Envive of Sullivan: Fall Documentation Failures - IN
When inspectors arrived at Envive of Sullivan on September 29, 2025, they were responding to a complaint. What they found was a documentation gap that stretched back more than three months, to June 13, 2025, the date of the fall.
The Director of Nursing handed over an incident report at 1:53 that afternoon. It was dated September 13, 2025, three months after the fall occurred. At the bottom of the document, a line read: "Privileged and confidential — not part of the medical record."
That designation meant the fall existed only in risk management files. Not in the resident's chart. Not in any place a physician, a nurse coming on shift, or a family member reviewing records would think to look.
The Director of Nursing told inspectors she had not known the risk management incident reports were being kept out of residents' medical records. She confirmed there was no other documentation of the June fall anywhere in the resident's file.
Nobody had written down what happened to her knee. Nobody had recorded whether her vital signs were checked. Nobody had documented whether she showed any change in cognition, any pain, any neurological concern. The fall protocol the facility had revised just a year earlier, in August 2024, called for all of that, within 24 hours.
The protocol the Director of Nursing provided at 2:00 that afternoon was detailed. It required nurses to assess and document vital signs, head and forehead injuries, musculoskeletal function, changes in cognition or consciousness, neurological status, pain levels, fall history since the last physician visit, how the fall happened and what preceded it, all current medications associated with dizziness or lethargy, and all active diagnoses. Staff were required to begin identifying possible causes within 24 hours. Physicians and staff together were supposed to identify interventions to prevent the next fall.
None of that had been done, or if it had, none of it was recorded anywhere inspectors could find.
The gap between the policy and what actually happened was total. A resident fell. She was found on her knees. She had an abrasion. And then, as far as her medical record was concerned, nothing had happened at all.
The inspection report does not name the resident or describe her underlying conditions. It does not say whether she fell again between June and September. It does not say whether anyone told her physician. The record is silent because the record, by design, contained nothing.
The risk management report that finally surfaced in September also lacked any notation that an intervention had been put in place after the June fall, even in the document that was supposed to capture what risk management knew. There was no follow-up plan recorded anywhere.
Inspectors cited the facility under F0689, which addresses the obligation to protect residents from accidents the facility can reasonably anticipate and to supervise residents adequately to prevent falls. The harm level was listed as minimal harm or potential for actual harm, affecting a small number of residents.
The citation came from a complaint, not a routine inspection. Someone had reason to raise the alarm. The inspection report does not say who filed it or what prompted it, only that inspectors came, asked questions, and found that a woman's fall had been buried in a document stamped confidential and left out of the record where it belonged.
The Director of Nursing said she wasn't aware. The protocol said what should have happened. The resident's chart showed none of it had.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Envive of Sullivan from 2025-09-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
ENVIVE OF SULLIVAN in SULLIVAN, IN was cited for violations during a health inspection on September 29, 2025.
When inspectors arrived at Envive of Sullivan on September 29, 2025, they were responding to a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.