Inspection Report Summary
The most recent inspection on June 2, 2025, identified multiple deficiencies related to medication management, care planning, assistance with daily living activities, infection prevention, and equipment maintenance. Earlier inspections showed a pattern of issues involving nursing staff coverage, medication errors, emergency preparedness, food safety, and resident care documentation. Complaint investigations included substantiated deficiencies for insufficient nursing staff certification in CPR, failure to follow advanced directives, and food temperature concerns, while most other complaints were unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history reflects ongoing challenges in clinical care and compliance areas without a clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 38
Capacity: 38
Deficiencies: 8
Date: Jun 2, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted May 27, 28, 29, 30 and June 2, 2025.
Findings
The facility was found to have multiple deficiencies including failure to complete AIMS assessments for residents on psychotropic medications, failure to conduct timely care plan meetings and updates, inadequate assistance with activities of daily living such as shaving, improper labeling and disposal of medications, failure to change and date oxygen equipment, administration of antibiotics past stop dates, incomplete tuberculin testing for residents, and lack of a designated Infection Preventionist nurse separate from the Director of Nursing.
Deficiencies (8)
Failed to ensure AIMS assessments were completed for 1 of 5 residents reviewed for unnecessary medications.
Failed to ensure care plan meetings were conducted quarterly for 1 of 16 residents and failed to ensure care plans were implemented and updated for 2 of 5 residents reviewed.
Failed to ensure residents were provided assistance to shave for 2 of 16 residents reviewed for ADL care.
Failed to ensure oxygen equipment was changed and dated according to facility policy for 1 of 1 residents reviewed for respiratory care.
Failed to ensure a resident's antibiotic was not administered past the stop date for 1 of 2 residents reviewed for antibiotic use.
Failed to ensure medications were labeled properly and expired medications were disposed of for 1 of 1 medication storage rooms and 2 of 3 medication carts reviewed.
Failed to ensure tuberculin testing was completed for 7 of 16 residents reviewed for immunizations and tuberculin testing administration.
Failed to ensure an Infection Preventionist nurse other than the Director of Nursing was designated to oversee the Infection Prevention and Antibiotic Stewardship programs within the facility.
Report Facts
Survey dates: 5
Census: 38
Total capacity: 38
Residents reviewed for AIMS assessments: 5
Residents reviewed for care plan meetings: 16
Residents reviewed for care plans: 5
Residents reviewed for ADL care: 16
Residents reviewed for respiratory care: 1
Residents reviewed for antibiotic use: 2
Medication doses delivered: 14
Residents reviewed for immunizations and TB testing: 16
Residents affected by lack of tuberculin testing: 7
Residents in facility: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Jo Parker | Executive Director | Signed the report |
| Licensed Practical Nurse 3 | Interviewed regarding AIMS assessments, ADL care, oxygen tubing, medication labeling, and insulin pen dating | |
| Director of Nursing | DON | Interviewed regarding AIMS assessments, care plans, oxygen use, antibiotic administration, infection preventionist role |
| Regional Nurse Consultant | Provided facility policies and interviewed about medication labeling and infection control | |
| Social Service Director | SSD | Interviewed regarding care plan meetings |
| Certified Nurse Aide 4 | Interviewed regarding resident shaving preferences | |
| Administrator | Interviewed regarding infection control policies and facility oversight |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 2, 2025.
Findings
Envive of Sullivan 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 for the Recertification and State Licensure Survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00451119, IN00451735, IN00450270, and IN00452377 completed on January 31, 2025.
Complaint Details
The visit was related to complaint investigations IN00451119, IN00451735, IN00450270, and IN00452377; compliance was found.
Findings
Envive of Sullivan 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 of the specified investigations.
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00451119, IN00451735, IN00450270, IN00449663, and IN00452377) regarding alleged deficiencies at the facility.
Complaint Details
The investigation involved complaints IN00451119, IN00451735, IN00450270, IN00449663, and IN00452377. Deficiencies related to complaints IN00451119, IN00451735, and IN00452377 were cited at F755 (Pharmacy Services). Complaint IN00450270 deficiencies were cited at F725 (Sufficient Nursing Staff). Complaint IN00449663 had no deficiencies cited.
Findings
The facility was found deficient in ensuring a licensed nurse was on duty 24 hours a day on one shift when two residents fell, and in timely reordering medications for one resident, resulting in medication unavailability. Some complaints were substantiated with deficiencies cited, while one complaint had no deficiencies related to the allegations.
Deficiencies (2)
Failed to ensure a licensed nurse was on duty 24 hours a day on 12/25/24, during which two residents fell.
Failed to ensure medications were reordered in a timely manner so they were available for administration for one resident.
Report Facts
Residents present: 42
Licensed capacity: 42
Residents affected by nursing staff deficiency: 42
Residents reviewed for pharmaceutical services: 18
Dates medication unavailable: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Jo Parker | Executive Director | Signed report as facility representative |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00448031 completed on December 20, 2024.
Complaint Details
Investigation of Complaint IN00448031; paper compliance review completed and found in compliance.
Findings
Envive of Sullivan 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 of the complaint investigation.
Report Facts
Complaint ID: 448031
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 1
Date: Dec 20, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00448031, IN00448448, and IN00448616) at Envive of Sullivan.
Complaint Details
Complaint IN00448031 was substantiated with deficiencies cited. Complaints IN00448448 and IN00448616 had no deficiencies related to the allegations.
Findings
The facility was found deficient related to Complaint IN00448031 for failing to ensure the temperature and palatability of food served, with food temperatures below the required 135 degrees Fahrenheit. No deficiencies were found related to the other two complaints.
Deficiencies (1)
Failed to ensure the temperature and palatability of food served for 1 of 1 test tray, with food temperatures measured below 135 degrees Fahrenheit.
Report Facts
Food temperature: 128
Food temperature: 118
Food temperature: 128
Census: 41
Total capacity: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Jo Parker | Executive Director | Signed the report as the facility representative. |
| Dietary Manager | Measured food temperatures and provided facility policy document. |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 36
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446401.
Complaint Details
Complaint IN00446401 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 census: 3
Medicaid census: 3
Other payor census: 30
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on April 19, 2024.
Findings
Envive of Sullivan 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 for the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 36
Capacity: 77
Deficiencies: 4
Date: May 9, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/09/2024 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were noted in emergency lighting testing documentation, battery-operated smoke alarm maintenance, sprinkler system maintenance, and ground fault circuit interrupter (GFCI) functionality.
Deficiencies (4)
Failed to ensure documentation for monthly 30-second testing of 3 battery backup emergency lights for February 2024.
Failed to ensure complete documentation for preventative maintenance of 31 battery operated smoke alarms in resident rooms.
Failed to maintain automatic sprinkler systems; 6 sprinkler heads in the kitchen showed corrosion and had not been replaced.
Failed to ensure all ground fault circuit interrupters (GFCI) were properly maintained; a GFCI receptacle in the nutrition room did not trip and had reversed wiring.
Report Facts
Certified beds: 77
Census: 36
Battery backup lights tested: 3
Battery operated smoke alarms: 31
Sprinkler heads needing replacement: 6
Inspection Report
Life Safety
Deficiencies: 1
Date: May 9, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted on 05/09/24 and completed on 06/12/24.
Findings
Envive of Sullivan was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. A deficiency related to sprinkler system maintenance and testing was noted but temporarily waived from 05/09/24 to 10/31/24.
Deficiencies (1)
Any non-required or partial automatic sprinkler system maintenance and testing requirements not met as evidenced by missing information on date last checked, who provided system test, and water system supply source.
Report Facts
Deficiency waiver timeframe: Temporary waiver from 05/09/24 to 10/31/24 for sprinkler system deficiency
Inspection Report
Annual Inspection
Census: 33
Capacity: 33
Deficiencies: 6
Date: Apr 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00431016 and IN00426555.
Complaint Details
Complaint IN00431016 and IN00426555 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including failure to post accurate nurse staffing information daily, medication administration errors related to inhaled medications, improper disposal of expired medications, incomplete refrigerator and freezer temperature logs, incomplete wound treatment documentation, and lack of required annual dementia training for some staff.
Deficiencies (6)
Failed to ensure accurate staffing sheets were posted daily for 3 of 5 days during the recertification survey.
Failed to ensure medication error rates were less than 5%, with a medication error rate of 6.67% due to improper administration of inhaled medications for one resident.
Failed to ensure expired medications were properly disposed of in the medication storage room.
Failed to maintain refrigerator temperature logs for 5 of 15 days and freezer temperature logs for 2 of 15 days in April.
Failed to ensure documentation of wound treatments was completed for 1 of 2 residents reviewed for pressure ulcers.
Failed to ensure annual dementia training was completed for 3 of 10 employee records reviewed.
Report Facts
Census: 33
Total Capacity: 33
Medication error rate: 6.67
Days missing refrigerator temperature logs: 5
Days missing freezer temperature logs: 2
Deficiency counts: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Deann Sanders | Executive Director | Signed plan of correction and mentioned in staffing deficiency |
| Jodi Sanders | HFA | Signed plan of correction and mentioned in staffing deficiency |
| LPN 7 | Licensed Practical Nurse | Involved in medication administration error with inhaled medications |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding proper inhaler administration |
| RN 9 | Registered Nurse | Interviewed regarding inhaler administration and expired medications |
| Business Office Manager | Business Office Manager | Interviewed regarding dementia training audit |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing sheets and wound treatment documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00422015 completed on November 30, 2023.
Complaint Details
Investigation of Complaint IN00422015; paper compliance review completed with findings of compliance.
Findings
Envive of Sullivan 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 of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00415462 completed on October 12, 2023.
Complaint Details
Investigation of Complaint IN00415462 was completed with findings of compliance.
Findings
Envive of Sullivan 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 for the complaint investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00419848 with unrelated deficiencies cited.
Complaint Details
Investigation of Complaint IN00419848; paper compliance review completed with unrelated deficiencies cited.
Findings
Envive of Sullivan 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 Investigation of Complaint IN00419848 with unrelated deficiencies cited.
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
This visit was for the investigation of complaints IN00422015 and IN00422092. Complaint IN00422015 resulted in federal/state deficiencies related to the allegations, while complaint IN00422092 had no deficiencies cited.
Complaint Details
Complaint IN00422015 was substantiated with federal/state deficiencies cited at F726. Complaint IN00422092 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure sufficient on-duty nursing staff were certified in CPR for 2 of 3 residents reviewed for emergent situations. Specifically, two residents (Residents B and D), both full code, did not have staff with current CPR certification when CPR was needed, resulting in their deaths prior to nursing staff arrival. The facility did not track CPR certifications nor offer certification classes, and lacked a policy related to CPR certification.
Deficiencies (1)
Failed to ensure sufficient on-duty staff were certified in CPR for residents in emergent situations.
Report Facts
Census: 32
Total Capacity: 32
Medicare residents: 3
Medicaid residents: 22
Other residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Deann Sanders | Executive Director | Signed the report as facility representative |
| RN 2 | Registered Nurse | Completed progress notes documenting CPR events on Residents B and D; lacked current CPR certification |
| Administrator | Administrator | Interviewed and confirmed lack of CPR certification tracking and policy |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 2
Date: Oct 25, 2023
Visit Reason
This visit was for the investigation of Complaint IN00419848. The complaint allegations were not substantiated, but unrelated deficiencies were cited.
Complaint Details
Complaint IN00419848 was investigated with no deficiencies related to the allegations cited. Unrelated deficiencies were cited.
Findings
The facility failed to ensure adequate treatment for a resident with dementia exhibiting increased behaviors, wandering, and hallucinations. Additionally, the facility failed to ensure abuse training was completed for 2 of 4 employees reviewed and lacked documentation of ongoing abuse training after a reported abuse allegation.
Deficiencies (2)
Failed to ensure a resident with dementia received appropriate treatment and services to maintain highest practicable well-being.
Failed to ensure abuse training was completed for employees and lacked documentation of ongoing abuse training after a reported abuse allegation.
Report Facts
Census: 31
Total Capacity: 31
Residents diagnosed with dementia reviewed: 3
Employees reviewed for abuse training: 4
Employees immediately trained: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Deann Sanders | Administrator | Signed report and provided documentation during investigation |
| Resident B | Resident with dementia exhibiting increased behaviors, wandering, hallucinations, and inappropriate sexual comments | |
| Resident C | Resident affected by Resident B's behaviors, including unwanted visits and sexual comments | |
| Registered Nurse 3 | RN | Interviewed regarding Resident B's dementia and behaviors |
| Social Service Director | SSD | Interviewed regarding referral and psych services for Resident B |
| Director of Nursing | DON | Interviewed regarding psych services and referral documentation for Resident B |
| Employee 5 | Interviewed about abuse training and reporting; lacked adequate training | |
| Employee 6 | Interviewed about abuse training and reporting; lacked adequate training | |
| Employee 7 | Interviewed about abuse training and reporting; lacked adequate training |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415462 regarding federal and state deficiencies related to advanced directives compliance.
Complaint Details
Complaint IN00415462 was substantiated with federal/state deficiencies cited at F578 related to advanced directives compliance.
Findings
The facility failed to ensure that a resident's advanced directive wishes were followed, specifically regarding code status changes after a Do Not Resuscitate (DNR) order was signed by the physician. The resident was incorrectly listed as full code despite the DNR order, leading to inappropriate resuscitation efforts.
Deficiencies (1)
Failure to ensure a resident's advanced directive wishes were followed, specifically regarding code status after a DNR order.
Report Facts
Census: 31
Medicare residents: 2
Medicaid residents: 24
Other residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Deann Sanders | Executive Director | Signed the report |
| Director of Nursing | Director of Nursing | Interviewed regarding the deficiency about advanced directives and code status |
| Social Services Director | Social Services Director | Mentioned as responsible for ensuring advanced directive information was placed correctly in the resident's medical record |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416267.
Complaint Details
Complaint IN00416267 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: 33
Total Capacity: 33
Medicare Residents: 3
Medicaid Residents: 25
Other Payor Residents: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00402621 completed on February 28, 2023.
Findings
Envive of Sullivan was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00402621.
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00410210 and IN00410502.
Complaint Details
Complaint IN00410210 and Complaint IN00410502 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00410210 and IN00410502 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 33
Total Capacity: 33
Medicare Census: 5
Medicaid Census: 19
Other Payor Census: 9
Inspection Report
Re-Inspection
Census: 37
Capacity: 77
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/16/23.
Findings
At this PSR survey, Envive of Sullivan was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Life Safety
Census: 36
Capacity: 77
Deficiencies: 7
Date: Mar 16, 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).
Findings
The facility was found not in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. Deficiencies included failure to maintain accurate time and date on the fire alarm system, use of a portable space heater in a resident area, and lack of documentation for 36-month emergency generator testing.
Deficiencies (7)
Failed to maintain the fire alarm system to assure accurate time and date information on the fire alarm control panel.
Use of a portable space heater in the dining room, which is prohibited in resident areas.
Failed to document 36-month period emergency generator testing for 1 of 1 emergency generators.
Failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually in accordance with 42 CFR 483.73(a).
Failed to develop and implement emergency preparedness policies and procedures that were reviewed and updated at least annually in accordance with 42 CFR 483.73(b).
Failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and was reviewed and updated at least annually.
Failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least annually.
Report Facts
Certified beds: 77
Census: 36
Deficiencies cited: 7
Compliance date: Mar 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Wente | Executive Director | Named in relation to findings and exit conference |
| Maintenance Supervisor | Named in relation to findings and exit conference but no full name provided | |
| Director of Maintenance | Named in relation to corrective actions and education on deficiencies |
Inspection Report
Recertification
Census: 40
Capacity: 40
Deficiencies: 10
Date: Feb 28, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of multiple complaints.
Complaint Details
Complaint IN00400152, IN00401609, IN00402401 had no deficiencies related to allegations. Complaint IN00402621 had Federal/State deficiencies related to allegations cited at F689.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, call light accessibility, grievance tracking, accuracy of assessments, activity provision, quality of care, fall management, food safety, and personnel reference checks.
Deficiencies (10)
The facility failed to ensure the dignity of a resident was maintained for 1 of 16 residents reviewed for dignity (Resident 6).
The facility failed to ensure call lights were within reach for 2 of 16 residents (Residents B and 38).
The facility failed to address grievances in a manner which could be tracked for 3 of 3 months reviewed for grievance resolutions of the Resident Council and 2 of 2 residents reviewed for call light response (Residents B and 38).
The facility failed to ensure staff provided ongoing communication to residents about their resident rights through the Resident Council and family groups meetings for 3 of 3 months of resident council meetings reviewed.
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 2 of 19 residents reviewed (Resident 6 and 25).
The facility failed to provide activities to a dependent resident incapable of self-initiated activities (Resident 38) and failed to consistently provide evening activities for 2 of 3 residents reviewed for activities (Residents 21 and 19).
The facility failed to ensure a resident received timely assessment, nursing services, documentation, treatment, and diagnostic testing after a weight fell onto her foot in the therapy gym, resulting in dark discoloration and pain to the right foot for 1 of 16 residents reviewed for non-pressure skin conditions (Resident 3).
The facility failed to ensure an effective fall management program by documenting nurse's notes of the fall for 1 of 3 residents reviewed for accidents (Resident B).
The facility failed to ensure the kitchen was cleaned, staff sanitized their hands appropriately, food items were labeled and dated, the cleaning solution in the QUAT buckets tested appropriately, and food temperatures were monitored for 1 of 2 kitchen observations; and failed to ensure pureed food items were prepared in a sanitary manner, and staff wore a beard restraint while preparing food in the kitchen for 1 of 2 kitchen observations. The facility also failed to ensure staff performed hand hygiene for 1 of 2 dining room service observations and failed to ensure food was covered when transported for 1 of 2 observations of food delivery of hall tray service.
The facility failed to ensure reference checks had been completed for newly hired employees for 5 of 10 employee records reviewed.
Report Facts
Census: 40
Total Capacity: 40
Falls: 9
Call light response audits: 5
Resident council grievance review: 6
Reference checks missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Miller | Chief Nursing Officer | Signed report |
| CNA 13 | Observed entering resident room without knocking; unaware of restraint for Resident 25 | |
| CNA 12 | Reported resident toe injury to nurse | |
| LPN 22 | Nurse assigned to Resident 3; did not document injury | |
| PT 14 | Physical therapist who observed resident toe injury but did not report | |
| Dietary Manager | Provided kitchen sanitation policy and observations | |
| Cook 18 | Observed preparing food without beard restraint | |
| DA 32 | Observed poor hand hygiene during dining service | |
| BOM | Business Office Manager | Failed to complete reference checks for new employees |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 1
Date: Dec 5, 2022
Visit Reason
The visit was conducted to investigate complaints IN00391794 and IN00395721, resulting in a Partially Extended Survey due to Substandard Quality of Care and Immediate Jeopardy.
Complaint Details
Complaint IN00391794 was unsubstantiated due to lack of evidence. Complaint IN00395721 was substantiated with federal/state deficiencies cited at F689 and F9999 related to the allegation.
Findings
The facility failed to notify the division of an occurrence where a cognitively impaired resident was removed from the facility and driven away by two unrelated individuals without staff knowledge. Complaint IN00391794 was unsubstantiated, while IN00395721 was substantiated with related deficiencies cited.
Deficiencies (1)
The facility failed to notify the division of an occurrence in which a cognitively impaired resident had been removed from the facility, placed in a car, and driven away without staff's knowledge.
Report Facts
Census: 37
Medicare residents: 7
Medicaid residents: 17
Other residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Miller | Chief Nursing Officer | Signed the report |
| Employee 1 verified details of the incident but full name not provided | ||
| Social Service Director | Interviewed regarding the incident; full name not provided | |
| Executive Director | In-serviced on policies and interviewed about the incident; full name not provided |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Oct 4, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00387554 and IN00391504.
Complaint Details
Complaint IN00387554 - Substantiated with no deficiencies cited. Complaint IN00391504 - Substantiated with no deficiencies cited.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 47
Total Capacity: 47
Medicare Census: 5
Medicaid Census: 22
Other Payor Census: 20
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
Paper compliance review to the Investigation of Complaints IN00383806 and IN00384274 completed on July 6, 2022.
Findings
Envive of Sullivan 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 of the investigations.
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00385841 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00385841 was unsubstantiated due to lack of evidence.
Findings
Complaint IN00385841 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and the COVID-19 Focused Infection Control Survey.
Report Facts
Census: 41
Total Capacity: 41
Medicare Census: 7
Medicaid Census: 22
Other Payor Census: 12
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Jul 25, 2025
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May 22, 2025
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Dec 3, 2024
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Jul 26, 2024
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Jul 26, 2024
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Mar 15, 2024
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Sep 19, 2023
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Jul 14, 2023
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Jul 14, 2023
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May 12, 2023
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Mar 20, 2023
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