Life Care Center of Sullivan

Inspectors wroteBased on observation, interviews, and record review, facility staff failed to provide care to meet the basic hygiene needs for five residents (Resident #2, #4, #5, #6, and #7) out of seven sampled residents who required assistance with Activities of Daily Living. The facility's census was 82. 1. Review of the facility's Activities of Daily Living (ADL) policy, revised 09/04/25, showed the residents will receive assistance as needed to complete ADLs. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's shower schedule showed each resident is scheduled to be assisted with a bath/shower twice per week by facility staff. 2. Review of Resident #2''s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; [...]

Inspectors wroteBased on observation, interviews and record review, facility staff failed to maintain professional standards of care, when staff failed to transcribe a wound treatment order from the hospital for one resident (Resident #1), and failed to document wound care and treatments as directed by the physician for three residents (Resident #1, #2, and #3) out of three sampled residents with wounds. The facility's census was 82.1. Review of the facility's Physician Orders policy, revised 02/11/26, showed the facility is to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Physician orders include medications and treatments. Review of the facility's Treatment Orders policy, revised 05/15/26, showed treatment orders are written per physician orders. The physician writes an order that includes the following: [...]

Inspectors wroteBased on interviews and record review facility staff failed to obtain orders and complete assessments for one resident (Resident #1's) surgical wound. The facility census was 67.1. Review of the facility's treatment order policy, reviewed 6/12/25, showed treatment orders are written per physician orders. If a resident has multiple wound sites, a complete and separate treatment order must be written for each site. The physician writes an order that includes the following: site of wound, name of cleanser, name of ointment, type of dressing and number of times to perform the treatment/duration of treatment. Review of the facility's Physician Orders, revised 2/11/26, showed a physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to one of one residents (Resident #40) who received a pureed diet and 10 residents who received mechanically altered diets. The facility census was 76.1. Review of the facility's policy titled Food Preparation, revised 04/29/25, showed the policy directed for the Director of Food and Nutrition Services to provide recipes and the recipes were to be followed by food service associates Review also showed the policy directed staff to prepare menu items in accordance with the menu, recipes and production sheets. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to educate and offer the Coronavirus disease 2019 (COVID-19) (a respiratory disease that can cause severe illness) vaccination for four residents (Resident #7, #10, #21 and #66) out of five sampled residents. The facility census was 76.1. Review of the facility's COVID-19 (SARS-CoV) Vaccination Program Policy for Residents, revised 11/25/25, showed the facility will educate residents or the resident representative regarding benefits and potential side effects associated with the Covid-19 vaccine and offer the vaccine unless it is medically contraindicated, or the resident has already been immunized. The resident's medical record includes documentation that indicates, at a minimum the following: -The resident or representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; [...]

Inspectors wroteBased on observations, interview and record review, facility failed to conduct regular maintenance of all bedrails to identify areas of possible entrapment for 9 (Resident #1, #2, #5, #7, #9, #11, #12, #26, #70) of 11 sampled residents who used bed rails. The facility census was 76.1. Review of the facility's policy titled Bed Rails-Safe and Effective Use, dated 09/3/25, showed if bed rails are determined appropriate for use with a resident, a reassessment will be assessed at a minimum of quarterly or potentially with a change of condition utilizing the Evaluation for Use of Bed Rails form. When installing or maintaining bedrails, the Maintenance Department will follow the manufacturer's recommendations and specifications. 2. Review of Resident #1's admission Minimal Data Set (MDS), a federally mandated assessment tool, dated 02/6/26, showed staff assessed the resident as: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide timely treatment to one resident (Resident #1) when he/she sustained a burn injury to his/her right thigh on 06/02/25 from hot coffee and staff did not document any treatment interventions for the burn until 06/04/25. The facility's census was 67. 1. Review of the facility's policies showed the facility did not provide a policy for how to address a change in a resident's condition after a burn injury. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/23/25, showed staff assessed the resident as moderate cognitive impairment, independent with eating, bed mobility, and transfers. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify the physician and resident representative in a timely manner of a change in condition, when one resident (Resident #1) spilled coffee on his/her thigh and resulted in a significant burn injury. The facility's census was 67. 1. Review of the facility's policies showed the facility did not provide a policy for when to notify the Physician/Resident Representative of an injury, or change in a resident's condition. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to review and revise comprehensive care plans to include interventions for one resident (Resident #1) after he/she sustained burns to his/her thigh from hot liquids, and smoking interventions for one resident (Resident #2) out of three sampled residents. The facility's census was 67. 1. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 09/11/24, showed staff are directed as follows: -A Comprehensive Care Plan must be reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments; -The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Resident #2 struck Resident #1 in the face. The facility census was 66. 1. Review of the facility's Abuse prevention policy, dated 6/17/24, showed it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, assess, and care plan for appropriate interventions and monitor residents with needs and behaviors which might lead to conflict or neglect such as verbally aggressive behaviors and physically aggressive behaviors. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/13/25, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Alzheimer's and dementia; -No mood disorders or behaviors. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to properly wash and sanitize soiled dishes to prevent cross-contamination. Facility staff failed to allow dishes to air dry prior to storage and use to prevent the growth of food-borne pathogens. Facility staff also failed to ensure waste containers in food preparation and utensil washing areas were covered when not in actual use. The facility census was 69. 1. Review of the facility's High-Temperature Dish Machine policy, dated 11/30/10, showed direction for the final sanitizing rinse temperature of the machine to be 180 degrees Fahrenheit (dF) and a booster heater is required to reach the 180 dF temperature for the rinse cycle. Review of the facility's Sanitation and Maintenance policy, dated 04/30/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a clean, safe, comfortable, and homelike environment when staff failed to adequately clean and properly maintain three of the four shower rooms. The facility census was 69. 1. Review of the facility's policy titled Housekeeping General Policy, revised 06/12/24, showed it is the responsibility of the Executive Director through the Environmental Service Director to assure that Housekeeping Policies are implemented and followed. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Housekeeping personnel are required to attend training classes. Review of the facility's policy titled Housekeeping Services, revised 06/04/24, showed the facility will provide a safe, clean, comfortable, and homelike environment. [...]

Inspectors wroteBased on interview and record review, facility staff failed to document they provide restorative therapy for two residents (Resident #9 and #41). The facility census was 69. 1. Review of the facility's policy titled Restorative Nursing dated 11/30/23, showed staff are instructed to provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Restorative indicators may be identified by multiple disciplines utilizing various assessments, physician orders, progress notes, environmental factors, caregiver conversations, and another means of communication. Communicate the restorative care plan and care directives to other members of the interdisciplinary (IDT) team. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received regular and easy to chew (EC) diets. The facility census was 69. 1. Review of the facility's Menus, Substitutions, and Alternatives policy, dated 04/30/24, showed Menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Residents with known dislikes of food and beverage items, who express refusal of the food served or request a different meal choice are offered a substitute of similar nutritive value. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to educate and offer the Covid-19 (a disease caused by a novel coronavirus) vaccination in accordance with current guidelines and policy for three (Residents #39, #57 and #61) of five sampled residents. The facility census was 69. 1. Review of the facility's policy Resident Vaccination, review dated 12/4/23, showed the facility in conjunction with the Public Health Authorities and CDC (Centers for Disease Control) guidelines will provide immunizations to older adults that are recommended and ordered by a physician once determined to be eligible and without contraindications. The facility should screen individuals prior to offering the COVID-19 vaccination to check for the following: Prior vaccination status; The presence of medical precautions and contraindication. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure two Nurse Aides (NA)'s (NA M and NA N) of fourteen sampled completed the nurse aide training program within four months of his/her hire date. The facility census was 69. 1. Review of the facility's policy titled Nurse Aide Requirements, undated, showed the facility must not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis. 2. Review of the facility's Active Payroll for September 2024 showed NA M with a hire date of 02/20/24, and NA N with a hire date of 01/11/24. 3. During an interview on 10/04/24 at 3:04 P.M., the Staffing Coordinator said NA M and NA N were scheduled to re-take the Certified Nurse Aide (CNA) test. The Staffing Coordinator said NA M and NA N were allowed to continue to work until they retook the test. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the three most recent years of survey results were posted and readily accessible to residents, family members or representatives of residents. The facility census was 69. 1. Review of the facility's policy titled Availability of Survey Results, dated 05/23/19, showed results from the most recent state surveys must be available and easily accessible to the residents and family members within the facility. Place readily accessible. This is a place such as a lobby or other area frequented by most residents, visitors or other individual where individuals wishing to examine survey results do not have to ask to see them. 2. Observation on 10/01/24 at 9:43 A.M., showed the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. 3. [...]

Inspectors wroteBased on observation and interview, facility staff failed to provide a clean, homelike and comfortable environment when staff failed to keep resident rooms and common areas clean and in good repair. The facility census was 69. 1. Review of the facility's policy titled, Resident Belongings and Home like Environment, reviewed 7/17/2023, showed it is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. Review of the facility's policy titled, Residents Rights , reviewed 10/6/2023, showed the resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. 2. Observation on 08/14/23 at 12:12 P.M., showed an approximate 12 inch (in) by (x) 12 in broken floor and wall tile in the dining room. [...]

Inspectors wroteBased on interview and record review, facility staff failed to obtain labs in a timely manner for one resident (Resident #37), and failed to produce documentation for pharmacist recommended interventions for one resident (Resident #60). Additionally, staff failed to perform blood sugar tests in a manner to obtain an accurate reading for four residents (#17, #23, #30, and #32). The facility census was 69. 1. Review of the facility's policy titled, Laboratory services, dated 3/21/23, showed staff are directed to do the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the resident's environment remained free of accident hazards when staff failed to properly store disposable razors in one of two shower rooms and left one resident (Resident #30) alone in the shower room with the disposable razors on the counter. Additionally, staff failed to properly propel five residents (Resident #33, #47, #55, #333, and one unidentified resident) in wheelchairs in a manner to prevent accidents. The facility census was 69. 1. Review of the facility's policy titled, Incident, dated 8/15/23, showed the facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident #21) of two sampled residents received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice when staff failed to provide ongoing assessments of the resident's condition, and monitoring for complications after dialysis treatments. The facility census was 69. 1. Review of the facility's dialysis contract, signed 11/13/17, showed both parties shall ensure that there is documented evidence of collaboration of care and communication between long term care facility and End-Stage Renal Disease (ESRD) Dialysis unit. Review of the facility's policy titled, Hemodialysis Offsite, dated 4/17/23, showed staff are directed to do the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff in accordance with their Facility Assessment based on the care needs of their residents. Additionally staff failed to assist seven residents (Resident #15, #30, #54, #57, #58, #63 and #221) with showers, assist one resident (Resident #21) to bed, and provide meal assistance for one dependent resident (Resident #44). The facility census was 69. 1. Review of the Facility Assessment, dated 6/15/23, showed facility staff documented the following staffing requirements are needed on a 24 hour basis to meet the needs of their residents: -Registered Nurse (RN): 6; -Licensed Practical Nurses (LPN): 6; -Certified Nursing Assistant (CNA): 16; 2. Review of the staff schedule, dated 8/14/23 through 8/17/23 showed: -08/14/23: -RN: 3; -LPN: 4; CNA: 14; -08/15/23: RN: 3; LPN: 6; CNA: 15; -08/16/23: RN: 3; LPN: 6; [...]

Inspectors wroteBased on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for one resident (Resident #12), and failed to ensure as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #13 and #58). The facility census was 69. 1. Review of the facility's policy titled, Pharmacy services and procedures manual, Psychotropic medications use, revised 10/2022, showed staff were directed to do the following: -PRN psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to ensure medications were stored in a safe and effective manner for three out of four medication carts, and failed to discard expired medications from one of two medication storage rooms and one of one over the counter medication storage cabinet. The facility census was 69. 1. Review of the facility's Storage and Expiration Dating of Medications Policy, dated 7/21/22, showed the policy directs staff as follows: -Facility should ensure that medications and biologicals that: (1) have an expired date on the label, (2) have been retained longer then recommended by manufacturer or supplier guidelines, or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria, when staff failed to wash or sanitize their hands in between glove changes during perineal care and wiped multiple times with the same area of the wipe for two (Resident #2 and #72) of two sampled residents, failed to wash or sanitize their hands in between gloves changes during wound care for one (Resident #59) of two sampled residents, failed to use a barrier for the glucometer and to properly clean and disinfect the glucometer, failed to use appropriate hand hygiene before and after blood sugar checks for four (Resident #17, #23, #30, and #32) of four sampled residents, before and after giving insulin for two (Resident #17 and #30) of two sampled residents, and before and after medication administration for three [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for seven residents (Resident #12, #33, #44, #49, #58, #220 and #221), obtain physicians orders for three residents (Resident #33, #49 and #58), and update care plans for four residents (Resident #33, #44, #49 and #220) who utilized bed rails. Additionally, staff utilized bed rails for one resident (Resident #49) who declined bed rail use due to potential risks. The facility census was 69. 1. Review of the facility's policy titled, Bed inspection and maintenance and bed rail installation, revised 12/12/2022, showed staff were directed to do the following: -When installing or maintaining bed rails, the maintenance department will follow the manufacturer's recommendations and specifications. [...]

Inspectors wroteBased on interview and record review, facility staff failed to accurately complete and or update a new diagnosis within the Pre-admission Screening and Resident Review (PASARR) documentation to incorporate the recommendations into resident assessment and care plan for two out of four sampled residents (Resident #12 and #15). The facility census was 69. 1. Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR), revised 10/06/2022, showed staff are directed to do the following: -The facility will ensure that potential admissions are to be screened for possible serious mental disorders (MD) or intellectual disabilities (ID) and related conditions. The initial pre-screening is referred to as PASARR Level 1, and is completed prior to admission to a nursing facility. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to prepare pureed foods in accordance with standardized recipes and in a manner that conserved nutritive value, flavor and appearance. The facility census was 69. 1. Review of the facility's policy titled, Therapeutic and modified diets, showed staff were directed as follows: -Therapeutic diets will be provided as prescribed by the attending physician or per state guidelines; -The intent of this is to ensure the resident receives and consumes food in the appropriate form and/or the appropriate nutrient content as prescribed by a physician to support the treatment and plan of care for each resident and in accordance with his/her goals. A modified texture diet is specifically prepared to alter the consistency of food and/or beverage in order to facilitate oral intake. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and the resident census on a daily basis. The facility census was 69. 1. Review of the facility's staffing policy, revised 3/9/2021, showed: -The facility posts daily staffing information in a clear readable format in a prominent place that is easily accessible to residents and visitors at any given time. -The daily posting must include: Facility name, current date, total number and actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident are per shift. i. Registered nurses ii. Licensed practical nurses or licensed vocational nurses iii. [...]