Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 River City during CMS and state inspections, most recent first.
The facility failed to follow physician orders for medication administration and implement fall prevention interventions for two residents. A resident with hypertension received medication without proper blood pressure monitoring, and non-slip strips were not placed in the shower as required. Another resident experienced a fall-related incident without new interventions being documented. The facility's policies on medication administration and care plans were not adhered to.
The facility failed to administer insulin according to professional standards, with insulin given late and by unqualified staff. A QMA administered insulin without certification, and there was a lack of nursing staff to administer insulin on time, leading to delays for several residents. Facility policies on medication administration and staffing were not followed, resulting in these deficiencies.
The facility failed to notify the physician and guardian when two residents left independently. One resident, with a court-appointed guardian, left multiple times without notification, despite a physician's order requiring guardian approval. Another resident, dependent on staff, left without the physician being informed. Facility policies on leave of absence and elopement were not followed, leading to these deficiencies.
A resident admitted with osteomyelitis and multiple wounds did not have necessary physician orders for their PICC line, wound care, and enhanced barrier precautions. A nurse administered vancomycin without donning a gown, and the clinical record lacked orders for saline flushes, PICC line management, and wound vac care. The DON confirmed these orders should have been in place upon admission.
The facility failed to ensure accurate MDS assessments for residents with specific medical conditions and incidents. A resident with PTSD and IV access was inaccurately assessed, and two residents with falls were not properly documented in their MDS assessments. The DON confirmed these omissions, indicating a failure to accurately reflect the residents' conditions and incidents.
A facility failed to establish a baseline care plan for a resident with multiple wounds and a wound vac, essential for infection control. The resident was admitted with osteomyelitis and had wounds on the gluteal folds, coccyx, and left toe, but the clinical record lacked care plans for these wounds. Observations and interviews indicated that care plans were not updated immediately upon admission, contrary to the facility's policy.
The facility failed to update care plans for two residents after significant incidents. One resident experienced multiple falls without care plan revisions, while another was involved in a methamphetamine incident and was at risk of elopement, yet her care plan was not updated. The facility's policies required care plans to be individualized and revised as conditions changed, but this was not followed.
A resident with PTSD and Borderline Personality Disorder did not receive necessary mental health services due to incorrect preadmission screening and billing issues with the contracted provider. Despite expressing a need for mental health support and showing signs of mild depression, the facility failed to arrange alternative services, impacting the resident's quality of life.
A facility failed to adhere to its policy of limiting PRN antianxiety medication to 14 days for a resident with generalized anxiety disorder. The resident was prescribed diazepam without an end date and received it on multiple occasions over a period exceeding 14 days. The facility's policy requires PRN psychotropic medications to have a 14-day stop date and be reviewed by a physician, which was not followed in this case.
The facility failed to properly label and store medications on a medication cart, with loose pills found and multi-dose containers lacking opening dates. The DON incorrectly stated that dating was unnecessary for certain medications, contrary to the facility's policy requiring opened multi-dose vials to be dated and discarded within 28 days.
The facility failed to prepare puree food correctly for two residents on altered diets. A dietary staff member was unsure of recipe conversions, and the Administrator provided incorrect conversions. The staff member used these incorrect measurements, resulting in improperly prepared puree food, which was then stored in a temperature holding area.
The facility failed to maintain complete and accurate documentation for residents, particularly in cases of elopement and falls. A resident with a court-appointed guardian left the facility multiple times without proper documentation, while another resident's leave of absence records lacked necessary details. Additionally, a resident with a history of falls had incomplete neurological checks documented. The facility's policies on documentation were not followed in these instances.
A facility failed to implement enhanced barrier precautions for a resident with a PICC line and multiple wounds, as observed when an RN administered vancomycin without donning a gown. The resident, diagnosed with osteomyelitis, had no orders for EBP in their clinical record, despite the facility's policy requiring PPE to prevent the spread of multi-drug resistant organisms.
The facility did not designate a certified Infection Preventionist (IP) who dedicates at least part-time hours to the role. The DON, responsible for the infection prevention and control program, could only allocate about 8 hours per week to this role while working full-time as the DON. The facility's program required a designated clinical team member to monitor and manage infection control activities.
The facility failed to post accurate nurse staffing information, omitting actual hours worked by RNs, LPNs, and CNAs for three days. Observations showed that the posted sheets did not specify actual shift hours, and the Administrator confirmed the inability to determine actual hours worked. This was contrary to the facility's policy requiring the recording of actual time worked.
Failure to Follow Physician Orders and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to follow physician orders for medication administration and implement care plan interventions for residents at risk of falls. Resident D, who was admitted with diagnoses including essential hypertension and orthostatic hypotension, had specific physician orders to hold lisinopril if systolic blood pressure was less than 110. However, the medication was administered without obtaining blood pressure readings on multiple occasions, and it was given even when the systolic blood pressure was below the specified threshold on several dates. Additionally, non-slip strips, which were part of the fall prevention interventions for Resident D, were not observed in the shower room where the resident resided. Resident B, with a history of transient ischemic attack and flaccid hemiplegia, experienced an incident where they were found sliding out of their chair and lowered to the floor. Despite this incident, no new interventions were documented in the clinical record to address the risk of falls. The Director of Nursing acknowledged that a new intervention should have been implemented following the incident. The facility's policies on medication administration and care plans emphasize the importance of administering medications as prescribed and developing comprehensive, person-centered care plans with measurable objectives. However, these policies were not adhered to, as evidenced by the failure to follow blood pressure parameters for medication administration and the lack of implementation of fall prevention interventions for the residents involved.
Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure insulin was administered in accordance with professional standards for five residents with type 2 diabetes mellitus. Insulin was administered late and by unqualified staff. For instance, Resident 18 received insulin from a Qualified Medication Aide (QMA) who was not certified to administer insulin. The Director of Nursing (DON) confirmed that QMAs were not allowed to administer insulin, indicating a breach in protocol. Additionally, there was a lack of nursing staff available to administer insulin at the scheduled times. On a specific day, there were no nurses present from 6:00 A.M. to 9:40 A.M., resulting in delayed administration of insulin for several residents, including Residents 1, 17, 11, and 8. The Registered Nurse (RN) on duty began their shift at 9:40 A.M., which was after the scheduled time for insulin administration. The facility's policies required medications to be administered within one hour of the scheduled time and documented accurately. However, the documentation was inaccurate, as evidenced by the QMA's incorrect documentation of insulin administration. The facility's policies also mandated that licensed nurses be available 24/7, which was not adhered to, leading to the deficiencies observed.
Failure to Notify Physician and Guardian of Resident Elopement
Penalty
Summary
The facility failed to notify the physician and resident representative when two residents left the facility independently, which was a requirement for their care. Resident 22, who had diagnoses including schizophrenia and stimulant dependence, was admitted with a court-appointed guardian. Despite being assessed as low risk for elopement, the resident's clinical record lacked a care plan related to the guardian or elopement risk. The resident signed out of the facility multiple times without the guardian or physician being notified, contrary to the physician's order that required guardian approval for leaving the facility. The Director of Nursing (DON) acknowledged that the former administrator had allowed the resident to leave without proper approval, and there was no documentation of the guardian's changing permissions. Resident 75, who was cognitively intact but dependent on staff for various activities, also left the facility independently without the physician being notified. The resident's clinical record included a physician's order allowing leave of absence with a responsible party as needed, but the order was not modified to reflect the resident's independent departures. The facility's policies required a sign-out log and notification of the physician and legal representative upon the resident's return, but these procedures were not followed. The facility's policies, including those for leave of absence, wandering and elopement, and adult guardianship, were not adhered to, resulting in a lack of proper documentation and notification. The DON and Administrator provided these policies during the survey, but the deficiencies in following them led to the failure to notify the necessary parties when the residents left the facility independently.
Lack of Admission Orders for Resident's PICC Line and Wound Care
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician orders upon admission for the management of their medical needs, including a PICC line, wound care, and enhanced barrier precautions. On observation, a registered nurse was seen administering vancomycin to the resident without donning a gown, despite a sign indicating enhanced barrier precautions. The nurse flushed the resident's PICC line and administered the medication without documented orders for saline flushes or the PICC line itself. Additionally, a wound vac was observed on the resident's coccyx, but there were no orders for its management or for wound care. The resident, who was admitted with a diagnosis of osteomyelitis, had several wounds and a PICC line for intravenous antibiotics. The clinical record lacked essential orders for the resident's immediate care needs, such as saline flushes for the PICC line, wound vac management, and enhanced barrier precautions. The Director of Nursing acknowledged that these orders should have been in place upon admission, as per the facility's policy, which requires immediate care orders to be provided by a physician or other qualified healthcare professional.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents with specific medical conditions and incidents. Resident 21, who was admitted with diagnoses including osteomyelitis and PTSD, was inaccurately assessed in the MDS dated 9/25/24, which failed to reflect the presence of PTSD and intravenous access, despite the care plan indicating IV medication administration. The Director of Nursing (DON) confirmed that the MDS should have included these details. Additionally, the facility did not accurately document falls for two residents. Resident 10, who required substantial assistance for daily activities, experienced an unwitnessed fall resulting in a hospital transfer, which was not recorded in the MDS assessment dated 9/27/24. Similarly, Resident 2, with a history of falls and cognitive impairment, had an unwitnessed fall on 7/19/24 that was not documented in the MDS assessment dated 9/13/24. The DON acknowledged these omissions, indicating a failure to accurately reflect the residents' conditions and incidents in the MDS assessments.
Failure to Establish Baseline Care Plan for Wound Management
Penalty
Summary
The facility failed to ensure that a baseline care plan was in place for a resident with multiple wounds and a wound vac, which is crucial for infection control. The resident, identified as Resident 225, was admitted with a diagnosis of osteomyelitis and had a power injection catheter in the right chest, along with wounds on the left gluteal fold, right gluteal fold, coccyx, and left toe. Despite these conditions, the clinical record lacked baseline care plans for all four documented wounds and the management of the wound vac. Observations and interviews revealed that the care plans were not updated immediately upon admission, as required by the facility's policy for comprehensive, person-centered care plans.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to revise care plans for two residents following significant incidents. Resident 2, who had a history of repeated falls and cognitive impairment, experienced multiple unwitnessed falls on different occasions. Despite these incidents, the care plan was not updated with new interventions to address the falls. The Director of Nursing acknowledged that care plans should be updated after each fall, but this was not done for Resident 2. Resident 22, diagnosed with schizophrenia and stimulant dependence, was involved in an incident where methamphetamine was found in her possession. The care plan was not updated following this incident, nor was it revised to reflect her risk of elopement, despite her inclusion in the facility's elopement binder. The Director of Nursing confirmed that residents at risk of elopement should have corresponding care plans, and the Regional Support noted the absence of a substance abuse policy, which had been retired without replacement. The facility's policies required care plans to be individualized and updated as residents' conditions changed, but this was not adhered to in these cases.
Failure to Provide Mental Health Services for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary social services to address the mental and psychosocial needs of a resident with a history of PTSD and Borderline Personality Disorder. The resident, who was admitted with these diagnoses, expressed anxiety and a desire for mental health services, which were not provided. The facility's Social Service Director acknowledged that the preadmission screening was completed incorrectly by the hospital and should have been reviewed and corrected upon admission. Despite the resident's indication of mild depression on the PHQ-9 Questionnaire, no mental health services were arranged due to billing issues with the contracted behavioral health company. The resident's care plan included a risk for ineffective coping due to past experiences, yet the facility did not take appropriate steps to ensure mental health services were provided. The Social Service Director admitted that the facility would have to cover the cost of services since the contracted provider could not bill the resident's insurance, but no alternative providers were contacted. This oversight resulted in the resident not receiving the necessary mental health support to achieve the highest possible quality of life, as required by the facility's standards.
Failure to Limit PRN Antianxiety Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of PRN antianxiety medication. Resident 18, who was diagnosed with generalized anxiety disorder and had no cognitive impairment, was prescribed diazepam, an antianxiety medication, to be taken as needed every 8 hours. The order, dated 8/28/24, did not include an end date, and the resident received the medication on multiple occasions from 8/28/24 to 10/9/24. The facility's policy, as confirmed by the Director of Nursing, requires that PRN orders for psychotropic medications have a stop date of 14 days and be reviewed by a physician every 14 days for continuance. However, this policy was not followed in the case of Resident 18, leading to the deficiency.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on one of the two medication carts observed. During an observation on the 100 hall medication cart, surveyors found an oblong maroon colored pill and a small round white pill that were loose and not properly stored. Additionally, two dropper bottles of medication were found without patient labels, and two open bottles of multi-dose medications lacked a date indicating when they had been opened. The Director of Nursing (DON) incorrectly stated that multi-dose medications like Miralax did not require the date of opening to be written on them. The facility's Medication Labeling and Storage policy, provided by the Administrator, indicated that multi-dose vials should be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer.
Incorrect Puree Food Preparation for Residents
Penalty
Summary
The facility failed to ensure that food was correctly prepared for two residents who required puree-altered diets. During an observation, a dietary staff member was preparing puree foods but was unsure of the conversion from a recipe designed for 15 servings to 5 servings. The Administrator provided handwritten conversions, which were later found to be incorrect. The dietary staff member proceeded to prepare the puree using these incorrect conversions, resulting in the wrong amounts of ham, apple juice, and food thickener being used. The puree was then stored in a temperature holding area. This incident was noted during an interview with the Administrator, who acknowledged the error in the conversions.
Incomplete Documentation for Resident Elopement and Falls
Penalty
Summary
The facility failed to ensure complete and accurate documentation for residents, particularly in cases of elopement and falls. Resident 22, diagnosed with schizophrenia and stimulant dependence, was identified as being at low risk for elopement but was listed in the elopement binder as at risk. Despite having a court-appointed guardian and a physician order restricting her from leaving the facility without approval, Resident 22 signed herself out multiple times without proper documentation of who she left with, expected return time, instructions provided, or medications sent. The Social Services Director acknowledged that the resident was supposed to check in but failed to document these occurrences. Resident 21, with diagnoses including osteomyelitis and PTSD, was cognitively intact and independent in certain activities. However, the facility's documentation for his leave of absence was incomplete, lacking records of medications sent, return times, and signatures of facility representatives. Additionally, there was no physician order authorizing independent leave of absence, despite the resident being listed in the elopement binder. Resident 2, with a history of repeated falls and mild cognitive impairment, had incomplete neurological checks following falls. The facility's documentation showed missing entries for required neuro checks after two separate falls. The Director of Nursing confirmed that neuro checks should be completed and documented, even if done late. The facility's policies on leave of absence and documentation emphasized the need for complete and accurate records, which were not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to ensure that a resident with a PICC line and multiple wounds was provided with enhanced barrier precautions (EBP) as required for infection control. During an observation, a registered nurse (RN) was seen preparing and administering vancomycin to the resident without donning a gown, despite a sign on the door indicating the need for EBP. The RN flushed the resident's PICC line and connected the medication without using the necessary protective equipment. The resident had a wound vac on the coccyx and was diagnosed with osteomyelitis, indicating a high risk for infection. A review of the resident's clinical record showed no orders for enhanced barrier precautions or transmission-based precautions related to the resident's wounds and PICC line. The care plans included various instructions for managing the resident's venous access device and monitoring for signs of infection, but did not address the need for EBP. The Director of Nursing later confirmed that staff should wear personal protective equipment when providing care to residents, aligning with the facility's policy on enhanced barrier precautions to prevent the spread of multi-drug resistant organisms.
Failure to Designate a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) who dedicates at least part-time hours to the role. The Director of Nursing (DON) was responsible for the infection prevention and control program but was only able to dedicate approximately 8 hours per week to this role, despite working full-time as the DON. The DON held an IP certification dated November 14, 2021. The job description for the Infection Preventionist Nurse indicated that the IP provides assistance to the DON when needed. The facility's Infection Prevention and Control Program, dated August 2022, required a designated clinical team member to monitor the program, perform surveillance, and manage infection control activities.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff responsible for resident care, for three out of four days during the annual survey period. On 10/8/24, an observation revealed that the posted nurse staffing data sheet did not specify the actual hours of shifts for RNs, LPNs, and CNAs. The sheet inaccurately indicated that a CNA worked 4 hours during the evening shift without specifying the actual hours worked. Further review of staffing sheets for 10/8/24, 10/9/24, and 10/10/24 confirmed that none reflected the actual hours worked. The Administrator admitted the facility did not have an evening shift and could not determine the actual hours worked from the posted sheets. The facility's policy, dated 8/2024, required that the actual time worked be recorded, which was not adhered to.
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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 Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Woodbridge Care Center | 0.1 mi | — | 0 | 0 |
| Columbia Healthcare Center | 0.1 mi | — | 9 | 0 |
| Brickyard Healthcare - Brentwood Care Center | 1.5 mi | — | 2 | 0 |
| North Park Nursing Center | 1.7 mi | — | 1 | 0 |
| Parkview Care Center | 1.9 mi | — | 24 | 0 |
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