Deficiency Records for Envive of Sullivan
Updated as of May 01, 2021
This is not the most recent data for Envive of Sullivan. For the most recent information, click here.
A list of the most recent deficiencies for Envive of Sullivan. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2019-11-26 | 2019-12-03 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-31 | 2019-11-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-31 | 2019-11-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-13 | 2019-10-28 | Y |
| 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. | Health | 2019-09-13 | 2019-10-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-13 | 2019-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-13 | 2019-10-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-13 | 2019-10-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-13 | 2019-10-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-13 | 2019-10-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-13 | 2019-10-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-13 | 2019-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-13 | 2019-10-13 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-09-13 | 2019-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-04 | 2019-06-20 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-13 | 2018-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-13 | 2018-08-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-07-13 | 2018-08-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-07-13 | 2018-08-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-07-13 | 2018-08-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-13 | 2018-08-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-07-13 | 2018-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-13 | 2018-08-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-13 | 2018-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-13 | 2018-08-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-07-13 | 2018-08-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-07-13 | 2018-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-13 | 2018-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-13 | 2018-08-12 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-08-29 | 2017-09-14 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-29 | 2017-09-14 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-08-29 | 2017-09-14 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-08-29 | 2017-09-14 | N |
