who live in LTC settings must give consent or agree to getting a COVID-19 vaccine.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(5)
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MUNCIE, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ENVIVE OF MUNCIE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.