Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Envive Of Liberty during CMS and state inspections, most recent first.
Two residents who experienced falls with head impact did not receive required neurological assessments, despite one developing a subdural hematoma and requiring hospitalization. In both cases, staff failed to follow facility policy and nursing standards for post-fall neurological checks, relying instead on limited assessments or waiting for provider orders, and did not document neurological monitoring in the residents' records.
Two residents suffered falls in the shower room due to a wet, slippery floor lacking adequate non-skid features or consistent use of safety measures. One resident, with multiple medical conditions and a recent pacemaker, sustained a fatal subdural hematoma after slipping and hitting his head. Another resident, assisted by an agency CNA unfamiliar with facility practices, slipped and fell when expected safety precautions were not in place. Staff and resident interviews confirmed the floor's hazardous condition and inconsistent application of preventive measures.
A resident with multiple medical conditions, including a recent pacemaker placement, fell in the shower and hit his head. Although the DON was notified and EMTs assisted, the LPN on duty did not inform the resident's physician or emergency contact as required by facility policy. The omission was confirmed through staff interviews and record review.
Improper Holding Temperatures for Pureed Foods: Pureed taco meat and green beans were observed below the required hot-holding temperature during meal service, with containers stacked to the side of the steam table instead of being maintained at 135 degrees Fahrenheit or above. Staff stated temperatures were checked only once before placement on the steam table, and the DON/Administrator indicated pureed foods should be held in metal containers on the steam table and served directly from the pan.
A CNA in a LTC facility verbally abused a resident after the resident used a racial slur. The CNA, feeling overwhelmed, responded inappropriately, which was witnessed by an RN. The resident, with cognitive impairments, had a history of falls. The facility documented the incident, issued a warning to the CNA, and provided stress management education.
The facility failed to investigate and document falls for three residents, leading to deficiencies in care. A resident with Alzheimer's experienced a fall with delayed documentation due to previous ownership and EHR issues. Another resident with hyponatremia had an unwitnessed fall, with unclear records regarding her hospitalization and return. A third resident with cognitive impairment had multiple falls, with missing documentation of her return to the facility. These issues were linked to changes in ownership and EHR systems.
The facility failed to implement effective fall prevention interventions for two residents. One resident, dependent on staff for all ADLs, fell off a shower bed due to missing pins and unlocked wheels, resulting in hospitalization for a subarachnoid hemorrhage. Another resident, with Alzheimer's, was not properly transported in a Broda chair, leading to her feet contacting the ground. The facility's policies were not followed, contributing to these deficiencies.
The facility failed to provide fresh ice water daily and ensure call lights and personal items were within reach for residents. A resident frequently went without fresh ice water, despite a physician order for additional fluids. Another resident's personal items were often out of reach, requiring her to yell for help. A third resident reported having warm, stale water with no fresh ice water provided. The facility's policy required fresh drinking water to be available at all times, but this was not followed.
A resident's BiPAP mask and nebulizer mouthpiece were not stored in bags as required for infection control, despite the facility's policy. The resident, who had multiple medical conditions and was cognitively intact, reported inconsistent practices by nursing staff. The DON confirmed the requirement for storing respiratory equipment in bags.
A resident with a urinary tract infection was prescribed Macrobid 100 mg to be taken on Monday, Wednesday, and Friday. However, the medication was incorrectly scheduled and administered every other day, leading to missed doses on the prescribed days. The DON confirmed the error, and an observation showed missing capsules from the medication cart.
Failure to Complete Neurological Assessments After Resident Falls with Head Impact
Penalty
Summary
The facility failed to complete neurological assessments after two residents experienced falls with head impact, resulting in one resident sustaining a subdural hematoma and requiring hospitalization. In the first case, a resident with multiple medical conditions, including sick sinus syndrome, syncope, and a recent pacemaker placement, fell in the shower room and hit his head on both the wall and the floor. Although the CNA reported the head impact to the LPN, no neurological assessments were performed. The LPN relied on a brief visual and tactile check and the resident's verbal response, but did not conduct or document neurological checks as per facility policy. Approximately 1 hour and 37 minutes after the fall, the resident was found unresponsive and was later diagnosed at the hospital with a large acute subdural hematoma, requiring transfer to a major medical center. In the second case, another resident with a history of unsteadiness, muscle weakness, and cognitive impairment was found on the floor after an unwitnessed fall and reported hitting their head. The resident was sent to the emergency room for evaluation, but no neurological assessments were completed or documented in the electronic health record before or after the transfer. The care plan for this resident identified a high risk for falls, but interventions did not include post-fall neurological checks. The DON stated that neurological checks were not performed because there were no findings on assessment and no provider order for such checks. Facility policy required routine neurological assessments after head injuries to monitor for changes indicative of neurological injury, including assessments of mental status, pupillary response, motor strength, sensation, and gait. Nursing standards also call for frequent neurological checks after a head injury, with the frequency determined by the severity of the injury and any changes in the resident's condition. In both cases, the facility did not follow its own policy or nursing standards, resulting in a failure to provide appropriate post-fall neurological monitoring for residents who had sustained head injuries.
Failure to Maintain Safe Shower Room Environment Results in Resident Falls and Serious Injury
Penalty
Summary
The facility failed to ensure a safe environment in the shower room, resulting in two residents suffering falls due to a wet and slippery floor. One resident, with a history of sick sinus syndrome, syncope, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, CVA, and hypertension, required substantial assistance for showering and was at risk for fall-related injury due to a recent pacemaker placement and a non-weight bearing left arm. During a shower, this resident slipped and fell, hitting his head on the wall and floor. The CNA assisting reported the incident, and the resident was initially responsive, but later became unresponsive in bed. Subsequent medical evaluation revealed a large acute subdural hematoma with significant midline shift and uncal herniation, leading to the resident's death after transfer to a major medical hospital. Observations confirmed that non-skid strips were not in place at the time of the fall, and the shower floor was a smooth, slippery fiberglass acrylic surface without additional safety measures such as bath mats or towels. Another resident, diagnosed with respiratory failure, chronic pain syndrome, and major depressive disorder, also required substantial assistance with bathing and had limited lower extremity range of motion. This resident experienced a fall in the shower room while being assisted by an agency CNA unfamiliar with the facility's usual safety practices. The resident slipped on the wet, slippery floor after standing up to be wiped off, and noted that there were no non-skid grippers on the floor at the time. The resident typically wore non-skid socks and expected a towel to be placed on the floor, but these precautions were not taken during the incident. The CNA was unaware of the facility's informal practice of placing a towel on the floor to prevent slipping. Interviews with staff and residents, as well as direct observation, confirmed that the shower room floor became very slippery when wet and lacked adequate non-skid features or consistent use of safety measures. The facility's policies required staff to identify and address environmental fall risks, but these were not effectively implemented in the shower room, directly contributing to the falls and resulting injuries.
Failure to Notify Physician and Emergency Contact After Resident Fall
Penalty
Summary
The facility failed to notify a resident's physician and emergency contact or representative after the resident experienced a fall and hit his head. The resident, who had multiple diagnoses including sick sinus syndrome, syncope, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, cerebral vascular accident, and hypertension, had recently received a pacemaker. On the evening of the incident, the resident fell in the shower room, hitting his head on both the wall and the floor. Emergency Medical Technicians were called to assist due to the recent pacemaker placement, and the Director of Nursing was notified. However, there was no documentation that the resident's physician or emergency contact was informed of the fall. Interviews with staff confirmed that the CNA reported the fall and head injury to the LPN on duty, but the LPN did not notify the physician or the resident's representative. The LPN stated she was overwhelmed by another emergency at the time and could not explain why the notifications were not made. The resident's emergency contact also confirmed that she was not informed of the incident. Facility policies required timely notification of the physician and family after a fall, and documentation of the date and time of such notifications, but these procedures were not followed in this case.
Improper Holding Temperatures for Pureed Foods
Penalty
Summary
The facility failed to maintain holding temperatures for pureed foods for four residents receiving pureed diets. During a kitchen tour, pureed taco meat was observed with a holding temperature of 90 degrees Fahrenheit and pureed green beans were observed at 100 degrees Fahrenheit. Four containers each of pureed taco meat and pureed green beans were stacked to the right side of the steam table rather than being held at the required temperature during meal service. During interview, kitchen staff stated temperatures were taken only once after the food was cooked and before it was placed on the steam table. At 11:00 a.m., the taco meat was 171 degrees Fahrenheit and the green beans were 160 degrees Fahrenheit before placement on the steam table. Staff also stated prepared containers of pureed food were held on the side of the steam table and that other staff sometimes microwaved prepared containers for one to two minutes before serving. The Administrator stated pureed food should be placed in a metal container, held on the steam table, and served directly from the pan rather than in bowls, and that holding temperatures should have been 135 degrees Fahrenheit or above.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. The incident involved a Certified Nurse Aide (CNA) who used inappropriate language towards a resident, Resident B, after the resident used a racial slur against the CNA. The incident was witnessed by a Registered Nurse (RN) and another resident's family member. The CNA admitted to being overwhelmed and stressed, which contributed to her reaction. The facility documented the incident and provided a written warning to the CNA, along with education on stress and burnout. Resident B, who was moderately cognitively impaired with diagnoses including unspecified dementia and benign intracranial hypertension, was involved in the incident. The resident had a history of falls and was found by the CNA attempting to get out of bed on her own, which led to the verbal exchange. The CNA expressed concern for the safety of Resident B and another resident who had assisted her in getting back to bed. The CNA acknowledged her inappropriate response and apologized to the resident. The facility's policy on abuse prohibition, reporting, and investigation was reviewed, indicating that verbal abuse is defined as language that includes disparaging or derogatory terms. The policy requires thorough investigation of alleged violations and protection of residents from abuse. The facility's response included removing the CNA from resident care during the investigation and providing re-education on appropriate resident interactions. The Executive Director, who was new to the position, noted that the staffing situation had improved since the incident.
Failure to Investigate and Document Falls
Penalty
Summary
The facility failed to thoroughly investigate and document falls for three residents, leading to deficiencies in care. Resident E, who had a history of Alzheimer's disease, dementia, and falls, experienced a fall on 10-12-24. The documentation of this fall was delayed, and the Director of Nursing (DON) indicated that the fall occurred under previous ownership with a different electronic health record (EHR) system, complicating access to records. The fall log and progress notes were incomplete, with no timely follow-up assessments documented. Resident G, diagnosed with hyponatremia and other conditions, experienced an unwitnessed fall on 1-21-25. Although the fall was initially documented, there was no explanation in the records for her subsequent hospitalization on the same day. The care plan noted her emergency room visit, but there was a lack of documentation regarding her return to the facility. Interviews with staff and the resident revealed gaps in the documentation of her hospitalization and return. Resident H, with a history of cognitive impairment and falls, was found on the floor on 12-31-24. Despite being sent to the emergency room, there was no documentation of her return to the facility. The DON acknowledged the absence of a readmission assessment and attributed it to the previous ownership and EHR system. Another fall occurred on 1-12-25, but records of her readmission were again missing. These documentation lapses were linked to changes in facility ownership and EHR systems, impacting the continuity of care and record-keeping.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure effective implementation of fall prevention interventions for Resident 6, who was dependent on staff for all activities of daily living, including bathing. Resident 6, who had a history of traumatic subarachnoid hemorrhage and other medical conditions, fell off a shower bed due to missing pins on the siderails and unlocked wheels, resulting in hospitalization for a subarachnoid hemorrhage. The CNA involved in the incident admitted to not locking the wheels and was unfamiliar with the shower beds, indicating a lack of proper training and equipment maintenance. Additionally, the facility did not ensure proper use of an assistive device for Resident 23, who had Alzheimer's disease and was at risk for falls. Resident 23's care plan required the use of a Broda chair with the chair dipped back to prevent her feet from touching the ground during transport. However, observations showed that Resident 23's feet intermittently contacted the ground while being transported, and CNA 2 confirmed that foot pedals were not used, and staff were working with PT for a new wheelchair. The facility's policies for showering residents and fall prevention were not adequately followed, contributing to the incidents involving both residents. The lack of proper equipment maintenance, staff training, and adherence to individualized care plans led to these deficiencies, resulting in significant risk and harm to the residents involved.
Failure to Provide Fresh Ice Water and Accessible Call Lights
Penalty
Summary
The facility failed to provide fresh ice water daily and ensure that call lights and personal items were within reach for three residents. Resident 20 frequently went without fresh ice water, only receiving fresh fluids with meals, despite having a physician order to offer additional fluids every shift. Observations confirmed that Resident 20 had a warm pitcher of water on her nightstand on multiple occasions. Resident 20's clinical record indicated diagnoses including diabetes, hypertension, anxiety, chronic kidney disease, and bladder disorder, and she was cognitively intact for daily decision-making. Resident 17's personal items, including her call light, were often out of reach, requiring her to yell for help. Despite being dependent on two people for transfers and unable to walk, her items were not consistently placed within reach. Resident 2 also reported having warm, stale water in his pitcher, with no fresh ice water provided within the last day. The facility's policy stated that fresh drinking water should be available to each resident at all times, but this was not adhered to. Interviews with the DON confirmed that nursing staff were responsible for ensuring water, call lights, and personal items were within reach.
Inadequate Infection Control for Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident's respiratory equipment. During observations, it was noted that Resident 17's BiPAP facial mask was left on the nightstand without being stored in a bag, and it had a brown substance around it. Additionally, the resident's nebulizer mouthpiece was found lying on the bedside table without a bag on multiple occasions. The resident reported that some nurses would place the nebulizer mouthpiece in a bag, while others would not. Resident 17 had a range of medical conditions, including peripheral vascular disease, congestive heart failure, anxiety, major depressive disorder, pain, diarrhea, insomnia, and difficulty walking. The resident was cognitively intact and had specific physician orders for respiratory treatments, including nebulizer treatments and the use of a BiPAP mask. The facility's policy required that respiratory equipment be stored in a bag labeled with the resident's name and date, but this was not consistently followed, as confirmed by the Director of Nursing.
Medication Administration Error for Resident with UTI
Penalty
Summary
The facility failed to administer medication as ordered for a resident diagnosed with a urinary tract infection. The resident was prescribed Macrobid 100 mg to be taken orally every Monday, Wednesday, and Friday for 36 doses. However, the medication administration record (MAR) indicated that the medication was scheduled to be given every other day, leading to incorrect administration on Sunday instead of the prescribed days. This error resulted in the medication not being administered on the correct days, as observed on specific dates in July. The Director of Nursing (DON) confirmed the error upon reviewing the MAR and acknowledged that the medication was set up incorrectly. An observation of the medication cart revealed that four capsules of Macrobid were missing from the 36 sent by the pharmacy. The facility's Medication Administration policy emphasizes the importance of administering medications as prescribed and observing the six rights of medication administration, which were not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage House Rehabilitation & Health Care Center | 8.9 mi | ★★★★★ | 7 | 0 |
| Majestic Care Of Connersville | 10.1 mi | ★★★★★ | 4 | 0 |
| Hickory Creek At Connersville | 10.9 mi | ★★★★★ | 3 | 0 |
| Caroleton Healthcare Center | 11 mi | ★★★★★ | 12 | 0 |
| Brickyard Healthcare - Golden Rule Care Center | 11.4 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.