Envive Of Hartford City
Inspection history, citations, penalties and survey trends for this long-term care facility in Hartford City, Indiana.
- Location
- 715 N Mill St, Hartford City, Indiana 47348
- CMS Provider Number
- 155699
- Inspections on file
- 23
- Latest survey
- November 7, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Envive Of Hartford City during CMS and state inspections, most recent first.
A resident's allegation that CNAs made inappropriate and demeaning comments about her continence was not reported to the State Agency within the required two-hour timeframe. The Administrator initially viewed the incident as a customer service issue and delayed reporting until further information was obtained from the resident, resulting in noncompliance with abuse reporting regulations.
A resident with significant medical needs reported being yelled at by CNAs, and the facility failed to conduct a thorough abuse investigation and did not implement immediate interventions to prevent potential abuse during the investigation. Documentation was incomplete, staff interviews were missing or improperly dated, and the resident and her representative described feeling intimidated and upset by staff comments regarding incontinence. The facility did not follow its own policy for investigating abuse allegations.
A medication cart was found to contain an uncovered cup with multiple pills labeled for a resident's evening dose. An LPN indicated the medications were likely refused and should have been destroyed immediately, but this was not done. The DON confirmed that facility policy requires immediate destruction of refused medications, and the failure to follow this policy resulted in the deficiency.
The facility failed to ensure timely review and response to pharmacy recommendations for two residents regarding PRN lorazepam orders. One resident with severe cognitive impairment had a PRN order that was not properly documented or reviewed by a physician, leading to a new order without a stop date. Another resident with anxiety disorder had a similar issue, with the DON acknowledging the oversight. The facility's policy for timely physician response was not followed.
The facility failed to attempt non-pharmacological interventions before administering PRN psychoactive medications to two residents. Both residents, with varying levels of cognitive impairment, were given lorazepam without documented attempts of alternative interventions, contrary to the facility's policy. Interviews with staff confirmed the requirement for such interventions, but documentation was lacking.
A facility failed to follow infection control procedures during insulin administration for two residents. An RN did not cleanse the rubber stopper of insulin pens before attaching needles, contrary to guidelines. Both residents had specific insulin orders due to type 2 diabetes. The oversight was acknowledged by the RN and confirmed by the President of Clinical Operations.
A cognitively intact resident reported being pushed by another resident, but the facility failed to report the abuse allegation to the state due to inconsistencies in the resident's account. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported, leading to a deficiency citation.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required timeframe. On one occasion, a resident's representative reported to a nurse that the resident had overheard CNAs making inappropriate comments about her continence and care needs during lunch. The nurse notified the Administrator of the concern on the same day, and the Administrator spoke with both the nurse and the resident's representative. However, the Administrator initially determined that the incident was a customer service issue rather than potential abuse and did not report it to the State Agency at that time. It was not until the following day, after speaking directly with the resident who described the CNAs as having yelled at her and became visibly upset, that the Administrator considered the situation as possible abuse. At that point, the Administrator initiated an investigation and reported the incident to the State Agency. This sequence of events resulted in a delay in reporting the allegation of abuse, which was not made within the required two-hour timeframe as specified by facility policy and state regulations.
Failure to Conduct Thorough Abuse Investigation and Implement Immediate Interventions
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse and did not implement immediate interventions to prevent potential abuse while the investigation was ongoing. A resident, who was cognitively intact and dependent on staff for activities of daily living due to multiple medical conditions including a femur fracture, chronic kidney disease, diabetes with neuropathy, and morbid obesity, reported to the Administrator that certified nursing assistants (CNAs) had yelled at her. The incident was reported to the state, and the CNAs were suspended pending the investigation outcome. However, the clinical record lacked documentation of the resident's allegation and subsequent facility actions, and the abuse investigation file was incomplete, missing a statement from one of the CNAs and additional staff and resident interviews. The investigation documents provided by the facility were inconsistent and contained errors, such as undated or incorrectly dated staff interviews. There was also evidence that staff interviews were not conducted promptly, and some documentation did not accurately reflect whether abuse had been witnessed or the correct dates of the interviews. Confidential interviews revealed that one CNA had referred to the resident in derogatory terms and had used inappropriate language in the presence of other staff, with uncertainty about whether residents overheard. The resident and her representative described incidents where the resident felt intimidated and upset by staff comments regarding her incontinence, and the resident expressed fear of retaliation after reporting the incident. Despite the facility's policy requiring all allegations of abuse to be thoroughly investigated and for accused employees to be placed on leave with no resident contact until the investigation is complete, the investigation was not comprehensive. The facility failed to obtain all relevant statements, did not document all actions taken, and did not ensure immediate protective interventions were in place while the investigation was ongoing. These deficiencies were directly observed and documented by surveyors during the review of records and interviews with staff, the resident, and her representative.
Failure to Properly Dispose of Refused Medications
Penalty
Summary
Surveyors observed that a medication cart contained an uncovered paper medication cup holding several pills, including a green capsule, two cream-colored capsules, two round white tablets, and one oblong oval-shaped white tablet. The cup was labeled with a resident's last name and the words 'evening meds.' The presence of these medications in the cart was not noticed by the LPN during the earlier medication pass. The LPN stated that the medications were likely refused by the resident and should have been destroyed immediately, but this was not done. The Director of Nursing confirmed that facility policy requires immediate destruction of medications refused by residents and that any medications found in cups within the medication cart should be destroyed upon discovery. The facility's policy, dated August 2024, specifies that medications which cannot be returned to the pharmacy, including those refused by residents, must be disposed of according to federal, state, and local regulations. The failure to properly label and dispose of the medications as required led to the deficiency.
Failure to Address Pharmacy Recommendations for PRN Medications
Penalty
Summary
The facility failed to ensure timely review and response to pharmacy recommendations for two residents regarding unnecessary medications. Resident 16, who had diagnoses including aphasia following cerebral infarction, depression, disorientation, and anxiety disorder, was prescribed lorazepam for anxiety/agitation. The medication regimen review indicated that the PRN order for lorazepam was limited to 14 days unless extended by the prescriber with documented rationale. However, the facility's records lacked documentation of physician notification and response to the medication regimen reviews conducted on 8/19/24 and 10/21/24. The PRN lorazepam order was eventually discontinued on 10/27/24, but a new order was started without a stop date. Similarly, Resident 28, diagnosed with anxiety disorder and congestive heart failure, was prescribed lorazepam with a PRN order that required a 14-day stop date or longer if clinically appropriate. The medication regimen review on 8/19/24 highlighted this requirement, but the facility's Nurse's Notes did not document physician notification and response. The Director of Nursing (DON) acknowledged missing the review and not having a physician response. The facility's policy required a written report to the physician within seven working days and a physician's written response within one month, which was not adhered to in these cases.
Failure to Attempt Non-Pharmacological Interventions Before PRN Medication Administration
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted prior to the administration of PRN psychoactive medications for two residents. Resident 16, who was severely cognitively impaired and dependent on staff for various activities, was given lorazepam multiple times without documented attempts of non-pharmacological interventions. The resident's clinical records consistently lacked documentation of any interventions attempted before administering the PRN medication, despite the care plan's requirement to monitor behavior and attempt to determine underlying causes. Similarly, Resident 28, who was moderately cognitively impaired and required assistance with daily activities, was administered lorazepam without prior non-pharmacological interventions. The resident's clinical records also lacked documentation of any interventions attempted before the administration of the PRN medication. The facility's policy required non-pharmacological approaches to be used to minimize the need for medications, but this was not adhered to in these cases. Interviews with facility staff, including an LPN, an RN, and the DON, confirmed that interventions should be attempted and documented before administering PRN medications. However, the facility was unable to provide documentation of such interventions for the residents involved. This lack of adherence to the facility's policy and the absence of documented interventions prior to medication administration led to the identified deficiency.
Infection Control Lapse in Insulin Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control procedures during insulin administration for two residents. During a medication administration observation, a registered nurse (RN) did not cleanse the rubber stopper of the multi-dose insulin pen before attaching the pen needle for both residents. This step is crucial as the rubber stopper is pierced multiple times, and cleansing it is necessary to prevent infection. The RN administered insulin to Resident 16 in the right lower abdomen and to Resident 7 in the left upper arm without following this protocol. Resident 16 has a diagnosis of type 2 diabetes mellitus with diabetic neuropathy, and the physician's orders included specific instructions for insulin administration. Similarly, Resident 7, who has type 2 diabetes mellitus with circulatory complications, also had detailed physician's orders for insulin administration. The RN acknowledged the oversight during an interview, and the President of Clinical Operations confirmed that the insulin pens should have been cleansed according to the manufacturers' guidelines. The facility's documents and external resources also outlined the proper procedure for preparing insulin pens, which includes wiping the rubber stopper with an alcohol swab.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation to the Indiana Department of Health involving two residents. Resident D, who was cognitively intact according to her Minimum Data Set (MDS) assessment, reported that Resident B pushed her into her room and told her to stay there. This incident was reported to the Administrator and the Social Service Director, and a grievance form was completed. However, the facility did not report the allegation to the state agency because Resident D later changed her story, stating that Resident B followed her to her room, put his hand on her door, and told her to stay inside. The facility's policy requires that all alleged violations involving abuse be reported immediately to the State Department of Health. Despite this policy, the Administrator did not report the incident due to the inconsistency in Resident D's account. The report includes various statements from staff members, including a Housekeeping Supervisor and an RN, who documented Resident D's initial claims. The facility's failure to report the incident as required by their policy resulted in a deficiency citation.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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