Envive of Sullivan

In the surveyor’s words

From the most serious findings on record at Envive of Sullivan, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 7, 2022

  Based on observation, record review, and interview, the facility failed to provide supervision to prevent a cognitively impaired resident assessed to be at risk for elopement from being removed from the facility by two unknown individuals unrelated to the resident, placed in a car, and driven away without staff's knowledge for 1 of 3 residents reviewed for supervision to prevent an accident (Resident B). The Immediate Jeopardy began on November 24, 2022, when a severely cognitively impaired resident with diagnoses of dementia and Parkinson's disease and assessed at risk of elopement with an order for a Wander Guard was taken from the facility by two strangers not related to the resident without the staff's knowledge. […]

• No harm, potential for more than minimal, widespreadF882Jun 2, 2025

  Based on record review and interview, the facility failed to ensure an Infection Preventionist (IP) Nurse other than the Director of Nursing (DON) was designated to oversee the Infection Prevention and Antibiotic Stewardship programs within the facility. This deficiency had the potential to affect 38 of 38 residents residing at the facility. Findings include: A review of the Infection control program identified antibiotic tracking and infection surveillance was not completed between 5/1/24 to 11/30/24. On 5/30/25 at 2:34 p.m., during interview the DON indicated she started working at the facility in December 2024 and began tracking at that time according to infection control policy. […]

• No harm, potential for more than minimal, widespreadF725Jan 31, 2025

  Based on interview and record review, the facility failed to ensure a licensed nurse was on duty 24 hours a day for 1 of 61 days reviewed on a shift when two residents fell (Residents W and T). This deficient practice had the potential to affect 42 of 42 residents who resided in the facility. Findings include: 1. During an anonymous interview Employee C indicated, on 12/25/24, there was no nurse in the facility on day shift, 6:00 a.m. to 6:00 p.m. The Director of Nursing (DON) came in at breakfast and lunch and administered insulin. Residents W and T fell on the shift, and there was no nurse at the facility at the time of the falls. […]

• No harm, potential for more than minimal, patternF812May 21, 2026

  Based on observation, interview, and record review, the facility failed to ensure the dish machine temperatures were monitored to be at appropriate temperatures for 1 of 3 kitchen observations. This had the potential to affect 34 of 35 residents who were served meals out of the kitchen. Findings include:During the initial kitchen tour, on 5/17/26 at 9:09 a.m., the chemical dish machine was observed. A placard on the top of the dish machine indicated the minimal wash temperature was to be 140 degrees Fahrenheit (F) and 140 degrees F for the rinse temperature. Three run attempts were completed before the machine reached the minimal wash and rinse temperatures. […]

• No harm, potential for more than minimal, patternF880Jun 2, 2025

  Based on record review and interview, the facility failed to ensure the facility tracked infections and antibiotic use within the facility and failed to ensure tuberculin testing was completed for 7 of 16 residents reviewed for immunizations and tuberculin testing administration (Residents 28, 4, 9, 14, 38, 192, and 5). Findings include: On 5/30/25 at 10:00 a.m., the medical record of Resident 28 was reviewed. The resident was admitted on [DATE]. A Tuberculin skin test (a Mantoux test involves injecting a small amount of fluid called tuberculin or purified protein derivative, PPD under the skin, and then checking for a reaction a few days later) was administered on 1/1/25. The record lacked evidence the results of the test were read. […]