Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ENVIVE OF SULLIVAN
SULLIVAN, IN · 77 certified beds · Last Life Safety survey June 2, 2025
CMS Certification Number 155468 · first certified October 1992
Ownership
Operated by ENVIVE HEALTHCARE · For profit - Corporation
- Ownership changed January 1, 2022 (change of ownership)from WITHAM MEMORIAL HOSPITAL
Position within IN
12 citations — more than 37% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten IN facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
4 of the 12 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 12 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 28, 2023 | 7 |
| April 19, 2024 | 4 |
| June 2, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0036 | Establish emergency prep training and testing. | 1 | 2023-02-28 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2023-02-28 |
| E-0029 | Develop a communication plan. | 1 | 2023-02-28 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2023-02-28 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-04-19 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2024-04-19 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2023-02-28 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2025-06-02 |
What the citations cover
- Emergency Preparedness Deficiencies 4
- Smoke Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Egress Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 4 |
| Smoke Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 2, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | No revisit needed (April 19, 2026) |
April 19, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 12, 2024) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (May 12, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (October 31, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 12, 2024) |
February 28, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 22, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (March 22, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (March 22, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (March 22, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 22, 2023) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 16, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 22, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.