Envive Of Liberty

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Envive of Liberty

215 West High Street Liberty, IN 47353

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Severe injury (GCS < 15): Perform neurological observations every 30 minutes until the GCS reaches 15.

Level of Harm - Actual harm

Mild injury (GCS 15 or higher):

Residents Affected - Few

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Envive of Liberty

215 West High Street Liberty, IN 47353

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

slippery. Resident C indicated there were no non-skid grippers on the shower room floor.

Level of Harm - Actual harm

A Fall Risk Evaluation note, dated [DATE REDACTED] 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.

Residents Affected - Few

An Assessing Falls and Their Causes policy was provided by the Director of Nursing (DON) on [DATE REDACTED] 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 REDACTED] 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)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet