Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Envive Of Anderson during CMS and state inspections, most recent first.
Failure to Develop Baseline Care Plan for Admission Pressure Injury: A resident was admitted with a coccyx wound, but the record did not contain a baseline care plan with individualized interventions within 48 hours. The admission assessment triggered a skin integrity prompt, and the later care plan addressed impaired skin integrity in general terms, while RN and DON interviews confirmed the wound should have been included in the baseline care plan.
A resident with CKD, CHF, atrial fibrillation, and moderate pressure injury risk was admitted with a stage 2 coccyx pressure ulcer and later documented with additional pressure injuries to the feet, including a DTI and an unstageable wound. The record lacked wound treatment orders for the coccyx and did not show an individualized care plan with healing goals or interventions. During wound care observation, an LPN said no wound treatment orders were in place other than skin protectant to the heels, and a dark area was noted on the right heel with no treatment order.
QAPI Program Failed to Address Repeat Pressure Injury Deficiencies: The facility did not have a current QAPI plan or action plan related to pressure injuries, and repeat concerns were cited again during survey. Based on interview, observation, and record review, the facility failed to provide wound assessments, wound monitoring, and wound treatments in a manner to promote healing of a pressure ulcer for 1 of 1 resident reviewed. The QAA committee reviewed prior citations and trends, but the pressure injury issue remained unresolved in the QAPI process.
Failure to Use EBP During Wound Care: An LPN performed dressing care for a resident with a stage 4 sacral pressure injury without wearing the required gown under EBP. The resident’s orders and care plans indicated EBP was required for the wound, and the DON confirmed that gown and gloves were required for the dressing change.
Outdated nursing staffing postings were observed at the entrance, including a form that lacked census information and remained posted after the date had changed. The scheduler said she prepared staffing sheets in advance and forgot to update the form over a weekend, so the posting was not current for several days and was not updated on the morning of the next shift. The facility policy required RN, LPN/LVN, and CNA/NA staffing numbers to be posted within 2 hours of each shift in a prominent, accessible location.
The facility did not consistently provide opportunities for residents who required supervision to go outside as they preferred, especially when staff were unavailable on weekends or outside of scheduled times. Several residents with significant medical conditions expressed that going outside was very important to them, but their access was limited by staffing constraints and facility procedures.
An LPN failed to secure a 30-pill card of tramadol, an opioid analgesic, after receiving it from the pharmacy. The medication was left unsupervised on a desk in the nurses' station, leading to its disappearance. Facility policy requires Schedule II medications to be stored under double lock, which was not followed in this instance.
A facility failed to manage a resident's personal funds properly, resulting in negative balances due to a returned check and erroneous care cost charges. The Business Office Manager and Corporate Business Office Consultant identified the issue but did not effectively follow up with the third-party billing company to resolve the inappropriate charges. The facility's policy on monthly audits of resident accounts was not adequately implemented, contributing to the deficiency.
A resident with a PICC line for IV antibiotics had a loose dressing that was not changed as ordered, leading to an infection control deficiency. Despite physician orders for weekly dressing changes and as needed, the dressing remained unchanged since 7/16/24. Observations confirmed the non-occlusive dressing, and interviews with the resident and staff highlighted the oversight. The facility's policy required immediate dressing changes if compromised, which was not adhered to, raising infection prevention concerns.
The facility failed to label insulin pens with resident identifiers on a medication cart, affecting six residents. Additionally, expired influenza vaccines were found in the medication room, indicating a lapse in timely disposal. RN 6 confirmed the deficiencies during observations.
The facility failed to implement corrective actions for systemic issues related to medication expiration and resident fund management. Despite having a QAPI action plan, inspections of medication rooms were incomplete, and audits showed no identified concerns. The facility's QAPI policy aimed to correct deficiencies, but the survey found it ineffective in addressing the issues.
Failure to Develop Baseline Care Plan for Admission Pressure Injury
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with a pressure injury. Resident 56 was admitted with a wound on the coccyx noted on the 4/1/26 admission assessment, and the assessment included a prompt for a baseline care plan related to impaired skin integrity with general interventions such as diet as ordered, observing skin with daily cares, and notifying the nurse of any new or worsening areas. The record did not contain a baseline care plan with individualized interventions for the coccyx wound that was present on admission. A current care plan was initiated on 4/2/26 and identified the resident as at risk for impaired skin integrity related to impaired mobility and self-care deficit, with interventions including encouraging nutrition and hydration, keeping skin clean and dry, using lotion on dry skin, observing skin with daily cares, notifying the nurse of any new or worsening areas, and treatments as ordered. During interviews, RN 4 stated that the admission assessment should generate a baseline care plan in the EHR and that it should include what staff needed to start caring for the resident, including a wound found during the admission assessment. The DON also stated that a wound found during the admission assessment should have been included in the baseline care plan.
Failure to Initiate Wound Treatment Orders and Individualized Pressure Injury Care
Penalty
Summary
The facility failed to ensure treatment orders were in place and interventions were developed and implemented to promote healing of a pressure injury for one resident. The resident had diagnoses including stage III chronic kidney disease, congestive heart failure, and atrial fibrillation, and was assessed as moderately at risk for pressure injury formation. On admission, the resident was documented as having a stage 2 pressure ulcer to the coccyx, and the record also reflected a reported wound to the left heel and coccyx. A later wound note identified a left medial foot deep tissue injury, a left lateral foot unstageable pressure injury, and a stage 2 pressure injury, all present on admission. The clinical record did not show wound treatment orders for the coccyx wound, and the record lacked an individualized care plan with goals for healing and individualized interventions to promote healing and comfort. During wound care observation, an LPN stated that no other wound treatment orders were in place other than applying skin protectant to the heels. The resident’s pressure relief boots were removed and skin protectant was applied to both heels, and a large dark area was observed on the right heel; the LPN stated he was unsure how long it had been present and that no orders were in place to treat it. The resident declined observation of the coccyx during the observation. The resident’s admission MDS indicated moderate cognitive impairment, total dependence for toilet hygiene and rolling, and that the resident was always incontinent of bowel and bladder. The care plan addressed enhanced barrier precautions and listed the pressure injuries, but the record lacked individualized healing goals and interventions. Staff interviews indicated that admission skin and wound assessments were completed and abnormal findings were to be communicated to the provider, and the DON stated that wound findings were documented and communicated through secure messaging. The facility policy required wound assessments and treatment to begin when pressure ulcers were identified, and required the care plan to be revised to reflect altered skin integrity, approaches, and goals for care.
QAPI Program Failed to Address Repeat Pressure Injury Deficiencies
Penalty
Summary
The facility failed to develop and implement approaches to maintain a QAPI program to prevent repeat deficiencies related to interventions for healing pressure injuries. Review of the prior annual recertification and licensure survey completed on July 25, 2025 showed deficiencies for failure to obtain wound assessments, monitoring, and treatments in a manner to promote healing of a pressure injury. During interview, the Administrator stated the QAA committee met monthly and reviewed areas of concern, trends, and increases in occurrence, and that previous annual survey citations were reviewed through the time frame listed on the POC, usually for six months. The facility did not have a current QAPI plan or action plan in place related to pressure injury. Repeat concerns regarding pressure injuries were cited again during the April 10, 2026 survey. Based on interview, observation, and record review, the facility failed to provide wound assessments, wound monitoring, and wound treatments in a manner to promote healing of a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers. The facility policy titled, Quality Assurance and Performance Improvement (QAPI)-Governance and Leadership, revised 8/24, stated the QAPI committee was responsible for collecting and analyzing performance indicator data, identifying and improving facility systems and processes, and helping resolve negative outcomes and care quality problems identified during the QAPI process.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions during a wound dressing change for a resident with a stage 4 sacral pressure injury. The resident’s record showed diagnoses including peripheral vascular disease and unspecified bipolar disorder, and current wound orders directed cleansing of the sacral wound, application of calcium alginate to the wound bed, zinc paste around the wound bed, and coverage with a bordered silicone dressing. The resident’s care plan and EBP care plan both indicated the resident required enhanced barrier precautions because of the wound and to help prevent the spread of organisms, and the quarterly MDS noted the resident was severely cognitively impaired and had one stage 4 pressure injury. During the wound treatment observation, the LPN set up supplies, performed hand hygiene, and donned gloves, but did not wear the required gown while removing the old dressing and applying the new treatment. He removed the old dressing, cleansed the wound, applied the calcium alginate and skin protectant, and covered the wound with a bordered silicone dressing. When interviewed at the time of the observation, the LPN stated he had forgotten to wear the proper PPE and had gotten nervous. The DON later stated that EBP was required for residents with wounds, medical devices, and/or a history of MDROs, and that the LPN should have worn both a gown and gloves during the dressing change.
Outdated nursing staffing postings
Penalty
Summary
The facility failed to post current and accurate nursing staff information daily for residents and visitors. On 4/6/26 at 6:13 a.m., the nurse staffing information posted on a small table to the right of the entrance doors was dated 4/2/26 and did not include a census number. The posting listed RN, LPN, QMA, and CNA hours for each shift, but it was not current. During later observations, the staffing posting remained outdated on 4/7/26 at 9:06 a.m., still showing the 4/6/26 form, and on 4/8/26 at 9:07 a.m., the 4/7/26 form was still posted. The scheduler stated she completed the form the night before and placed it under the current posting, and that management removed the previous day’s posting the following morning. She also stated she had worked as a CNA over the weekend of 4/3/26 through 4/5/26 and forgot to update the form, so the staffing posting would not have been updated and/or current on those days or on the morning of 4/6/26. The facility policy required the number of licensed nurses and unlicensed nursing personnel to be posted within two hours of the beginning of each shift in a prominent, accessible, clear, and readable location.
Failure to Ensure Resident Access to Outdoor Areas per Preference
Penalty
Summary
The facility failed to ensure that residents were consistently afforded the opportunity to go outside according to their preferences, weather permitting, as required by resident rights regulations. Four residents with varying diagnoses, including chronic respiratory failure, dementia, COPD, and non-traumatic brain dysfunction, were identified as valuing outdoor access as very important. Interviews and record reviews revealed that residents who could not sign themselves out or required supervision were only able to go outside if staff were available to accompany or monitor them. On weekends, when the receptionist and some activity staff were not present, these residents often could not go outside due to lack of supervision. Staff interviews confirmed that the ability for residents to go outside was dependent on staff availability, with some residents only able to go out during scheduled smoke breaks or when the receptionist was present to supervise. A facility list indicated which residents could sign themselves out and which required supervision, but those needing supervision were not always accommodated, especially on weekends. This practice affected at least 17 residents who could not go outside without supervision, limiting their ability to exercise their rights to a dignified existence and self-determination.
Failure to Secure Narcotics Leads to Missing Medication
Penalty
Summary
The facility failed to ensure the safe handling of narcotics, specifically tramadol, due to improper procedures followed by an LPN. On the evening of 11/24/24, the LPN received a delivery of medications from the pharmacy, including a 30-pill card of tramadol, an opioid analgesic. Instead of securing the medication immediately, the LPN placed the pill card unsupervised on the back of the desk in the nurses' station. The LPN became distracted and did not secure the tramadol in the locked narcotic drawer of the medication cart, as required by facility policy. The oversight was discovered during the morning medication administration pass when the LPN realized the tramadol was missing. Interviews conducted during the survey revealed that medications from the pharmacy should be checked and signed off by the nurse upon receipt, and narcotics should be locked in a cart until they can be delivered to the proper cart. The DON confirmed that the LPN had reported being distracted and leaving the tramadol unsecured, which resulted in the medication going missing. The facility's policy on controlled medication ordering and receipt mandates that Schedule II medications be stored under double lock, and the medication nurse on duty should maintain possession of the key to controlled medications. This incident was related to a complaint investigation, indicating a failure to adhere to established protocols for handling controlled substances.
Deficiency in Managing Resident Funds
Penalty
Summary
The facility failed to manage a resident's personal funds in accordance with acceptable accounting principles, resulting in a deficiency. The Business Office Manager provided a Resident Funds Trial Balance sheet, which revealed that one resident had two separate accounts with negative balances. Specifically, one account had a negative balance of $2,911.47, and another had a negative balance of $15.16. The issue arose when a personal check credited to the resident's account was returned, leading to a negative balance. Additionally, automated care cost withdrawals were deducted after deposits were made, and a second care cost charge was erroneously applied in the same month. Furthermore, the funds were deposited into an inappropriate account for medical expenses, which was later corrected, resulting in two accounts for the resident. Interviews with the Corporate Business Office Consultant and the Business Office Manager revealed that they had reached out to a third-party billing company regarding the inappropriate charges but had not received a response. The Business Office Manager did not follow up on the initial communication. The Corporate Business Office Consultant later spoke with a representative from the third-party billing company, who assured that the charge error would be refunded. The facility's policy on Resident Funds Management System, which mandates monthly audits of resident accounts, was not effectively implemented in this case, leading to the oversight and subsequent deficiency.
Failure to Maintain Intact PICC Dressings
Penalty
Summary
The facility failed to ensure that protective PICC dressings were intact and changed as ordered for a resident, leading to a deficiency in infection control. Resident 151, who was admitted with cellulitis of the left upper limb and sepsis due to streptococcus group A, had a PICC line in her right upper arm. Observations on multiple occasions revealed that the PICC dressing was loose and had not been changed since 7/16/24, despite a physician's order for weekly dressing changes and as needed when the dressing was loose. The resident's clinical record lacked evidence of PICC line dressing changes during the specified times, even though the dressing was visibly non-occlusive. Interviews with Resident 151 and facility staff confirmed that the dressing had not been changed as required. The Director of Nursing (DON) acknowledged that PICC line dressings should be changed every seven days or immediately if not occlusive, and that they should be assessed each time IV antibiotics are administered. The facility's policy on Central Venous Catheter Care and Dressing Changes, revised in March 2022, also emphasized the need for immediate dressing changes if the integrity of the dressing is compromised. The failure to maintain an occlusive dressing was identified as an infection prevention and control concern.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling of insulin pens with resident identifiers on one of the medication storage carts reviewed. During an observation of the front treatment cart, several Humalog Kwikpens were found without labels indicating the resident's name or directions for use. RN 6, who was present during the observation, was unable to confirm how long the unlabeled pens had been in the cart. It was noted that six different residents received insulin from this cart, highlighting the importance of proper labeling to ensure accurate administration. Additionally, the facility did not dispose of expired vaccinations in a timely manner. During an observation of the front medication room, two boxes of Influenza Vaccine with expired dates were found stored in the refrigerator. RN 6 acknowledged that these vaccines were expired and should not be administered to residents, indicating a lapse in the facility's adherence to its policy on medication storage. The facility's policies, dated 2020, require that medications be labeled with specific information and that outdated or deteriorated medications be immediately removed from stock.
Failure to Implement Corrective Actions for Medication and Resident Fund Management
Penalty
Summary
The facility failed to implement corrective and preventive actions to address systemic issues related to resident funds, medication labeling, and medication expiration. The root cause analysis revealed that medication carts and rooms were not routinely inspected, leading to the presence of expired medications. Despite having a QAPI action plan dated 5/17/24, which included inspecting and removing expired medications from the front medication room by 5/16/24, the back unit medication room inspection lacked a completion date. Furthermore, the facility's QAPI team met monthly, with the last meeting on 6/28/24, but there was no evidence of audits related to acceptable accounting principles for managing resident funds. The facility's undated current policy on Quality Assurance and Performance Improvement (QAPI) indicated objectives to correct identified quality and safety deficiencies. However, the survey findings showed that the facility did not effectively implement these processes. Audit tools for May, June, and July 2024, provided by the Chief Operating Officer, showed no identified concerns, and comments on the audits mentioned adjustments would be made as needed for ongoing compliance. Despite these measures, the facility failed to demonstrate an effective ongoing program to address the deficiencies identified in the survey.
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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.
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Nursing homes near Anderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Pointe Health Campus | 1.8 mi | — | 4 | 1 |
| Beaumont Rehabilitation And Healthcare Center | 1.9 mi | — | 27 | 0 |
| Edgewater Woods | 2 mi | — | 5 | 0 |
| Northview Health And Living | 2.2 mi | — | 19 | 0 |
| Countryside Manor Health & Living Community | 2.7 mi | — | 20 | 0 |
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