Envive Of Hartford City

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review and interview, the facility failed to report an allegation of abuse to the State Agency within the required time frame. (Resident B) Findings include A facility reported incident, dated 10/27/25 at 4:19 p.m., submitted to the Indiana Department of Health indicated an incident occurred on 10/27/25 at 3:01 p.m. The reported incident indicated the following: On 10/27/25 Resident B reported to the Administrator that CNAs yelled at her on 10/26/25. On 10/27/25 an investigation was initiated, and the CNAs were suspended pending the investigation outcome. Review of the facility's abuse investigation file, provided on 11/6/25 at 11:49 a.m., included the following: RN 9's statement indicated Resident B's representative approached the nurses station on 10/26/25 at approximately 1:00 p.m. and asked to talk to someone about a concern she had regarding the resident. Resident B had reported to her that Resident B had overheard, at lunch, the CNAs say from around a corner that she was old enough and should not be peeing herself, and that they were not going to continue to get her up and down like a yo-yo. During an interview, on 11/7/25 at 2:13 p.m., RN 9 indicated on 10/26/25, after lunch, the CNAs were taking residents from the dining room to their rooms. Resident B's representative asked to speak to the Administrator. The resident's representative indicated Resident B had told her the CNAs had said Resident B was old enough to hold her urine, and they had to keep getting her up and down like a yo-yo to go to the bathroom. During

an interview, on 11/7/25 at 2:24 p.m., RN 9 indicated she had let the Administrator know about the incident

on 10/26/25 at 1:26 p.m., according to the date and time on her phone. During an interview, on 11/7/25 at 3:30 p.m., the Administrator indicated she had received a text from RN 9 about the incident with Resident B

on 10/26/25. She had spoken to RN 9 and the Resident B's representative on 10/26/25. RN 9 indicated Resident B was not overly upset. The Administrator had not believed this was abuse, but more of a customer service issue since Resident B had overheard something. Once she spoke to Resident B on 10/27/25 at 3:00 p.m., and Resident B indicated the CNAs yelled at her, cried, and indicated she did not want the CNAs to be fired, the Administrator decided the situation was possible abuse. She began the investigation and notified the State Agency at that time. A current facility policy, dated 8/2024, titled Abuse, Neglect, Exploitation and Misappropriate, Reporting, and Investigating, provided by the Administrator on 11/6/25 at 4:23 p.m., indicated the following: .All reports of resident abuse (including injuries of unknow origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigation by facility management.

Findings of all investigation are documented and reported.If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. ‘Immediately' is defined as: h. within two hours of an allegation involving abuse. Cross Reference F-F610. This citation relates to Intake 2657526. 3.1-28(c)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Envive of Hartford City

715 N Mill St Hartford City, IN 47348

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

kept changing her story. On 10/27/25 at 3:00 p.m., she talked to Resident B. The resident cried and indicated she did not want the CNAs to be fired or get in trouble. The Administrator began the investigation and reported the incident at that time to the State agency. The Administrator had believed this was not abuse, but more of a customer service issue since Resident B had overheard something. However, once

she talked to Resident B, she felt like this was an abuse thing. The CNAs were suspended after the Administrator talked to Resident B. She had one previous report of CNA 5 swearing in the hall. The person who reported the swearing indicated no resident had been around when the swearing happened. The Administrator spoke with CNA 5 and told her swearing was not acceptable in the facility. She indicated it could be intimidating to bring alleged perpetrators into the resident's room for the resident to identify them.

She was uncertain why CNA 3's statement was not included in the investigation. She indicated all parties involved should be included to ensure a thorough investigation. The staff and resident interviews regarding

the abuse allegation were completed on the dates that were on the papers. A facility document, provided by

the Administrator on 11/7/25 at 3:54 p.m., was notes on an interview with CNA 3. The document indicated CNA 3 said she got up Resident B and put her to bed. The resident had said no, it was not the CNAs that said the statements about her incontinence. The CNAs always go into the resident's room and take care of her. A current facility policy, dated 8/2024, titled Abuse, Neglect, Exploitation and Misappropriate, Reporting, and Investigating, provided by the Administrator on 11/6/25 at 4:23 p.m., indicated the following: .All reports of resident abuse (including injuries of unknow origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigation by facility management. Findings of all investigation are documented and reported.All allegations are thoroughly investigated.Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. This citation relates to Intake 2657526. 3.1-28(d)

Event ID:

Facility ID:

If continuation sheet