Envive Of Sullivan

Based on observation, interview, and record review, the facility failed to ensure medications were labeled properly and the facility failed to ensure expired medications were disposed of for 1 of 1 medication storage rooms reviewed and for 2 of 3 medication carts reviewed (Residents 193 and 24). Findings include: 1. On 5/29/25 at 3:10 p.m., the medication storage room contained an undated multi use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution. During an interview, on 5/29/25 at 3:10 p.m., Licensed Practical Nurse (LPN) 3 indicated she was not aware of how long Aplisol was good for once opened, but was aware the vial should be dated once opened. During an interview, on 5/29/25 at 3:15 p.m., the Regional Nurse Consultant indicated the vial of Aplisol was good for 30 days once opened. During an interview, on 5/29/25 at 3:16 p.m., the Director of Nursing indicated the vial of Aplisol should be dated once opened. On 5/29/25 at 4:04 p.m., the Regional Nurse Consultant provided an undated document, titled, Medications with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. A Facility Assessment, dated 10/24/24, indicated the facility's staffing pattern included two licensed nurses on day shift and one licensed nurse on night shift. A Daily Nursing Assignment Sheet, dated 12/25/24, indicated a Registered Nurse (RN) was scheduled as the charge nurse from 6:00 a.m. to 6:00 p.m., but the name was crossed out. Two Qualified Medication Aides (QMAs) were scheduled on day shift. The top of the document included the DON's name and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were reordered in a timely manner so they were available for administration for 1 of 18 residents reviewed for pharmaceutical services (Resident D). Findings include: Resident D's record was reviewed on 1/31/25 at 11:04 a.m. An annual Minimum Data Set (MDS) assessment, dated 12/20/24, indicated the resident was cognitively intact. Diagnoses on the resident's face sheet included, but were not limited to, unspecified polyneuropathy (nerve damage throughout the body). A care plan, initiated on 8/30/22, indicated the resident had the potential for pain related to polyneuropathy. Interventions included, but were not limited to, administer medications as ordered. A Medication Administration Record (MAR), dated December 2024, indicated pregabalin (nerve pain medication) 75 milligrams (mg), 1 capsule 3 times daily for unspecified polyneuropathy. The MAR indicated the pregabalin was not available for administration on 12/27/24, 12/28/24, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to ensure the temperature and palatability of food served for 1 of 1 test tray. Findings include: During a confidential interview, conducted during the survey, the interviewee indicated the resident's hall tray food was served cold for all meals, breakfast, lunch, and supper. During an interview, on 12/19/24 at 11:05 a.m., Resident C indicated she ate meals in her room and the food was served cold at times. Resident F, on 12/19/24 at 11:20 a.m., indicated he ate meals in his room and sometimes the food was not hot, but cold. During an interview, on 12/19/24 at 11:30 a.m., Resident E indicated she ate meals in her room and the food was often cold when she got it and did not taste very good. On 12/19/24 at 12:03 p.m., test tray food temperatures were measured by the Dietary Manager (DM). The fried potatoes temperature measured at 128 degrees Fahrenheit (F), the cooked broccoli temperature measured at 118 F, and the BBQ sandwich measured at 128 F. The DM indicated the food was too cool and the food temperatures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure refrigerator temperature logs were maintained for 5 of 15 days in April and freezer temperature logs were maintained for 2 of 15 days in April. Findings include: During the initial kitchen tour, on 4/15/24 at 10:10 a.m., with the housekeeping supervisor, the temperature logs for the walk-in refrigerator and walk-in freezer were observed to have not been completed. At the same time, the housekeeping supervisor indicated she was filling in as the cook for that day. The regular cook, had the day off. The walk-in refrigerator temperature log, was observed sitting on a shelf in the dry storage area. The log lacked documentation of the refrigerator's temperatures for 4/1/24, 4/11/24, 4/12/24, 4/13/24, and 4/14/24. At the same time, the housekeeping supervisor documented the temperature of the walk-in refrigerator for the date of the initial tour, on the log. The walk-in freezer temperature log, was observed posted on the door of the walk-in freezer. The temperature log lacked documentation of the freezer's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure proper administration of inhaled medication during the medication administration pass for 1 of 3 residents observed, resulting in a medication error rate of 6.67% (Resident 6). Finding includes: During a medication administration observation, on 4/17/24 at 9:01 a.m., Licensed Practical Nurse (LPN) 7 was administering an Advair (medication used to prevent asthma symptoms) inhaler (small handheld devices that allows you to breath medicine through your mouth, directly to your lungs) to Resident 6. Resident 6 then handed the inhaler back to the nurse and the nurse immediately gave the resident a Spiriva (medication used to prevent bronchospasms) inhaler to use. The resident did not rinse and spit after the use of the first inhaler nor did she wait in between administering the two inhaled medications. Resident 6's record was reviewed on 4/17/24 at 10:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, emphysema (a condition that causes shortness of breath), unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of properly for 1 of 1 medication storage room reviewed for medication storage. Finding includes: On 4/18/24 at 10:31 a.m., the medication storage room contained an opened multi-use vial of Aplisol (a clear, colorless solution for injection as an aid in the diagnosis of tuberculosis) solution and had an open date of 2/27/24. On 4/18/24 at 10:33 a.m , the medication storage room contained an opened multi-use vial of flu vaccine solution and had an open date of 11/2/23. During an interview, on 4/18/24 at 10:35 a.m., Registered Nurse (RN) 9 indicated she was not aware of the facility policy for how long the medication was good for once it was opened but did believe they needed to be discarded. During an interview, on 4/18/24 at 10:51 a.m., the Administrator indicated the medication vials were expired. During an interview, on 4/18/24 at 11:20 a.m., [NAME] President of Clinical Operations indicated both the medications should have been discarded and were expired. On 4/18/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the documentation of wound treatments being completed for 1 of 2 residents reviewed for pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) (Resident 25). Findings include: Resident 25's record was reviewed on 4/17/24 at 11:00 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose is too high), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). An admission Minimum Data Set (MDS) assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 3/21/24, indicated the resident had severe cognitive deficit and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure sufficient on-duty staff were certified in cardio-pulmonary resuscitation (CPR-an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) for 2 of 3 residents reviewed for emergent situations (Residents B and D). Findings include: An anonymous interviewee indicated some residents have had CPR performed on them in the past few months, but no staff in the facility had CPR certification. The previous director had commented to a staff that no one had CPR certification and if something happened the director would be the one to administer CPR. 1. Resident B's closed record was reviewed on [DATE] at 10:58 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident received adequate treatment who exhibited an increase in behaviors, wandering, and hallucinations for 1 of 3 residents reviewed (Resident B). Finding includes: Review of a facility reported incident, dated [DATE], indicated it was reported to staff that Resident B had made inappropriate comments to a female resident who resides at the facility. Resident B's record was reviewed on [DATE] at 11:00 a.m. The profile indicated the resident diagnoses included, but were not limited to, unspecified dementia with psychotic disturbance (a decline in thinking and problem solving that often makes daily life and independent living difficult along with a person with psychosis had trouble figuring out what is real and what is not), hallucinations ( a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there), and depression (a group of conditions associated with the elevation or lowering of a person's mood).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, 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. Findings include: On 10/25/23 at 11:15 a.m., during an interview with Employee 5, the employee indicated if she was made aware of an abuse situation between residents, she would immediately report the incident to the head nurse. Maybe the ombudsman if there were signs but was not sure. If she witnessed physical abuse, she would immediately tell someone. The employee indicated she received a little training in abuse when she first started, two months ago but not very much. She indicated she had not received any training in abuse prevention or reporting since she was hired. On 10/25/23 at 11:25a.m.,during an interview with Employee 6, the employee indicated she had worked at the facility for about a month. The employee indicated she did not receive any abuse training when she was hired. She indicated she would remove the residents if she witnessed abuse and call for help and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's advanced directive (a written document stating how you want medical decisions to be made if you lose the ability to make them for yourself) wishes were followed for 1 of 3 residents reviewed for advanced directives (Resident D). Finding includes: Resident D's record was reviewed on [DATE] at 10:00 a.m. The profile indicated the resident had admitted to the facility on [DATE], for diagnoses which included, but were not limited to, heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), stage 3 chronic kidney disease (a condition where the kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), and essential hypertension (abnormally high blood pressure that's not the result of a medical condition). A quarterly Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

A. Based on observation, interview, and record review, 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 the facility 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. B. Based on observation, interview, and record review, the facility 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. Findings include: A1. During the initial kitchen tour with the Dietary Manager (DM), on 2/20/23 at 10:15 a.m., the DM washed her hands for less than (<) ten seconds, turned off the faucet with her bare hand, and then began the tour of the kitchen. The flooring throughout the kitchen, dry storage room, walk-in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the dignity of a resident was maintained for 1 of 16 residents reviewed for dignity (Resident 6). Findings include: During a random observation, on 2/20/23 at 11:32 a.m., Hospice Aide 31 and Certified Nursing Assistant (CNA) 13 were observed talking in hallway outside of Resident 6's room. Hospice Aide 31 was observed to enter the resident's room without knocking. CNA 13 was observed to stand in the doorway of the resident's room and continued to converse with the hospice aide. CNA 13 then walked into resident's room without knocking and the two staff continued to carry on a personal conversation while standing over resident in her bed. The conversation was not related to the resident's personal care. During a random observation, on 2/23/23 at 10:06 a.m., two unidentified facility staff were observed to enter the resident's room without knocking. The staff were carrying linens. The staff immediately closed the door behind them.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for 2 of 16 residents (Residents B and 38) for residents observed for call light placement. Findings include: 1. During an initial pool interview on 2/21/23 at 9:23 a.m., Resident B indicated she had fallen many times since residing in the facility to include 3 times that morning. Her roommate had called for staff to come help her as she was unable to reach her call light. She did not routinely need assistance with transfers to and from her wheelchair or to and from the toilet but this week she had been dizzy and her blood pressure was up. Resident B indicated she would usually yell for staff to assist her versus using her call light as she was unable to reach it across the room, and staff did not answer the buzzers very fast. Resident B's call light was observed coiled up and hanging off the railing on the side of the bed. Resident B's record was reviewed on 2/22/23 at 1:33 p.m. Diagnoses on Resident B's profile included, but were not limited to, Alzheimer's disease,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, 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). Findings include: Resident Council minutes were provided by the Activity Director (AD) on 2/21/23 at 2:46 p.m. The minutes for the 3 months reviewed indicated the following concerns by the Resident Council: a. Not enough staff for showers. b. Call lights taking too long to be answered by staff. During the Resident Council meeting, on 2/24/23 at 2:00 p.m., the residents indicated the facility had not been fully addressed, resolved, nor acted promptly upon the grievances of not enough staff for showers and call lights taking too long to be answered by staff. During an interview with the Activities Director (AD), on 2/21/23 at 2:50 p.m., she indicated she took minutes for the Resident Council meetings and then spoke with the Social Services Director, who was the facility's grievance officer, the department heads, and staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, 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. Finding includes: Resident Council minutes were provided by the Activity Director (AD) on 2/21/23 at 2:46 p.m. The Resident Council minutes lacked documentation that resident rights were reviewed during the resident council meetings for 3 of 3 months reviewed. The AD indicated she was unaware the residents' rights should have been reviewed at the meetings with the residents. The residents were provided the residents rights with their admission paperwork to read, and the Resident Rights were posted in the facility, but she was not aware the residents' rights should have been reviewed at resident council meetings. On 2/27/23 at 10:24 a.m., the Administrator (ADM) provided and identified a document as a current facility policy, titled Resident Rights, dated 9/2022. The policy indicated, Employees shall treat all residents with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide activities to a dependent 1 of 1 resident reviewed that was 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). Findings include, 1. During a random observation on 2/20/23 at 11:53 a.m., Resident 38 was observed lying in bed on her left side facing the doorway to the hall in a fetal position, wearing a hospital gown, and a throw covering her up to her shoulders. The room was dark with the lights off and blinds closed, no television (TV) or radio on. When spoken to the resident opened her eyes but did not engage in conversation. No activity calendar in the room. Random observations of the resident without activity involvement on 2/20/23, a. On 2/20/23 at 12:10 p.m., observation of Certified Nursing Assistant (CNA) 17 opening the resident's door and leaving resident's room. Room observed to be dark with no lights on, blinds closed, no radio or TV for stimulation, resident remained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, 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). Findings include, During an initial pool interview on 2/20/23 at 2:48 p.m., Resident 3 indicated she had a black toe due to an accident the prior week while in the therapy gym when she was working with weights. When staff stood her up to ambulate, a weight rolled off her lap and fell onto her right foot causing bruising and pain to her right 3rd toe. She did not think the toe was broken but did not remember having an x-ray. The toe hurt at times and was tender but did not throb. On 2/21/23 at 9:49 a.m., Resident 3's right foot was observed with Licensed Practical Nurse (LPN) 16 who indicated she was unaware the resident had an injury to her toe. The entire right 3rd toe was observed to have dark purple and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, 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 (Residents B). Findings including: On 2/20/23 at 12:27 a.m., Resident B was observed in the dining room, seated in a Broda chair (tilt in space positioning wheelchair), moving/rocking herself back and forth with her feet. During a random observation on 2/20/23 at 3:01 p.m., Resident B was sitting in a Broda chair leaning over from the waist reaching for personal items. Her room was cluttered with personal items around the bed, between the bed and window, on and under the bed, on the floor, stacked around her side of the room, and partially filled open containers of food and fluids were on the over the bed table and sitting in the trash can. On 2/21/23 at 9:11 a.m., Resident B was observed alone in the activity room, sitting at a small round table with her eyes closed and forehead laying on a newspaper on the table. During an initial pool interview on 2/21/23 at 9:23 a.m., Resident B…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.