Envive of Liberty: Fall Hazard Violation Causes Harm - IN
Federal inspectors cited Envive of Liberty following a complaint investigation completed November 6, 2025, finding the facility failed to protect a resident from a fall hazard that caused actual harm. The citation, designated F0689, covered a small number of residents.
The resident, identified in inspection records as Resident C, told inspectors there were no non-skid grippers on the shower room floor. The floor was slippery. That detail came from Resident C directly.
What made the finding harder to explain away was the facility's own paperwork. A Fall Risk Evaluation note, timed at 8:41 p.m. on the date of the fall, listed Resident C as a low fall risk. Among the immediate interventions written into that note was a single, specific instruction: make sure the shower room floor is dry before transferring the resident.
The floor was not dry. There were no non-skid grippers. Resident C fell.
The Director of Nursing provided inspectors with two separate internal policies during the investigation. The first, an Assessing Falls and Their Causes policy, laid out what staff are supposed to do after a resident goes down. Step 10 directs staff to evaluate for possible injuries to the head, neck, spine, and extremities. Step 15 requires staff to observe for delayed complications for approximately 48 hours after an observed or suspected fall and to document those findings in the medical record.
The second policy, a Fall Risk Assessment, directed staff to identify environmental factors that may contribute to falling, including lighting and room layout. It also required staff and the attending physician to collaborate on identifying and addressing modifiable fall risk factors.
A wet floor without non-skid grippers in a shower room used by a resident with a documented instruction to keep the floor dry is, by any reading, a modifiable environmental factor.
Inspectors rated the level of harm as actual harm, not the potential-for-harm finding that appears in many routine citations. Something happened to Resident C. The inspection report does not describe the nature of the injury, but the federal harm rating means inspectors determined the fall produced real consequences for a real person.
The gap at the center of this citation is not complicated. The facility wrote the rule. A staff member, or several, did not follow it. Resident C went into a shower room with a wet floor and nothing underfoot to prevent a slip, despite a care note that said the opposite should happen, and despite policies the Director of Nursing was able to hand over to inspectors on request, which means they existed, which means staff had access to them.
Envive of Liberty is located in Liberty, Indiana. The inspection was conducted in response to a complaint, intake number 2654128.
The policies were on file. The intervention was documented. The floor was still wet.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Envive of Liberty from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
ENVIVE OF LIBERTY in LIBERTY, IN was cited for violations during a health inspection on November 6, 2025.
The citation, designated F0689, covered a small number of residents.
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.