Envive of Liberty

In the surveyor’s words

From the most serious findings on record at Envive of Liberty, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 6, 2025

  Based on interview and record review the facility failed to complete neurological assessments after two residents fell and hit their head resulting in Resident B sustaining a subdural hematoma (collection of blood that forms between the dura mater (the outer layer of the brain's protective membranes) and the brain itself) and requiring hospitalization for 2 of 3 residents reviewed for accidents (Residents B and D). Findings include:1. 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. […]

• Actual harm, isolatedF689Nov 6, 2025

  Based on observation, interview, and record review, the facility failed to ensure a safe environment in the shower room (wet/slick floor) with two residents suffering a fall in the shower room (Resident B and C). This deficiency resulted in Resident B acquiring a large right acute subdural hematoma with left midline shift and uncal herniation. Findings include: 1. Review of the clinical record of Resident B on [DATE] 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. […]

• Actual harm, isolatedF689Jul 12, 2024

  1. Based on observation, interview, and record review, the facility failed to ensure staff effectively implemented fall prevention interventions while using an assistive device in the shower to prevent accidents for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident 6 experiencing a fall that required hospitalization for the treatment of a subarachnoid hemorrhage. 2. The facility failed to ensure fall interventions were in place while utilizing an assistive device for 1 of 2 residents reviewed for positioning and mobility. (Resident 23) Findings include: 1. […]

• No harm, potential for more than minimal, patternF812Sep 23, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF580Nov 6, 2025

  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. […]