Inspection Reports for
Envive of Hartford City
715 N MILL ST, HARTFORD CITY, IN, 47348
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
21.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
417% worse than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 7, 2025
Visit Reason
The inspection was conducted due to a complaint alleging abuse involving Resident B, specifically that CNAs yelled at the resident and made inappropriate comments about her incontinence.
Complaint Details
The complaint involved allegations that CNAs yelled at Resident B and made inappropriate comments about her incontinence. The resident and her representative reported the incident. The facility delayed reporting the abuse to the State Agency and did not fully investigate or document the allegations. The CNAs involved were suspended pending investigation.
Findings
The facility failed to timely report the allegation of abuse to the State Agency and did not conduct a thorough investigation or implement immediate interventions to prevent potential abuse while the investigation was ongoing. The investigation lacked statements from all involved staff and did not fully document the abuse allegations.
Deficiencies (2)
F 0609: The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe after the incident involving Resident B was reported.
F 0610: The facility failed to conduct a thorough investigation of the abuse allegation involving Resident B and did not implement immediate interventions to prevent potential abuse during the investigation.
Report Facts
Date of incident: Oct 27, 2025
Date of investigation initiation: Oct 27, 2025
Date of survey completion: Nov 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 9 | Registered Nurse | Reported the incident to the Administrator and participated in the investigation of the abuse allegation involving Resident B. |
| CNA 3 | Certified Nursing Assistant | Named in the abuse allegation and participated in care of Resident B; statement missing from initial investigation. |
| CNA 5 | Certified Nursing Assistant | Named in the abuse allegation and participated in care of Resident B; had previous report of swearing in the hall. |
| Administrator | Facility Administrator | Received report of abuse, delayed reporting to State Agency, initiated investigation, and suspended CNAs. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 26, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, dignity, activities of daily living, nutrition, and provision of ordered adaptive equipment.
Findings
The facility was found to have minimal harm deficiencies related to failure to provide necessary mechanical lift slings resulting in residents being left in bed, failure to provide ordered adaptive eating equipment, failure to provide transfer assistance to a dependent resident, and failure to follow physician-ordered diet instructions for a resident.
Deficiencies (4)
F 0550: The facility failed to protect a resident's dignity by not providing necessary mechanical lift slings, causing a resident to remain in bed against her preferences for daily activities.
F 0676: The facility failed to ensure ordered adaptive eating equipment was provided for a resident, who was served regular utensils and plates instead.
F 0677: The facility failed to provide transfer assistance to a dependent resident due to lack of mechanical lift slings, resulting in the resident being left in bed for prolonged periods.
F 0692: The facility failed to ensure the physician-ordered diet was followed for a resident, who was served mashed potatoes despite an order for no mashed potatoes.
Report Facts
Facility mechanical lift slings: 21
Mechanical lift sling shortage duration: 24
Residents reviewed: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 11 | Reported limited supply of mechanical lift slings and lack of adaptive dining equipment use. | |
| CNA 5 | Reported residents had to stay in bed due to lack of mechanical lift slings. | |
| DON | Director of Nursing | Provided information about mechanical lift sling oversight and adaptive dining equipment. |
| Administrator | Provided information about mechanical lift sling inventory and adaptive dining equipment. | |
| RN 12 | Registered Nurse | Unaware of resident being left in bed due to lack of mechanical lift sling. |
| CNA 13 | Reported resident left in bed due to lack of mechanical lift sling. | |
| CNA 3 | Reported resident left in bed due to lack of mechanical lift sling and checked laundry. | |
| CNA 3 | Assisted resident with eating mashed potatoes despite diet order. | |
| Dietary Manager | Unaware of resident's no mashed potatoes diet order and explained dietary communication process. | |
| Speech Therapist | Entered diet order and discussed confusion about no mashed potatoes order. | |
| RN 7 | Registered Nurse | Confirmed diet order process and communication to dietary. |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to assess the cleanliness and safety of the nursing home environment, specifically focusing on the condition of carpeting in resident rooms, hallways, and common areas.
Findings
The facility failed to ensure that carpeting in resident rooms, hallways, and common areas was clean and free from stains. Multiple areas throughout the facility had dark spots, stains, and discoloration on carpets, which had not been professionally cleaned since November 2024, with only occasional shampooing reported.
Deficiencies (1)
F 0921: The facility failed to maintain clean and stain-free carpeting in resident rooms, hallways, and common areas, with numerous dark spots and discolorations observed throughout multiple areas. This condition had the potential to impact all 25 residents in the facility.
Report Facts
Residents potentially impacted: 25
Date of last professional carpet cleaning: Nov 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding carpet cleaning frequency and facility's carpet shampooing practices |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459469.
Complaint Details
Complaint IN00459469 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 20
Census Payor Type - Other: 5
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 0
Date: May 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457843.
Complaint Details
Complaint IN00457843 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 4
Medicaid residents: 20
Other payor residents: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 11, 2025
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00453004 completed on March 13, 2025.
Complaint Details
Investigation of Complaint IN00453004 was completed with findings of compliance.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456841.
Complaint Details
Complaint IN00456841 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 31
Total Capacity: 31
Medicare Census: 2
Medicaid Census: 21
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 29
Capacity: 29
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The visit was conducted for the investigation of Complaints IN00453004 and IN00453733. Complaint IN00453004 resulted in federal/state deficiencies cited, while Complaint IN00453733 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00453004 was substantiated with federal/state deficiencies cited at F761. Complaint IN00453733 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure resident medications were properly labeled and disposed of for 1 of 3 medication carts observed. Specifically, an uncovered paper medication cup with medications was found in the medication cart, indicating failure to destroy refused medications immediately as required by policy.
Deficiencies (1)
Facility failed to ensure resident medications were properly labeled and disposed of for 1 of 3 medication carts observed.
Report Facts
Census: 29
Licensed Capacity: 29
Medicare Residents: 4
Medicaid Residents: 21
Other Payor Residents: 4
Medication Cart Audits Frequency: 5
Medication Cart Audits Frequency: 3
Medication Cart Audits Frequency: 2
Date of Completion: Apr 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Director of Nursing | Interviewed regarding medication disposal procedures | |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding observation of medication cart |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00453004) regarding medication management practices at the facility.
Complaint Details
This citation relates to Complaint IN00453004.
Findings
The facility failed to ensure that resident medications were properly labeled and disposed of on one of three medication carts observed. Specifically, medications refused by a resident were not destroyed immediately as required by facility policy and professional standards.
Deficiencies (1)
F 0761: The facility failed to ensure drugs and biologicals were labeled according to accepted professional principles and stored in locked compartments. Medications refused by a resident were not destroyed immediately and were found in an uncovered paper cup in the medication cart.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication destruction policy and practice. | |
| LPN 3 | Interviewed regarding observation of medication cart and medication refusal. |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 78
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
An Emergency Preparedness Survey was conducted including a Complaint Survey for complaint number IN00453892. The complaint investigation was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
Complaint Number IN00453892 was unsubstantiated.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The complaint was unsubstantiated. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 78
Census: 30
Inspection Report
Re-Inspection
Census: 29
Capacity: 78
Deficiencies: 2
Date: Jan 31, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/05/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. Two deficiencies related to ramps and sprinkler system maintenance were noted but temporarily waived.
Deficiencies (2)
Ramps and Other Exits did not meet requirements per NFPA 101 provisions 7.2.5 through 7.2.12 and 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10.
Sprinkler System - Maintenance and Testing not in compliance with NFPA 25 standards; records and testing details missing.
Report Facts
Facility capacity: 78
Census: 29
Inspection Report
Complaint Investigation
Census: 26
Capacity: 26
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450281.
Complaint Details
Complaint IN00450281 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 26
Total Capacity: 26
Medicare Residents: 1
Medicaid Residents: 19
Other Payor Residents: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 13, 2025
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey and the Investigation of Complaint IN00444162 completed on November 8, 2024.
Complaint Details
Investigation of Complaint IN00444162 was completed and found to be in compliance.
Findings
Envive of Hartford City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey and the complaint investigation.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 24
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448147.
Complaint Details
Complaint IN00448147 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 24
Total Capacity: 24
Medicaid Census: 19
Other Payor Census: 5
Inspection Report
Annual Inspection
Census: 29
Capacity: 78
Deficiencies: 7
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as an Annual Survey including Emergency Preparedness, Life Safety Code Recertification, and State Licensure Survey to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including non-compliant exit ramps, inadequate fire alarm system testing, sprinkler system maintenance issues, smoke barrier penetrations, HVAC fire damper failures, dryer room combustion air intake issues, and malfunctioning electrical system indicator lights.
Deficiencies (7)
Ramps in 2 of 6 exit discharges did not meet Life Safety Code provisions; ramps lacked handrails and had excessive slope.
Fire alarm system initiating devices, specifically heat detectors, were not tested in accordance with NFPA 72 schedules.
Automatic sprinkler systems were not maintained per NFPA 25; several sprinkler heads tested abnormal and replacement documentation was lacking.
One of five smoke barrier walls was not protected to maintain fire resistance rating due to unsealed penetrations above corridor door.
Six of 44 fire dampers failed inspection and repair/replacement documentation was not available.
Dryer room lacked continuous intake combustion air due to disconnected mechanical arm on intake vent.
Automatic transfer switch indicator lights were not illuminated to indicate switch position.
Report Facts
Facility capacity: 78
Census: 29
Deficiencies cited: 7
Ramp measurements: 25.5
Ramp rise: 7
Ramp measurements: 6.6
Ramp rise: 9
Number of heat detectors: 9
Number of fire dampers: 44
Number of failed fire dampers: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed as Laboratory Director or Provider/Supplier Representative |
| Director of Maintenance | Named in multiple findings related to ramp measurements, fire alarm testing, sprinkler system, smoke barrier, fire dampers, HVAC, and electrical system | |
| Field Maintenance Supervisor | Named in multiple findings related to ramp measurements, fire alarm testing, sprinkler system, smoke barrier, fire dampers, HVAC, and electrical system | |
| Administrator | Participated in observations and exit conference | |
| Director of Nursing | Participated in observations and exit conference |
Inspection Report
Annual Inspection
Census: 33
Capacity: 33
Deficiencies: 5
Date: Nov 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00444162.
Complaint Details
Complaint IN00444162 was investigated, with federal/state deficiencies related to the allegations cited at F684.
Findings
The facility was found deficient in following physician orders for resident care, timely addressing pharmacy recommendations, ensuring non-pharmacological interventions prior to PRN psychoactive medication administration, infection prevention during insulin administration, and accurate documentation of mandatory tuberculin skin tests for employees.
Deficiencies (5)
Facility failed to follow physician's orders for 1 of 16 residents reviewed for resident choices.
Facility failed to ensure pharmacy recommendations were reviewed and addressed in a timely manner for 2 of 5 residents reviewed for unnecessary medications.
Facility failed to ensure non-pharmacological interventions were attempted prior to administration of PRN psychoactive medication for 2 of 5 residents reviewed.
Facility failed to utilize infection prevention and control procedures during insulin administration for 2 of 4 residents reviewed for medication administration.
Facility failed to accurately document the administration and results of mandatory tuberculin skin tests performed on 4 of 5 new employee files reviewed.
Report Facts
Residents reviewed for choices: 16
Residents reviewed for unnecessary medications: 5
Residents reviewed for medication administration: 4
New employee files reviewed: 5
Facility census: 33
Facility total capacity: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed the report |
| LPN 7 | Interviewed regarding PRN medication and TB test procedures | |
| RN 8 | Interviewed regarding PRN medication and TB test procedures | |
| DON | Director of Nursing | Interviewed regarding follow-up on physician orders, PRN medication administration, and TB test documentation |
| Vice President of Clinical Services | Interviewed regarding facility policies and physician order follow-up | |
| Vice President of Clinical Operations | Interviewed regarding insulin pen administration | |
| DNS | Director of Nursing Services | Educated on multiple deficiencies and responsible for monitoring compliance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 8, 2024
Visit Reason
The inspection was conducted in response to complaint IN00444162 regarding failure to follow physician's orders and failure to follow up on resident concerns.
Complaint Details
This citation relates to complaint IN00444162.
Findings
The facility failed to provide compression wraps as ordered for one resident with swelling in lower extremities and failed to follow up on a resident's request for pain medication adjustment. The facility lacked a policy for following physician orders and did not timely respond to resident requests.
Deficiencies (2)
F 0684: The facility failed to follow physician's orders for compression wraps for one resident with chronic peripheral venous insufficiency. Compression wraps were not applied as ordered until several days after the order was received.
F 0684: The facility failed to follow up on a resident's increased pain complaint and request for gabapentin. No new order or physician response was documented.
Report Facts
Residents reviewed: 16
Pain level: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding follow-up on physician orders and facility policy. | |
| President of Clinical Services | Interviewed regarding facility policy on following physician orders. | |
| Licensed Practical Nurse (LPN) 7 | Described process for physician communication and follow-up on resident requests. | |
| Registered Nurse (RN) 8 | Described documentation process for resident complaints and physician notifications. | |
| CNA 9 | Reported no knowledge or observation of compression wraps on resident during care. | |
| LPN 11 | Notified physician about resident's increased pain. |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 8, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication regimen review, psychotropic medication use, infection prevention and control, and related regulatory requirements.
Findings
The facility failed to ensure timely review and physician response to pharmacy recommendations for unnecessary medications for two residents. Non-pharmacological interventions were not attempted prior to administration of PRN psychotropic medications for two residents. Infection prevention procedures were not followed during insulin administration for two residents.
Deficiencies (3)
F 0756: The facility failed to ensure pharmacy recommendations were reviewed and addressed timely for 2 of 5 residents regarding unnecessary medications. Physician notification and response documentation were lacking for medication regimen reviews dated 8/19/24 and 10/21/24.
F 0758: The facility failed to ensure non-pharmacological interventions were attempted prior to administration of PRN psychoactive medications for 2 of 5 residents. Clinical records lacked documentation of interventions prior to PRN medication administration.
F 0880: The facility failed to implement infection prevention procedures during insulin administration for 2 of 4 residents. Insulin pen rubber stoppers were not cleansed prior to needle attachment as required by manufacturer guidelines.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for medication administration: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding pharmacy medication regimen review process and psychotropic medication interventions | |
| RN 5 | Observed administering insulin without cleansing insulin pen rubber stopper | |
| Licensed Practical Nurse (LPN) 7 | Interviewed about PRN medication interventions | |
| Registered Nurse (RN) 8 | Interviewed about PRN medication administration procedures | |
| [NAME] President of Clinical Operations | Interviewed regarding insulin pen cleansing procedures |
Inspection Report
Original Licensing
Census: 32
Capacity: 78
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
A Preoccupancy Survey was conducted for the addition of a locked separation door for a memory care unit including specific rooms, to ensure compliance with regulatory requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility is fully sprinklered with appropriate smoke detection systems.
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 0
Date: Aug 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440908.
Complaint Details
Complaint IN00440908 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 36
Medicare Census: 7
Medicaid Census: 24
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438237 at Envive of Hartford City.
Complaint Details
Complaint IN00438237 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 36
Medicare residents: 4
Medicaid residents: 25
Other payor residents: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 22, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00432995 completed on June 17, 2024.
Complaint Details
Investigation of Complaint IN00432995 completed on June 17, 2024; facility found in compliance.
Findings
Envive of Hartford City 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 Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 17, 2024
Visit Reason
The inspection was conducted due to a complaint alleging failure to report suspected abuse involving residents at the facility.
Complaint Details
This citation relates to Complaint IN00432995. The allegation was not substantiated because the resident changed her story during the investigation.
Findings
The facility failed to report an abuse allegation involving Resident D and Resident B to the Indiana Department of Health. Resident D reported being pushed and threatened by Resident B, but the allegation was not reported because Resident D changed her story during the investigation.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. This involved an abuse allegation between two residents that was not reported to the state agency.
Report Facts
Residents affected: 4
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Jun 14, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432995 and IN00434633 at Envive of Hartford City.
Complaint Details
Complaint IN00432995 was substantiated with deficiencies related to abuse reporting. Complaint IN00434633 was not substantiated with any deficiencies.
Findings
The facility failed to ensure an abuse allegation was reported to the Indiana Department of Health for 1 of 4 residents reviewed for abuse. Complaint IN00432995 resulted in federal/state deficiencies cited, while Complaint IN00434633 had no deficiencies related to the allegations.
Deficiencies (1)
Failure to report an abuse allegation to the Indiana Department of Health in a timely manner for 1 of 4 residents reviewed for abuse.
Report Facts
Census: 41
Medicare residents: 6
Medicaid residents: 22
Other residents: 13
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428406 and IN00427956.
Complaint Details
Complaint IN00428406 - No deficiencies related to the allegations are cited. Complaint IN00427956 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00428406 and IN00427956 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 39
Census total residents: 39
Census Medicare residents: 2
Census Medicaid residents: 22
Census Other payor residents: 15
Inspection Report
Life Safety
Census: 34
Capacity: 78
Deficiencies: 0
Date: Feb 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/08/24 by the Indiana Department of Health.
Findings
Envive of Hartford City was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Re-Inspection
Census: 33
Capacity: 33
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on December 19, 2023.
Findings
Envive of Hartford City 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.
Report Facts
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 3
Inspection Report
Life Safety
Census: 30
Capacity: 78
Deficiencies: 7
Date: Jan 8, 2024
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 and fire protection requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including maintenance of smoke barrier doors, documentation of smoke alarm maintenance, corridor door latching, fire extinguisher installation, smoke barrier penetrations, and ground fault circuit interrupter (GFCI) protection in wet locations. Immediate interventions were taken and plans of correction were submitted.
Deficiencies (7)
Failed to maintain latching hardware on 1 of 5 smoke barrier doors which did not close and latch properly.
Failed to ensure documentation for preventative maintenance of all battery operated smoke alarms on 100 Hall was complete.
Failed to maintain 1 of 3 corridor doors for cooking facilities to ensure they are protected and not open to the corridor.
Failed to ensure 1 portable fire extinguisher in the maintenance shop was installed and secured per NFPA standards.
Failed to ensure 1 corridor door to janitor closet would close and latch into the frame.
Failed to ensure penetrations caused by wire/conduit through 1 of 5 smoke barrier walls were protected to maintain smoke resistance.
Failed to ensure 3 of over 10 wet locations were provided with functioning ground fault circuit interrupter (GFCI) protection.
Report Facts
Facility capacity: 78
Census: 30
Number of smoke barrier doors inspected: 5
Number of corridor doors for cooking facilities: 3
Number of portable fire extinguishers in maintenance shop: 1
Number of smoke barrier walls with penetrations: 5
Number of wet locations without GFCI protection: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed as Laboratory Director's or Provider/Supplier Representative's Signature |
| Director of Maintenance | Named in multiple findings related to repairs and corrective actions for smoke doors, smoke alarms, fire extinguishers, corridor doors, smoke barrier penetrations, and GFCI replacements | |
| Administrator | Participated in exit conferences and interviews regarding findings | |
| Executive Director | Provided education to Director of Maintenance on corrective actions |
Inspection Report
Annual Inspection
Census: 30
Capacity: 30
Deficiencies: 7
Date: Dec 19, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted December 13-19, 2023.
Findings
The facility was found deficient in multiple areas including residents' right to receive mail on Saturdays, trauma-informed care for a resident with PTSD, ensuring 8 consecutive hours of RN coverage daily, individualized non-pharmacological interventions for dementia care, proper medication storage and disposal, food storage temperatures, and offering the latest COVID-19 vaccines to residents.
Deficiencies (7)
Facility failed to ensure residents’ right to receive mail on Saturdays was maintained for 9 of 9 residents interviewed during a resident council meeting.
Facility failed to ensure a resident with PTSD received care to mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed for trauma informed care.
Facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 30 of 30 residents.
Facility failed to ensure a resident received individualized, non-pharmacological interventions for dementia-type behaviors before increasing psychoactive medications for 2 of 5 residents reviewed for dementia care.
Facility failed to ensure residents’ medications were properly disposed of or sent back to pharmacy for credit for 1 of 1 medication storage rooms observed.
Facility failed to ensure the appropriate storage of refrigerated foods using a refrigerator unable to maintain refrigeration at safe levels. The deficiency had the potential to affect 30 of 30 residents.
Facility failed to ensure residents were offered the latest and recommended COVID-19 vaccine for 4 of 5 residents reviewed for COVID-19 vaccinations.
Report Facts
Census: 30
Total Capacity: 30
Deficiency Count: 7
Refrigerator Temperature: 46
Refrigerator Temperature Range: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed report |
| LPN 7 | Interviewed regarding trauma informed care and resident behaviors | |
| LPN 52 | Interviewed regarding resident behaviors and medication | |
| Administrator | Interviewed regarding mail delivery and refrigerator issues | |
| Social Service Director | Interviewed regarding trauma informed care and behavior monitoring | |
| DON | Director of Nursing | Interviewed regarding RN coverage, trauma informed care, medication storage, and COVID-19 vaccine |
| Business Office Manager | Interviewed regarding RN coverage coding | |
| Dietary Manager | Interviewed regarding refrigerator temperatures and food storage | |
| Maintenance Director | Interviewed regarding refrigerator maintenance |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 19, 2023
Visit Reason
Routine inspection of Envive of Hartford City nursing home to assess compliance with regulatory requirements including resident rights, trauma informed care, RN coverage, dementia care, medication management, food safety, and COVID-19 vaccination.
Findings
The facility had multiple deficiencies including failure to ensure residents received mail on Saturdays, inadequate trauma informed care for a resident with PTSD, lack of RN coverage for 8 consecutive hours on several days, insufficient individualized dementia care before increasing psychoactive medications, improper medication storage and disposal, unsafe refrigerator temperatures for food storage, and failure to offer the latest COVID-19 vaccine to eligible residents.
Deficiencies (8)
F 0576: Facility failed to ensure residents' right to receive mail on Saturdays for 9 of 9 residents interviewed.
F 0699: Facility failed to provide trauma informed care to a resident with PTSD by not identifying triggers or interventions to mitigate re-traumatization.
F 0727: Facility failed to ensure a Registered Nurse worked 8 consecutive hours on multiple days, potentially affecting 30 residents.
F 0744: Facility failed to provide individualized non-pharmacological interventions before increasing psychoactive medications for residents with dementia-related behaviors.
F 0758: Facility failed to implement gradual dose reductions and non-pharmacological interventions prior to increasing psychotropic medication for a resident.
F 0761: Facility failed to ensure biologicals requiring refrigeration were monitored per CDC guidelines and failed to properly dispose of or return medications to pharmacy.
F 0812: Facility failed to maintain refrigerator temperatures at safe levels, resulting in unsafe food storage and disposal of refrigerated foods.
F 0887: Facility failed to offer the latest and recommended COVID-19 vaccine to eligible residents and properly document vaccination status.
Report Facts
Residents affected: 9
Residents affected: 1
Residents affected: 30
Residents affected: 5
Residents affected: 5
Residents affected: 30
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Interviewed about resident behavior triggers and interventions |
| Social Service Director | Social Service Director | Interviewed about resident behavior monitoring and trauma informed care |
| DON | Director of Nursing | Interviewed about RN coverage, trauma informed care, and COVID-19 vaccine offering |
| Business Office Manager | Business Office Manager | Interviewed about RN coverage coding |
| LPN 52 | Licensed Practical Nurse | Interviewed about resident behaviors and medication |
| Dietary Manager | Dietary Manager | Interviewed about refrigerator temperatures and food storage |
| Maintenance Director | Maintenance Director | Interviewed about refrigerator malfunction and thawing |
| Administrator | Facility Administrator | Interviewed about refrigerator malfunction and COVID-19 vaccine offering |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 7, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00420684 completed November 3, 2023.
Complaint Details
Investigation of Complaint IN00420684 completed November 3, 2023; facility found in compliance.
Findings
Envive of Hartford City 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 Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Nov 3, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00420684 regarding allegations related to treatment and service for dementia.
Complaint Details
Complaint IN00420684 was substantiated with federal/state deficiencies cited related to treatment/service for dementia and failure to implement individualized care plans for sexually inappropriate behaviors.
Findings
The facility failed to develop and implement individualized interventions for a cognitively impaired resident (Resident C) who displayed sexually inappropriate behaviors. The investigation included interviews and record reviews documenting multiple incidents of inappropriate sexual behavior and inadequate care planning.
Deficiencies (1)
Failed to develop and implement individualized interventions for a cognitively impaired resident who displayed sexual behaviors.
Report Facts
Census: 31
Medicare residents: 3
Medicaid residents: 22
Other residents: 6
Deficiency completion date: Dec 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 3, 2023
Visit Reason
The inspection was conducted in response to Complaint IN00420684 regarding the facility's failure to provide appropriate treatment and services to a resident diagnosed with dementia who displayed sexual behaviors.
Complaint Details
This citation relates to Complaint IN00420684.
Findings
The facility failed to develop and implement individualized interventions for a cognitively impaired resident (Resident C) exhibiting sexually inappropriate behaviors. Multiple interviews and clinical record reviews documented ongoing sexual behaviors, inadequate intervention, and attempts to manage the resident's behaviors with limited success.
Deficiencies (1)
F0744: The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia who displayed sexual behaviors. Resident C exhibited sexually inappropriate behaviors including exposing herself and inappropriate touching of other residents, and the facility's interventions were insufficient to fully manage these behaviors.
Report Facts
Deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419149 and IN00419153.
Complaint Details
Investigation of Complaints IN00419149 and IN00419153 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00419149 and IN00419153 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 37
Total Capacity: 37
Medicare Census: 6
Medicaid Census: 25
Other Payor Census: 6
Inspection Report
Re-Inspection
Census: 31
Capacity: 31
Deficiencies: 0
Date: Mar 31, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on February 10, 2023.
Findings
Envive of Hartford City 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.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 4
Inspection Report
Re-Inspection
Census: 31
Capacity: 78
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/21/23 was performed by the Indiana Department of Health.
Findings
At this Life Safety Code Survey, Envive of Hartford City was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Life Safety
Census: 33
Capacity: 78
Deficiencies: 8
Date: Feb 21, 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 fire safety and life safety code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including malfunctioning self-closing corridor doors, lack of current inspection certificates for fuel fired water heaters, exposed wiring in the kitchen, missing annual fire door inspections, untested non-hospital grade electrical receptacles in resident rooms, and improper use of extension cords and power strips.
Deficiencies (8)
Corridor door to kitchen dishwashing room self-closing device not functioning properly, door would not latch.
Resident room 201 corridor door would not close due to bed obstruction.
Four fuel fired water heaters lacked current inspection certificates; last certificates expired 03/13/21.
Exposed wiring on refrigerator/freezer plug in kitchen.
Annual inspection and testing of fire door assemblies not completed; last inspection in 2021.
Non-hospital grade electrical receptacles in 39 resident sleeping rooms were not tested annually.
Flexible cords used as substitute for fixed wiring in kitchen; freezer plugged into extension cord.
Power strip in activity room did not meet UL-1363 standards.
Report Facts
Facility capacity: 78
Census: 33
Fuel fired water heaters: 4
Resident sleeping rooms: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Bledsoe | Executive Director | Named in relation to review of findings during exit conference |
| Maintenance Director | Interviewed and involved in observations related to deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 30
Capacity: 30
Deficiencies: 3
Date: Feb 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 6 to 10, 2023.
Findings
The facility was found deficient in following the grievance process for a resident-reported concern regarding edema, failure to prevent and treat pressure ulcers for one resident, and failure to administer ordered medications for one resident. Corrective actions and plans of correction were submitted for these deficiencies.
Deficiencies (3)
Facility failed to follow the grievance process for a resident-reported concern for 1 of 2 residents reviewed for edema (Resident 27).
Facility failed to prevent the development and progression of pressure injuries for 1 of 5 residents reviewed for pressure injuries (Resident 25).
Facility failed to administer ordered medications for 1 of 5 residents reviewed for unnecessary medications (Resident 3).
Report Facts
Census: 30
Total Capacity: 30
Survey Dates: 5
Medication doses unavailable: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Bledsoe | Executive Director | Signed the report |
| CNA 6 | Reported resident's swelling and discomfort with elevation methods | |
| Maintenance Manager | Discussed recliner availability and resident requests | |
| CNA 7 | Reported resident's frequent requests for recliner or foot elevation | |
| Registered Nurse 9 | Noted resident edema and lack of recliner | |
| ADON | Assistant Director of Nursing | Discussed grievance process and recliner policy |
| DON | Director of Nursing | Discussed grievance process and recliner availability |
| Social Services Director | Explained grievance process and resident recliner requests | |
| LPN 4 | Observed pressure injuries and discussed medication administration | |
| CNA 12 | Encouraged resident to wear heel boots | |
| CNA 6 | Encouraged resident to wear heel boots | |
| LPN 2 | Described medication unavailability and notification process | |
| LPN 3 | Described medication unavailability and notification process |
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