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 July 2026. Survey timing is at the state agency's discretion.
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 resident who was cognitively intact and dependent on a mechanical lift for transfers was left in bed because the needed full body sling was unavailable after being sent to laundry. She preferred full body slings for comfort and safety, but staff reported the facility had a limited supply of slings and residents were sometimes kept in bed when slings were being washed or could not be found. The resident stated this had happened before and caused her to miss activities she enjoyed, including BINGO.
Failure to provide ordered adaptive dining equipment for a resident with intellectual disabilities, vascular dementia, generalized weakness, and dysphagia. Although the resident had orders and a care plan for built up utensils, a spouted cup, a scoop bowl, and a suction-base plate at all meals, staff observed the resident using regular plates, bowls, cups, and utensils during lunch, and no adaptive items were seen in the dining room. CNA staff said the resident did not use specialty items, while the DON stated dietary staff were responsible for providing the equipment and the Administrator noted it was not listed on the dietary slip.
Failure to provide mechanical lift sling for dependent resident transfers. A cognitively intact resident with muscle wasting, a recent femur fracture, morbid obesity, and weakness was totally dependent for transfers and required a mechanical lift with 2 staff. She reported being left in bed because her full-body sling was soiled and unavailable while being laundered, and staff confirmed residents were sometimes kept in bed when slings were not available. The DON and Administrator could not account for the sling inventory, and only a few slings were found in the linen closet.
A resident with DM, dementia, and a physician-ordered mechanical soft diet with no mashed potatoes was observed being served and eating mashed potatoes at lunch. The meal ticket listed mashed potatoes, CNAs had been serving them, and the Dietary Manager, ST, and DON described breakdowns in how the diet order was entered and communicated to dietary.
Stained Carpeting Throughout Resident Areas: The facility failed to keep carpeting clean and free from stains in resident rooms, hallways, and common areas on the 100 and 200 halls. Interviews described long-standing spots and stains, infrequent shampooing, and no facility carpet shampooer, while the DON said a borrowed shampooer had been used near the end of June. Surveyors observed numerous dark marks, spill-like stains, and discolored areas in hallways, resident rooms, the lobby/lounge, Nursing Station, Therapy room, and other common areas.
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.
Mechanical Lift Sling Shortage Prevented Resident Transfers
Penalty
Summary
The facility failed to protect a resident’s dignity by not providing an available mechanical lift sling for transfers, which resulted in the resident remaining in bed despite her preference to get up and participate in daily activities. Resident 26 was cognitively intact, dependent for toileting and hygiene, required substantial to maximal assistance for lower body dressing, and was totally dependent on two-plus staff for transfers. Her care plan identified that she required a mechanical lift with two staff assistance, did not walk, and had personal preferences that included attending activities of her choice and having her desires honored within the parameters of safe care. Resident 26 reported that she had to stay in bed over the weekend because a full body sling was not available after her sling became soiled from incontinence and was sent to laundry. She stated she waited two days for the sling to be washed, air dried, and returned to the floor. She also stated this was not the first time she had been left in bed because of sling availability, and that she missed BINGO on a prior occasion. She preferred full body slings because split slings were uncomfortable, went under her knees, and caused knee pain; she also stated she felt unsafe in split slings because of her size and physical problems. Staff interviews confirmed that the facility had a limited supply of mechanical lift slings and that residents had been left in bed when slings were unavailable or in laundry. CNAs stated residents had to remain in bed due to sling shortages, and one CNA reported this was not the first incident. The DON and Administrator were unable to locate a sling inventory list, and the Administrator observed only three split slings and one shower sling in the linen closet. The facility policy stated residents should be treated with dignity and supported in choosing activities and ADLs, including mobility and toileting, but the resident was left in bed when the needed sling was not available.
Failure to Provide Ordered Adaptive Dining Equipment
Penalty
Summary
The facility failed to ensure ordered adaptive eating equipment was provided for one resident who had diagnoses including unspecified intellectual disabilities, vascular dementia, generalized muscle weakness, and oropharyngeal dysphagia. The resident’s current orders directed use of built up handled utensils, a one-handled cup with spout, a scoop bowl, and a plate with suction base at all meals, and the care plan also listed these adaptive dining items. However, during observations on two separate lunch meals, the resident was served and used regular plates, bowls, cups, and utensils, and no adaptive dining equipment was observed in the dining room. Record review showed the resident’s annual MDS assessment indicated severe cognitive impairment and independence with eating. Interviews with CNA staff showed they were aware the resident fed himself but did not use specialty items during dining service, and one CNA stated everyone in the main dining room used regular dining ware. The DON stated the adaptive dining equipment was listed on the resident’s Kardex and that dietary staff were responsible for providing it at meals, while the Administrator reviewed the dietary slip and noted the adaptive dining equipment was not listed even though it should have been. Facility policies stated residents were to be provided the proper assistive devices identified by the care plan and that adaptive devices would be provided for residents who need or request them.
Failure to Provide Mechanical Lift Sling for Dependent Resident Transfers
Penalty
Summary
The facility failed to provide transfer assistance to a dependent resident who required a mechanical lift for bed-to-wheelchair and wheelchair-to-bed transfers. Resident 26 was cognitively intact, had diagnoses including muscle wasting and atrophy, a lower femur fracture, morbid obesity, muscle weakness, and anxiety, and was assessed as totally dependent on two-plus persons for transfers. Her care plan directed that she receive a mechanical lift with two staff assistance for transfers and that she be provided toileting devices as appropriate. During interview, Resident 26 stated she had been left in bed over the previous weekend because a mechanical lift sling was not available. She reported that she had soiled her sling due to incontinence and then waited two days for it to be washed, air dried, and returned to the floor. She also stated this was not the first time she had been unable to get out of bed because of sling availability, and that she became very stiff after being in bed for a prolonged period. She said she missed BINGO on a prior occasion because of the same issue and that slings were often in laundry for 24 to 48 hours. Staff interviews confirmed that the facility had a limited supply of full body slings and that residents had been left in bed when slings were unavailable or being laundered. CNAs reported that Resident 26 stayed in bed because a full body sling was in the wash and that another sling that fit properly was unavailable. The DON and Administrator were unable to account for the sling inventory, and an observation of the linen closet found only three split slings and one shower sling, with only one sling numbered. The facility policy stated residents unable to perform ADLs independently would be provided appropriate care and assistance with mobility and elimination in accordance with the plan of care.
Diet Order Not Followed for Resident with Diabetes and Dementia
Penalty
Summary
The facility failed to ensure a physician-ordered diet was followed for a resident with type 2 diabetes mellitus without complications, vitamin B12 deficiency anemia, and dementia. The resident’s current orders included a regular diet with mechanical soft texture, no mashed potatoes, straws with liquids, and small sips given on the right side of the mouth. The quarterly MDS indicated the resident was severely cognitively impaired and required supervision and cueing with eating. The nutritional care plan identified the resident as at risk for malnutrition related to chronic disease, a body mass index greater than 25, and altered carbohydrate metabolism from diabetes, and included interventions to provide the diet as ordered and have the RD evaluate diet changes as needed. During dining observations, the resident was served and ate mashed potatoes and gravy despite the order for no mashed potatoes. The resident’s lunch meal ticket listed mashed potatoes as the starch, and CNA 3 stated she assisted the resident with eating the mashed potatoes and that he had received mashed potatoes on his meal trays other times she had worked. The Dietary Manager stated she had not been aware of the no mashed potatoes order and that the diet card listed mashed potatoes for serving. The ST stated she did not know how the no mashed potatoes order was entered and had not investigated it further, and the DON stated the diet orders should have been followed and the resident should not have received mashed potatoes.
Stained Carpeting Throughout Resident Areas
Penalty
Summary
The facility failed to ensure carpeting in resident rooms, hallways, and common areas was clean and free from stains on both the 100 hall and 200 hall. During confidential interviews, staff and others reported that hallway carpets had spots and stains, that the carpet had not been shampooed often, that dark spots had been present for over a year and a half, and that the facility did not have a way to shampoo carpets. Resident Council meeting minutes for May, June, and July 2025 also reflected concerns about the frequency and thoroughness of room cleaning and floor cleaning. During the environmental tour on 8/6/25, surveyors observed numerous stained and discolored carpet areas throughout the facility. Findings included dark brown quarter-sized marks in the Theater Room, grayish discoloration at resident room thresholds, spill-like marks and smudges in hallways, and multiple discolored areas in unoccupied resident rooms. Additional observations included large dark marks in the 200 hallway, staining outside the shower room threshold, discoloration in the Entrance Lobby/Lounge, Nursing Station, Administrator's office area, Therapy room, and the 100 Hall/Secured Dementia Unit. The carpet in the combination Lounge and Dining room and the small lounge by the 100 hall nursing station also had visible stains and dark marks. During interview, the DON stated the facility had borrowed a carpet shampooer from a sister facility and shampooed carpets near the end of June 2025. A professional carpet cleaning statement provided by the Administrator indicated the carpeting in the three halls, lobby, Nurses Station, Office, and a spot in the Therapy Room was last professionally cleaned on 11/5/24. The citation was related to Intake 2578686.
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.
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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 Hartford City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Hartford City Skilled Nursing Facility | 1.7 mi | ★★★★★ | 1 | 0 |
| University Nursing Center | 7.3 mi | ★★★★★ | 18 | 1 |
| Waters Of Dunkirk Skilled Nursing Facility, The | 9.6 mi | ★★★★★ | 3 | 1 |
| Albany Health Care & Rehabilitation Center | 12.3 mi | ★★★★★ | 13 | 0 |
| Twin City Health Care | 13.1 mi | ★★★★★ | 2 | 0 |
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