Envive of Indianapolis: Assault Investigation Failures - IN
That is what federal inspectors found when they visited Envive of Indianapolis on September 5, 2025, following a complaint about a resident-to-resident assault that had occurred nearly two weeks earlier.
The incident happened on or about August 23. Resident E, described by the administrator as protective of other residents and staff, struck Resident D on the left side of his face. According to the administrator, Resident E had heard Resident D say something inappropriate about someone and responded by slapping him. Resident D, arriving at the nurses' station in an electric wheelchair, was yelling and accusing Resident E of hitting him. Resident E came out of his room into the hallway. The two argued before staff intervened and directed them back to their rooms.
Resident D asked to call the police. The administrator, who said he was on the phone with the nurse at the time, told her to call the police if that was what Resident D wanted. Resident D then changed his mind and told the nurse he did not want them called.
The investigation file the administrator handed inspectors on September 5 contained two documents. The first was a written statement signed by LPN 5. The second was a document signed by the administrator himself, dated August 29, logging four brief entries across six days.
The problem with the first document: LPN 5 had not been present during the incident and had not observed either resident that day. Her statement said she had been notified by other residents that Resident E had struck Resident D because Resident D had been "picking and calling other residents names," and that Resident E had been acting to protect others. It was secondhand information, attributed to unnamed residents, written as the facility's account of what happened.
The administrator's own log told a more complicated story. On August 25, he spoke with Resident D, who said he did not know why he had been hit. That same day, he spoke with Resident E, who said he was upset about Resident D talking badly about other residents. Three days later, on August 28, Resident D said he had not said anything wrong. The following day, Resident E told LPN 5 that the two had apologized and there were no issues between them.
The administrator told inspectors the investigation was as thorough as it needed to be and that the residents had worked things out. Both men were cognitively intact, he said, and he felt confident the matter was resolved.
He was unaware that Resident D remained uncomfortable around Resident E.
He had not interviewed other residents. He had not interviewed staff who had been present.
The nurse practitioner who saw Resident D on August 25 told inspectors she had observed no swelling, redness, or bruising to the left side of his face. He had not told her he felt fearful or in danger around Resident E. She had seen him in common areas and outside smoking with other residents, and she was confident he would have said something to her if he were uncomfortable.
On September 5, during his interview with inspectors, Resident E said he had made a mistake and had apologized to Resident D. He said he had misunderstood something Resident D said and had hit him. He believed the two were fine to be around each other.
What Resident D said to inspectors about his comfort level is not recorded in the inspection narrative. What is recorded is that the administrator, as of the inspection date, did not know.
The facility's own incident investigation policy, dated August 2024 and provided by the administrator during the inspection, states that all accidents or incidents involving residents shall be investigated and reported to the administrator. The administrator acknowledged that this was the only policy the facility had governing resident-to-resident incidents, and that beyond it, the facility followed Indiana Department of Health guidelines.
The citation was classified as minimal harm or potential for actual harm, affecting a few residents.
A man got hit in the face. He asked to call the police and then thought better of it. Days later, he told someone he hadn't done anything wrong. The facility's file on what happened was signed by a nurse who wasn't there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Envive of Indianapolis from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
ENVIVE OF INDIANAPOLIS in INDIANAPOLIS, IN was cited for violations during a health inspection on September 5, 2025.
The incident happened on or about August 23.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.