Inspection Report Summary
The most recent inspection on May 30, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern, with some citations related to resident care issues such as verbal abuse and falls investigation, as well as Life Safety Code deficiencies involving fire safety equipment and building maintenance. Complaint investigations were mostly unsubstantiated, though one complaint involving a sprinkler head causing ceiling damage and resident relocation was substantiated and corrected. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some recurring issues with resident safety and environment, but recent inspections indicate corrective actions have been taken and compliance has improved.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 25
Capacity: 25
Deficiencies: 0
May 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456591.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00456591 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 20
Census Payor Type - Other: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 5, 2025
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00444074 and IN00445202 completed on January 24, 2025.
Findings
Envive of Liberty was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the investigations. Both complaints IN00444074 and IN00445202 were corrected.
Complaint Details
The visit was related to complaints IN00444074 and IN00445202, both of which were corrected.
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 2
Jan 22, 2025
Visit Reason
This visit was for the investigation of four complaints (IN00444074, IN00445202, IN00445491, and IN00446196) concerning alleged deficiencies at the facility.
Findings
The facility was found to have failed to protect a resident from verbal abuse by a staff member and failed to ensure falls were thoroughly investigated and documented for three residents. Two complaints had deficiencies cited, while two complaints had no deficiencies related to the allegations.
Complaint Details
Complaint IN00444074 resulted in a deficiency related to verbal abuse (F600). Complaint IN00445202 resulted in a deficiency related to falls investigation and documentation (F689). Complaints IN00445491 and IN00446196 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| 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). | SS=D |
| Failed to ensure falls were investigated and documented thoroughly for 3 of 3 residents reviewed for falls (Residents E, G, and H). | SS=D |
Report Facts
Census: 28
Total Capacity: 28
Medicare Census: 7
Medicaid Census: 19
Other Payor Census: 2
Number of complaints investigated: 4
Fall date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Cunningham | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| CNA 4 | Certified Nurse Aide | Named in verbal abuse finding and received written warning |
| RN 5 | Registered Nurse | Witnessed verbal abuse incident and intervened |
| Executive Director | Executive Director (ED) | Interviewed regarding verbal abuse incident and staffing |
| Director of Nursing | Director of Nursing (DON) | Provided fall logs and interviewed regarding fall investigations |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding Resident G's fall |
Inspection Report
Life Safety
Census: 22
Capacity: 60
Deficiencies: 0
Sep 3, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Whitewater Commons Senior Living was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 21
Capacity: 21
Deficiencies: 0
Aug 16, 2024
Visit Reason
This visit was for the investigation of complaints IN00439456 and IN00439891, conducted in conjunction with the Post Survey Revisit to the Recertification and State Licensure Survey completed on 7/12/2024.
Findings
No deficiencies related to the allegations in complaints IN00439456 and IN00439891 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Complaint Details
Complaint IN00439456 and Complaint IN00439891 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census: 21
Total Capacity: 21
Medicare Census: 1
Medicaid Census: 19
Other Payor Census: 1
Inspection Report
Re-Inspection
Census: 21
Capacity: 21
Deficiencies: 0
Aug 16, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-07-12, conducted in conjunction with the Investigation of Complaints IN00439891 and IN00439456.
Findings
Whitewater Commons Senior Living was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Complaint Details
The visit was conducted in conjunction with the investigation of complaints IN00439891 and IN00439456.
Report Facts
Census: 21
Total Capacity: 21
Medicare Census: 1
Medicaid Census: 19
Other Payor Census: 1
Inspection Report
Follow-Up
Census: 26
Capacity: 60
Deficiencies: 0
Aug 6, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the investigation of Complaint Number IN00437361 conducted on 07/05/24, conducted in conjunction with the Life Safety Code Recertification and Emergency Preparedness Survey.
Findings
Whitewater Commons Senior Living was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinkled except for three detached wooden storage sheds which were not sprinkled.
Complaint Details
Complaint Number IN00437361 was corrected as of this visit.
Report Facts
Facility capacity: 60
Census: 26
Inspection Report
Life Safety
Census: 22
Capacity: 60
Deficiencies: 4
Aug 6, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted in conjunction with a Life Safety Code Complaint Investigation that exited on 08/06/24.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with delayed egress door signage, corridor doors not latching properly, and a non-functioning ground fault circuit interrupter (GFCI) receptacle. No residents were directly affected but all had the potential to be affected.
Complaint Details
This visit was in conjunction with the Life Safety Code Complaint Investigation PSR that exited on 08/06/24.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure means of egress through 2 of over 8 delayed egress locks had proper signage as required by LSC 7.2.1.6.1. | SS=E |
| Failed to ensure 2 of over 30 corridor doors had no impediment to closing and latching into the door frame and would resist passage of smoke. | SS=E |
| Failed to ensure 1 of 1 ground fault circuit interrupter (GFCI) exterior receptacle was properly maintained for protection against electric shock. | SS=E |
| Failed to ensure 1 of 1 wall light fixtures in room 215 contained a cover and was protected from damage not exposing wires and connections. | SS=E |
Report Facts
Certified beds: 60
Census: 22
Delayed egress locks inspected: 8
Corridor doors inspected: 30
Residents potentially affected by delayed egress signage deficiency: 15
Residents potentially affected by corridor door deficiency: 2
Staff potentially affected by GFCI deficiency: 2
Residents potentially affected by exposed wiring deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Blackmon | HFA | Laboratory Director or Provider/Supplier Representative who signed the report |
| Maintenance Director | Named in relation to findings and acknowledgments of deficiencies | |
| Regional Director of Operations | Present at exit conference acknowledging deficiencies | |
| DON | Director of Nursing | Present at exit conference acknowledging deficiencies |
| Administrator | Present at exit conference acknowledging deficiencies |
Inspection Report
Annual Inspection
Census: 26
Capacity: 26
Deficiencies: 5
Jul 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of Complaint IN00437363.
Findings
The facility was found deficient in several areas including failure to provide fresh ice water and keep call lights and personal items within reach for residents, inadequate fall prevention interventions resulting in a resident fall with major injury, improper storage of respiratory equipment, and failure to administer a resident's medication as ordered. No deficiencies were related to the complaint investigated.
Complaint Details
Complaint IN00437363 was investigated during the visit and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 3
SS=G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide fresh ice water daily and failed to keep call light and personal items within reach for 3 of 3 residents reviewed for choices. | SS=D |
| Failed to ensure staff effectively implemented fall prevention interventions while using assistive devices, resulting in a fall with subarachnoid hemorrhage and hospitalization. | SS=G |
| Failed to store Bi Pap facial mask and nebulizer mouthpiece in a bag to maintain infection control for 1 of 4 residents reviewed for respiratory therapy. | SS=D |
| Failed to provide and administer a resident's medication as ordered for 1 of 1 resident reviewed for antibiotic use. | SS=D |
| Failed to report a fall with major injury resulting in hospitalization to the Indiana Department of Health within required timeframe for 1 of 1 resident reviewed for accidents with major injury. | — |
Report Facts
Census SNF/NF beds: 26
Census total residents: 26
Census Medicare residents: 3
Census Medicaid residents: 20
Census Other payor residents: 3
Medication doses: 36
Medication doses missing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Blackmon | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Certified Nursing Assistant 1 | Named in relation to call light and personal items placement for Resident 17 | |
| Certified Nursing Assistant 2 | Re-educated on fall interventions for Resident 23 and observed transporting Resident 23 in wheelchair | |
| Certified Nursing Assistant 3 | Re-educated on proper use of shower bed after Resident 6 fall | |
| Director of Nursing | DON | Interviewed regarding staff responsibilities and re-education on multiple deficiencies |
| Executive Director | ED | Interviewed regarding fall incident and policies |
| Certified Occupational Therapy Assistant | COTA | Interviewed regarding Resident 23 wheelchair use |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 60
Deficiencies: 1
Jul 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Number IN00437361, which was substantiated. The visit included an Emergency Preparedness Survey and a Life Safety Code inspection following an incident involving a sprinkler head releasing water and causing ceiling damage.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to a missing escutcheon plate around a sprinkler head in resident room #203, which caused ceiling damage and resident relocation. The sprinkler system was restored and corrective actions were initiated.
Complaint Details
Complaint Number IN00437361 was substantiated. The complaint involved a sprinkler head in the attic releasing water, saturating the ceiling above resident room #203, causing ceiling collapse and resident relocation. The facility's vendor verified other sprinkler heads activate at the required temperature. A fire watch was conducted during repairs.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain the ceiling construction in accordance with NFPA 13 due to a missing escutcheon plate around a sprinkler head in resident room #203. | SS=E |
Report Facts
Certified beds: 60
Census: 26
Fire watch duration (hours): 2.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Blackmon | Laboratory Director's or Provider/Supplier Representative | Signed the report |
| Director of Nursing | Interviewed regarding sprinkler head incident and acknowledged findings | |
| Maintenance Director | Interviewed regarding sprinkler head incident, acknowledged missing escutcheon, and responsible for corrective actions |
Inspection Report
Re-Inspection
Census: 30
Capacity: 60
Deficiencies: 0
Aug 10, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 06/20/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Whitewater Commons Senior Living was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 60
Census: 30
Inspection Report
Life Safety
Census: 30
Capacity: 60
Deficiencies: 6
Jun 20, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with Life Safety Code and state licensure requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including improper storage of propane tanks near ignition sources, failure of a hazardous area door to self-close, lack of full hydrostatic flush on sprinkler piping, a leaking sprinkler head in the cooler, and improper use of power strips and flexible cords as substitutes for fixed wiring.
Severity Breakdown
SS=E: 4
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure propane tanks were stored properly away from all ignition sources near the patio smoking area. | SS=E |
| Failed to ensure 1 of over 10 hazardous area doors had a properly working self-closing device; the corridor door to the kitchen failed to self-close and latch. | SS=E |
| Failed to ensure a full hydrostatic flush was performed on automatic sprinkler piping systems as required by NFPA 25. | SS=F |
| Failed to maintain sprinkler head in the cooler; sprinkler head was leaking. | SS=F |
| Failed to ensure power strips were not used as a substitute for fixed wiring to provide power to equipment with high current draw in the MDS office. | SS=E |
| Failed to ensure flexible cords were not used as a substitute for fixed wiring; a light switch in the attic was powered by a cord plugged into a ceiling light outlet. | SS=E |
Report Facts
Certified beds: 60
Census: 30
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 29
Capacity: 29
Deficiencies: 5
Jun 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00409078.
Findings
The facility was found deficient in multiple areas including respect and dignity during care, safe and clean environment maintenance, oral care provision, safe resident transfers, and pain management. Deficiencies were related to specific residents and systemic issues were addressed with staff re-education and quality assurance monitoring.
Complaint Details
Complaint IN00409078 was investigated, with federal/state deficiencies cited related to allegations of disrespectful care, unsafe environment, inadequate oral care, unsafe transfers, and pain management issues.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide a respectful and dignified environment during care for Resident B. | SS=D |
| Failed to maintain a safe, clean, comfortable, and homelike environment for Residents E, F, and B, including peeling paint, urine odor, and dirty windows. | SS=D |
| Failed to provide oral care for Resident 18, who had a thick film with white substance on teeth and gums. | SS=D |
| Failed to transfer Resident B in a safe manner, including not using a gait belt and causing damage to resident's pants. | SS=D |
| Failed to implement nonpharmacological pain control, administer as needed pain medication, and notify physician of breakthrough pain for Resident 11. | SS=D |
Report Facts
Census: 29
Total Capacity: 29
Deficiencies cited: 5
Survey dates: May 31, June 1, 2, 5, & 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Blackmon | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| CNA 1 | Named in findings related to disrespectful care and unsafe transfer of Resident B | |
| Director of Nursing | DON | Involved in staff re-education and monitoring of care practices |
| Administrator | Interviewed regarding complaint and facility practices | |
| Nurse Consultant | Provided policies and interviewed regarding pain management and resident rights |
Inspection Report
Renewal
Deficiencies: 0
Jun 6, 2023
Visit Reason
Paper compliance review to the Recertification, State Licensure and Complaint Survey.
Findings
Whitewater Commons Senior Living was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification, State Licensure and Complaint Survey.
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Mar 14, 2023
Visit Reason
This visit was for the investigation of complaints IN00403445 and IN00403931.
Findings
No deficiencies related to the allegations in complaints IN00403445 and IN00403931 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00403445 and Complaint IN00403931 were investigated with no deficiencies cited related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 25
Other census: 4
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 0
Jul 28, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00381438 and IN00377414.
Findings
Complaint IN00381438 was substantiated, while complaint IN00377414 was unsubstantiated due to lack of evidence. No deficiencies related to the allegations were cited, and the facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00381438 was substantiated. Complaint IN00377414 was unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 27
Medicare residents: 1
Medicaid residents: 21
Other payor residents: 5
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