Envive of Sullivan

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on June 15, 2026.

  CMS has cited this home for F0812 3 times since 2023.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 4.0 to 3.5 hours per resident per day.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on November 23, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on November 23, 2025.

  CMS has cited this home for F0689 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation F0882. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  CMS lists it as corrected on June 30, 2025.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on June 30, 2025.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on June 30, 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on June 30, 2025.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on June 30, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on June 30, 2025.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on June 30, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on June 30, 2025.

  CMS has cited this home for F0761 2 times since 2024.

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CMS lists this as a standard inspection.

• Citation K0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on April 19, 2026.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.3 to 2.6 hours per resident per day.

• Fine

  CMS changed the fine from December 7, 2022 from $12,649 to $12,923.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0725. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on February 16, 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on February 16, 2025.

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CMS lists this as a complaint inspection.

• Citation F0804. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on January 13, 2025.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.6 to 3.2 hours per resident per day.

• Fine

  CMS changed the fine from December 7, 2022 from $19,460 to $12,649.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on May 9, 2024.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on May 9, 2024.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on May 9, 2024.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on May 9, 2024.

• Citation F0732. Severity B: potential for minimal harm, pattern.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on May 9, 2024.

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CMS lists this as a standard inspection.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on October 31, 2024.

• Citation K0511. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on May 12, 2024.

• Citation K0291. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on May 12, 2024.

• Citation K0300. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Meet other general requirements that are deficient.

  CMS lists it as corrected on May 12, 2024.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Fine

  CMS changed the fine from June 5, 2023 from $4,194 to $4,233.

• Fine

  CMS changed the fine from June 26, 2023 from $2,098 to $2,117.

CMS lists this as a complaint inspection.

• Citation F0726. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on December 21, 2023.

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CMS lists this as a complaint inspection.

• Citation F0744. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS lists it as corrected on November 23, 2023.

• Citation F0940. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop, implement, and/or maintain an effective training program for all new and existing staff members.

  CMS lists it as corrected on November 23, 2023.

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CMS lists this as a complaint inspection.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on November 2, 2023.

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CMS lists this as a standard inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on March 28, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on March 28, 2023.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on March 28, 2023.

• Citation F0565. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on March 28, 2023.

• Citation F0572. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give residents a notice of rights, rules, services and charges.

  CMS lists it as corrected on March 28, 2023.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on March 28, 2023.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 28, 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 28, 2023.

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CMS lists this as a standard inspection.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on March 22, 2023.

• Citation K0781. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on March 16, 2023.

• Citation E0004. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on March 22, 2023.

• Citation E0013. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Develop Emergency Preparedness policies and procedures.

  CMS lists it as corrected on March 22, 2023.

• Citation E0029. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on March 22, 2023.

• Citation E0036. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish emergency prep training and testing.

  CMS lists it as corrected on March 22, 2023.

• Citation K0345. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on March 22, 2023.

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