Envive Of Liberty
ENVIVE OF LIBERTY in LIBERTY, IN — inspection on November 6, 2025.
Found 3 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
Based on interview and record review the facility failed to notify a resident's physician and emergency contact/resident representative when a resident fell and hit his head for 1 of 3 residents reviewed for accidents (Resident B).
Finding include:
Review of the clinical record of Resident B on 11/6/25 at 11:02 a.m., indicated the resident's diagnoses included, but were not limited to sick sinus syndrome, syncope and collapse, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, cerebral vascular accident (CVA) and hypertension.
The progress note for Resident B, dated 10/22/25 at 8:58 p.m., indicated the resident fell in the shower room around 8:20 p.m., the Emergency Medical technician (EMT) was called to assist the resident off the floor because the resident had a pacemaker placed on 10/21/25.
The Director of Nursing (DON) was notified.
There was no documentation of the physician or the resident's representative being notified.
During an interview with CNA 1, on 11/5/25 at 11:20 a.m., she indicated she was assisting Resident B with a shower on 10/22/25 when he fell. CNA 1 indicated the resident slipped and hit his head on the wall and hit his head on the floor. CNA 1 indicated she reported to LPN 2 who was the nurse on duty that the resident hit his head when he fell.
During an interview with LPN 2, on 11/5/25 at 12:55 p.m., she indicated she was the nurse caring for Resident B on 10/22/25 when he fell in the shower.
LPN 2 indicated she did not know why she did not call the physician or the resident's representative when the resident fell and hit his head. LPN 2 indicated she was so scared and had another emergency down the other hallway with another resident.
During an interview with Resident B's Emergency Contact 1, on 11/5/25 at 1:15 p.m., she indicated she was not notified when Resident B fell in the shower and hit his head.
The assessing for falls and their causes policy provided by the DON on 11/5/25 at 12:50 p.m., indicated after a resident fall the attending physician and family would be notified in an appropriate time frame.
The accidents and incidents reporting policy provided by the DON on 11/6/25 at 10:55 a.m., indicated the it would be documented the date and time the attending physician and family member was notified of the accident.
This citation relates to Intake 2654128. 3.1-5(a)(1)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Envive of Liberty
215 West High Street Liberty, IN 47353
SUMMARY STATEMENT OF DEFICIENCIES
Severe injury (GCS < 15): Perform neurological observations every 30 minutes until the GCS reaches 15.
Mild injury (GCS 15 or higher):
Perform observations every 30 minutes for the first two hours.
Perform hourly observations for the next four hours.
Perform every two hours thereafter.
If deterioration occurs: Immediately revert to checks every 30 minutes and restart the protocol.
Nursing responsibilities Frequent reassessment: Continue to monitor the patient's condition closely and adjust the frequency of checks based on clinical judgment and the patient's stability.
Communication: Report any deterioration or new findings immediately to the physician or nurse practitioner.
Documentation: Document all findings accurately and thoroughly in the patient's chart.
Care plan management: Update the care plan to reflect the patient's changing status and any interventions being performed. https://www.ncbi.nlm.nih.gov/books/NBK593206/ (chapter 6) and www.aacnnursing.org This citation relates to intake 2654128 3.1-37
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Envive of Liberty
215 West High Street Liberty, IN 47353
SUMMARY STATEMENT OF DEFICIENCIES
slippery.
Resident C indicated there were no non-skid grippers on the shower room floor.
A Fall Risk Evaluation note, dated [DATE] at 8:41 P.M., indicated Resident C was a low fall risk.
Immediate interventions included, but were not limited to, make sure shower room floor is dry before transferring.
An Assessing Falls and Their Causes policy was provided by the Director of Nursing (DON) on [DATE] at 12:50 P.M. It indicated,.Steps in the Procedure- After the Fall:.10. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.15.
Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record.
A Fall Risk Assessment policy was provided by the DON on [DATE] at 10:55 A.M. It indicated,.8.
The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout.9.
The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.
This citation relates to intake 2654128 3.1-45(a)
Facility ID: