Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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 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.
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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 | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.