Envive Of Liberty

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain holding temperatures for pureed food for 4 of 4 residents receiving pureed foods. (Resident 10, 17, 23, and 29) Findings include: A tour of the kitchen was conducted, on 9/19/25 at 11:30 a.m., with [NAME] 2. During an observation of the pureed food temperatures being obtained, it was noted that pureed taco meat was recorded with a holding temperature of 90 degrees Fahrenheit, and pureed green beans had a holding temperature of 100 degrees Fahrenheit. During an observation of the steam table with [NAME] 2, four containers of pureed taco meat and four containers of pureed green beans were stacked to the right side of the steam table. During an interview with [NAME] 2, they indicated food temperatures were obtained one time after being cookedand before they were placed on the steam table. Food temperatures were obtained, on 9/19/25 at 11:00 a.m., before the food was placed on the steam table. [NAME] 2 indicated the taco meat was 171 degrees Fahrenheit, and the green beans were 160 degrees Fahrenheit.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for verbal abuse. (Resident B) Findings include: The facility completed an incident report and sent it to the Indiana Department of Health (IDOH) Long Term Care division, on 9-25-24, related to Resident B and Certified Nurse Aide (CNA) 4. In a written witness statement, dated 9-25-24, Registered Nurse (RN) 5, indicated on the same date at 5:15 p.m., he and another resident's family member, overheard [name of CNA 4] using inappropriate language and speaking in a raised tone towards the resident. The resident was heard using a racial slur directed at the staff member. In response, [name of CNA 4] stated 'You will not call me that, do you f-----g understand?' and added, 'You cannot attempt to get out of bed on your own; I already had to help your a-- off the floor once today.' This writer intervened by removing [name of CNA 4] from the room and escorting her to the break room to collect her belongings, followed by an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure falls were investigated and documented thoroughly for 3 of 3 residents reviewed for falls. (Residents E, G and H) Findings include: 1. The clinical record of Resident E was reviewed on 1-23-25 at 2:52 p.m. Her diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, chronic pain, spinal stenosis, and general muscle weakness. Her most recent Minimum Data Set (MDS) assessment, dated 11-18-24, indicated she was severely cognitively impaired, used a wheelchair for mobility, and was dependent for walking, toileting, and bed mobility. It indicated she had falls within the last six months, but no fractures. The Director of Nursing (DON) provided a fall log, indicating Resident E had a fall without injury on 10-12-24 at 3:55 p.m. During an interview with the DON on 1-23-25 at 3:16 p.m., she indicated Resident E had a diagnosis of dementia and did have a history of falls. I will have to look in her old chart and the old records for her information. She is the only person with a fall listed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide fresh ice water daily and failed to keep a call light and personal items within reach for 3 of 3 residents reviewed for choices (Resident 20, Resident 17 and Resident 2). Findings include: 1. During an observation and interview with Resident 20, on 7/9/24 at 12:59 p.m., she had a warm pitcher of water on her nightstand. The resident indicated she frequently went without fresh ice water and only received fresh fluids with meals. During an observation, on 7/10/24 at 10:58 a.m., Resident 20 had a water pitcher of water on her nightstand. Review of Resident 20's clinical record, on 7/12/24 at 11:32 a.m., indicated the diagnoses included, but were not limited to, diabetes, hypertension, anxiety, chronic kidney disease, and bladder disorder. The admission Minimum Data Set (MDS) assessment, dated 6/21/24, indicated Resident 20 was cognitively intact for daily decision making. The resident was consistent and reasonable. The physician order for Resident 20, dated 6/18/24, indicated to offer additional 120…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to store a Bi Pap facial mask and nebulizer mouthpiece in a bag to maintain good infection control practices for 1 of 4 residents reviewed for respiratory therapy (Resident 17). Findings include: During an observation, on 7/09/24 at 1:31 p.m., Resident 17's Bi Pap (airway support administered through a mask) facial mask was lying on the nightstand and not in a bag. The facial mask had brown substance around the facial mask. During an observation, on 7/10/24 at 10:57 a.m., Resident 17 was sitting in her geriatric chair and her nebulizer machine mouthpiece was lying on the bedside table with no bag. During an observation and interview, on 7/10/24 at 1:30 p.m., Resident 17's nebulizer machine mouthpiece was lying on the bedside table with no bag. The resident indicated some nurses put the nebulizer mouthpiece in a bag and some do not. Review of the record for Resident 17, on 7/10/24 at 12:52 p.m., indicated the resident's diagnoses included, but were not limited to, peripheral vascular disease, congestive heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide and administer a resident's medication, as ordered, for 1 of 1 resident reviewed for antibiotic use. (Resident 18) Findings include: The clinical record for Resident 18 was reviewed on 7/10/24 at 11:17 a.m. The diagnosis included, but were not limited to, urinary tract infection. The chronic urinary tract infection care plan, last revised 7/1/24, indicated the goal was for Resident 18 to be free from signs and symptoms of urinary tract infection. Two of the interventions were to administer medications as ordered and Macrobid 100 milligrams (mg) on Monday, Wednesday, and Friday for 36 doses. The 6/20/24, Urology Visit Summary indicated, Chief Complaint as stated by patient: f/u [follow up] UTI [urinary tract infection.] How long have you been experiencing this issue?: weeks What improves/worsens this issue?: Requesting ongoing low dose abx [antibiotic ] PLAN .pt [patient] here for more UTI .Will get str [straight] cath [catheter] cx [culture] sent out and start on low dose preventative antibx…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to provide a respectful and dignified environment during care for 1 of 2 residents reviewed for dignity (Resident B). Finding include: During an interview with Resident B's family member on 6/1/23 at 10:19 a.m., indicated they were visiting their family member on 4/18/23. The resident was in the bathroom and pushed the call light for assistance. CNA (Certified Nursing Assistant) 1 came into the resident's room and said what do you want I have better things to do. Resident B indicated to the family member that girl was mean to me. The family member filed a grievance and within in an hour was contacted by the Administrator. The Administrator indicated CNA 1 was having a bad day and the facility would retrain her. The family member did not feel the grievance was resolved and CNA 1 was rude and disrespectful to Resident B. During an interview with CNA 1 on 6/2/23 at 2:20 p.m., indicated on 4/18/23 Resident B was in the bathroom and had pushed the call light. CNA 1 went into the bathroom and the resident told her she had bugs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to keep bedroom wall in good repair, maintain and odor free environment and keep bedroom window clean and good repair for 3 of 3 residents reviewed for environment (Resident E, Resident F and Resident B). Findings include: 1. During an observation on 5/31/23 at 11:18 a.m., Resident E had peeling paint and scratches on the bedroom wall. During an interview with Resident E's family member on 5/31/23 at 2:25 p.m., indicated the resident had always been particular and clean. The resident's bedroom wall was in disrepair with peeling paint. 2. During an interview and observation on 5/31/23 at 11:41 a.m., Resident F's bedroom had a strong odor of urine. Resident F indicated he could smell the urine in his room. The resident indicated the facility did not clean his mattress regularly and would change his sheets without washing the bed. During an observation on 6/1/23 at 2:12 p.m., Resident F's bedroom had a strong smell of urine. During an observation on 6/2/23 at 2:20 p.m., Resident F's bedroom had a strong smell of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide a resident with oral care for 1 of 2 residents reviewed for Activities of Daily Living (ADLs). (Resident 18) Finding include: During an observation on 5/31/23 at 1:40 p.m., Resident 18 had a thick film with white substance on his teeth and gum line. During an observation on 6/1/23 at 2:08 p.m., Resident 18 had a thick film with white substance on his teeth and gum line. During an observation on 6/2/23 at 3:01 p.m., Resident 18 had a thick film with white substance on his teeth and gum line. During an observation and interview with Resident 18 on 6/5/23 at 1:55 p.m., the resident had a thick film with white substance on his teeth and gum line. Resident 18 indicated the facility staff did not assist him with brushing his teeth or flossing. The resident indicated he was right-handed, and it was difficult to brush his own teeth because he was missing four fingers on his right hand. Resident 18 indicated he would appreciate it if staff would help him with oral care. Review of the record of Resident 18 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to transfer a resident in a safe manner for 1 of 4 residents reviewed for accidents (Resident B). Finding include: During an interview with Resident B's family member on 6/1/23 at 10:19 a.m., indicated on 4/18/23 Resident B was in the bathroom and pushed her call light for help getting up. CNA 1 came into the bathroom and was pulling on the resident's arm and pants to get her off the toilet. The CNA did not use a gait belt and ripped the resident's pants during the transfer. During an interview with CNA 1 on 6/2/23 at 2:20 p.m., indicated on 4/18/23 she transferred Resident B from the toilet by holding the resident under her arm and by her pants. CNA 1 indicated she did not use a gait belt during the transfer. The CNA indicated she felt rushed that day. Review of the record of Resident B on 6/5/23 at 12:45 p.m., indicated the resident's diagnoses included, but were not limited to, muscle weakness, unsteadiness on feet, anxiety, difficulty walking, major depression disorder, acute kidney disorder, low back pain, syncope, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to implement nonpharmacological pain control, failed to administer as needed pain medication for verbal reports of pain, and failed to notify the physician of breakthrough pain for 1 of 2 residents reviewed for pain management. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 6/2/2023 at 1:05 p.m. The medical diagnosis included chronic pain. A Quarterly Minimum Data Set Assessment, dated 2/22/2023, indicated that Resident 11 was cognitively intact and experiences constant pain. An interview with Resident 11 on 5/31/2023 at 1:41 p.m. indicated he had a history of chronic pain related to breaking his tailbone in the past. He indicated that his pain was currently a 4/10 and he had already told the nurse working, but she did not do anything to help him. He stated he received his routine Tylenol around lunch. In the past when he reported his pain to the staff, they do not give him anything like medication or offer heat/ice, massage, or any other intervention. He reported only takes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.