Envive of Sullivan: Fall Documentation Failures - IN
The fall occurred on June 13, 2025. When state inspectors arrived more than three months later, on September 29, they found the incident report had been stamped "Privileged and confidential — not part of the medical record." It wasn't in her chart. No intervention had been recorded at the time of the fall. No follow-up documentation existed anywhere in her file.
The Director of Nursing told inspectors she had no idea the risk management incident reports were being kept out of residents' medical records. She confirmed there was nothing further in the chart about the June fall.
The facility's own Falls-Clinical Protocol, last revised in August 2024, lays out exactly what staff are supposed to do after a resident goes down: assess vital signs, check for head injury, evaluate range of motion and weight bearing, review medications that cause dizziness, identify possible causes within 24 hours, and put interventions in place to prevent the next fall. The protocol runs to ten specific assessment items.
None of it happened here. Or if it did, nobody wrote it down.
The inspection, triggered by a complaint, was conducted September 29, 2025. Inspectors rated the harm as minimal, affecting few residents. The citation was issued under Indiana's long-term care regulations.
The resident found on her knees that June morning had a bleeding abrasion and no documented plan to protect her from falling again.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
ENVIVE OF SULLIVAN in SULLIVAN, IN was cited for violations during a health inspection on September 29, 2025.
The fall occurred on June 13, 2025.
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.