Sullivan County Adult Care Center

Inspectors wroteBased on observations, record review, and interviews conducted, the facility failed to investigate an allegation of abuse and implement appropriate corrective actions to protect a resident from further abuse. This was evident for one resident (Resident #1) of four residents reviewed for abuse. Specifically, on 05/11/2026, Certified Nurse Aide #1 reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 that they observed Certified Nurse Aide #2 forcibly grab Resident #1 and push the resident into a wheelchair, then use the dining room table as a barrier preventing Resident #1 from getting out of the wheelchair. Certified Nurse Aide #1 also reported that they heard Certified Nurse Aide #2 repeatedly use profanities toward Resident #1. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a Survey, the facility did not ensure a resident's right to be free from abuse for one (1) Resident #1 of four (4) residents reviewed for abuse. Specifically, on 05/11/2026, Certified Nurse Aide #1 reported observing Certified Nurse Aide #2 forcibly grab Resident #1, and push the resident against a wheelchair, using the dinning room table as a barrier preventing Resident #1 from getting out of the wheelchair and repeatedly used profanities towards Resident #1. Certified Nurse Aide #1 reported the allegation of verbal and physical abuse involving Resident #1 and Certified Nurse Aide #2 to Registered Nurse Supervisor #1 and Licensed Practical Nurse #1. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey, the facility failed to ensure that alleged violations involving abuse were reported to the Department of Health immediately, but not later than 2 hours after the allegation if the events that caused the allegation result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not result in serious bodily injury, and report the results of the investigation to the Department of Health within 5 working days. This was evident for one (1) Resident #1 of four (4) residents reviewed for abuse. Specifically, on 05/11/2026, Certified Nurse Aide #1 reported an alleged physical/verbal abuse of Resident #1 by Certified Nurse Aide #2 to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1. [...]

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey, the facility failed to ensure Resident #1's Comprehensive Care Plan was reviewed and revised following assessment and as necessary to reflect changes in the resident's needs for one (1) (Resident #1) of four (4) residents reviewed for care planning. Specifically, following allegations of verbal and physical abuse of Resident #1 by Certified Nurse Aide #2, the resident's psychosocial well-being, risk to be victimized/aggressor, and behavior care plans were not reviewed or revised. Review of the psychosocial well-being and risk to be victimized/aggressor care plans revealed they were last revised on 04/09/2026. Review of the behavior care plan revealed it was last revised on 04/24/2026. The Findings Include: [...]

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey, the facility failed to ensure nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to residents for one (1) (Certified Nurse Aide #1) of nine (9) facility staff records reviewed for mandatory training requirements. Specifically, Certified Nurse Aide #1 was assigned resident care duties and worked on 05/11/2026; however, the facility was unable to provide documentation verifying completion of required orientation and mandatory training, which included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, and Trauma Informed Care. The Findings Include: [...]

Inspectors wroteBased on record review and staff interviews conducted during a survey, the facility failed to ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for three (3) of six (6) residents reviewed for accidents (Resident #1, #2, & 3). Specifically, 1) On 11/01/2024, Certified Nurse Assistant #2 did not follow the care plan and attempted to transfer Resident #1 by themself as a stand pivot and the resident fell, hit their head, and subsequently required transfer to the hospital. 2) On 12/26/2025, Resident #2 was provided with morning care, was unable to walk and had a significant bruise on their right hip. Resident #2 was sent out to the hospital for x-rays, and it was determined that they had a fractured right hip. [...]

Inspectors wroteBased on record review and staff interviews conducted during an abbreviated survey the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown origin were reported immediately, but not later than 2 (two) hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the New York State Department of Health. This was evident for 2 (two) of 6 (six) residents reviewed for injury of unknown origin. (Resident #2 and Resident #3). Specifically, 1) On 12/26/2025, Resident #2 was provided with morning care, was unable to walk and had a significant bruise on their right hip. Resident #2 was sent out to the hospital for x-rays, and it was determined that they had a fractured right hip. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey the facility did not ensure accidents of unknown origin were thoroughly investigated for 2 (two) of 6 (six) residents reviewed for accidents (Resident #2 and Resident #3). Specifically, 1) On 12/26/2025, Resident #2 was provided with morning care, was unable to walk and had a significant bruise on their right hip. Resident #2 was sent out to the hospital for x-rays, and it was determined that they had a fractured right hip. There was no indication of how this occurred, no facility investigation, and no report to the New York State Department of Health. 2) On 12/15/2025, Resident #3 was noted to have a bruise on their left leg, was transferred to the emergency department on 12/19/2025 and diagnosed with a fracture of unknown origin to their left tibia and fibula. [...]

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (544161), the facility did not ensure that adequate supervision and safety monitoring interventions were consistently implemented and documented to prevent accidents and recurrence of self-injurious behaviors for one (Resident #1) of one resident reviewed for accidents. Specifically, Resident #1 who was severely cognitively impaired and care planned as ha having behavior of chewing on nonfood items, was transferred to the hospital on [DATE] for evaluation after biting their left middle finger. Resident #1 had a portion of their left middle finger amputated and was diagnosed with self-inflicted traumatic amputation of the left finger. Resident #1 returned to the facility on [DATE] with an initial physician's order for hourly safety checks which was changed to 15 minute safety checks on 3/13/2024. [...]

Inspectors wroteBased on record reviews and interviews conducted during an abbreviated survey (2620167), the facility did not ensure the Medical Director fulfilled their responsibility for the implementation of resident care when the resident died. This was evident for 1 of 3 residents reviewed for death. Specifically, Resident # 1 died on [DATE] and the Medical Director signed the death certificate electronically on [DATE]. In accordance with State Public Health Law 4041, this was required within 72 hours of death. Resident #1's diagnoses include, but not limited to, Dementia, repeated falls, chronic kidney disease stage 3, and basal cell carcinoma of skin of nose. A significant change Minimum Data Set, dated [DATE] documented Resident #1 had a brief interview for mental status score of 09; indicating the resident has moderate cognitive impairment with no behaviors present. [...]

Inspectors wroteBased on record review and interviews the facility failed to initiate and complete a thorough investigation of an alleged violation of abuse to prevent further potential abuse. Specifically , On 3/2125 at 12:00pm Resident #1 was at the nurse's station and 3 staff witnessed (Certified Nurse Aide #1 and #2 and Domestic Aide #1)and reported to different Registered Nurses (Registered Nurse #1 and #2) and to the Director of Nursing that they witnessed an incident where Resident #1 was picked up from behind in a bear hug and dropped on the floor and then carried to their room by Domestic Aide #2. There was no evidence that the nursing staff reported the allegation of abuse to the facility Administrator or that they conducted an investigation into the allegations of abuse. Resident #1 had diagnoses including Unspecified Dementia, Mood Disturbance, and Non-Alzheimer Dementia. [...]

Inspectors wroteBased on record reviews, and interviews conducted during a Complaint survey (NY00376081) the facility did not ensure that services provided met professional standards of quality. This was evident for 1 (Resident #1) of 3 residents reviewed for Medication Administration. Specifically, Resident #1 was administered an intramuscular injection of Lorazepam solution 1 MG that had been prescribed for another resident.

Inspectors wroteBased on record review and interviews conducted during an abbreviated and extended survey (NY00376081), the facility did not ensure that all nursing staff were competent and trained in providing care to residents with various psychiatric/mood disorders as listed in the current facility assessment. Specifically, 1 (Resident #1) of 4 residents with psychiatric diagnoses do not have staff in the facility that are trained to provide appropriate behavioral health care. The facility was unable to provide documented evidence that they provided nursing staff education on behavioral health training other than for dementia. Resident #1 Minimum Data Set, dated [DATE] with diagnoses unspecified dementia, moderate with mood disturbance. non traumatic brain dysfunction, non-Alzheimer's dementia. No behaviors are noted. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY00333577 and NY00320085) from 9/22/2024 to 9/27/2024, the facility did not ensure that the residents environment remained as free of accident hazards as possible for 2 (Residents #219 and #95) of 7 residents reviewed for accidents. Specifically, 1. Resident #219 who- was being transferred via Mechanical lift by two certified nurse aides, fell from the mechanical lift due to the battery dying and Certified Nurse Aides #20 and #23 unhooking the straps instead of using the emergency lower button, subsequently causing a hematoma (large pool of blood under the skin resulting from injury) to the back of Resident #219's head which resulted in them having to be transferred to the emergency room for further evaluation. 2. [...]

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 9/22/24 to 9/27/24, the facility did not ensure that food was stored in accordance with professional standards for food safety practice, and essential equipment was not in safe operating condition. Specifically, 1. Food was stored in the walk-in freezers and refrigerators that was unlabeled, undated and without expiration dates. 2. Expired foods were stored in refrigerators and the dry storage room. 3. Freezers #6 and #7's insulation door seals were not attaching properly causing the formation of ice on the ceiling and walls inside the freezers. 4. Damaged tile flooring next to the dishwashing machine formed an uneven and wobbly surface.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated surveys (NY 00351488 and NY 00335211) from 9/22/24 to 9/27/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule for multiple days and on all three shifts of staffing for each floor, the facility did not provide adequate staffing to meet the needs of the residents.

Inspectors wroteBased on observation and interview conducted during the Recertification survey from 9/22/24 to 9/27/24, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, food was served out of temperature (chicken, pasta, vegetables, and milk).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 9/22/24 to 9/27/24, the facility did not ensure that the residents had a right to make choices about aspects of his or her life in the facility that are significant to the resident for 1(Resident #110 ) of 1 residents reviewed for Choices. Specifically, Resident #110 was moved from their room(163) on 9/22/24 to another room(169) while the ceiling in their room was being repaired, and on 9/23/24 when the repair was completed, Resident #110 was not moved back into their room as per their preference until 9/26/24.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 9/22/24 to 9/27/24, the facility did not ensure that the residents had a right to a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (Resident #34 and #110 ) of 5 residents reviewed for Environment. Specifically, the ceiling in room [ROOM NUMBER] on Unit 2 where Residents #34 and #110 resided, was observed with a large hole in the ceiling, a basin on the floor that was collecting water, with a bed pad underneath.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and complaint (NY00335402) survey from 9/22/2024 to 9/27/2024, the facility did not ensure that all alleged violations involving misappropriation of resident property were reported to the New York State Department of Health. This was evident for 1 (Resident #49) of 3 residents reviewed for abuse. Specifically, the facility did not report an allegation that Resident #49's gold necklace was removed by a staff member and never returned to the resident.

Inspectors wroteBased on interview and record review and observation during the recertification survey from 9/22/24-9/27/24, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standard of practice for 1 of 2 residents (Resident #105) reviewed for Respiratory Care. Specifically, oxygen was applied to Resident #105 and did not have a physician order.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 9/22/24 to 9/27/24, the facility did not ensure that the Physician reviewed the resident's total program of care, including medications, and treatments, at each visit for 1(Resident #107 ) of 1 residents reviewed for Hospice. Specifically, Resident #107 was admitted to the facility on [DATE], on Hospice, had no Physicians order to receive Hospice services.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00311382), the facility did not immediately notify the designated representative (DR) and/or Health Care Proxy (HCP) when there was a significant change in Residents medical/clinical status. This was evident for 1 of 3 residents (Resident #1) reviewed for notification. Specifically, Resident #1 tested positive for covid on 02/15/2023. The HCP was not informed until 02/22/2023 when the HCP was contacted by the facility regarding Resident #1's chest X-ray results.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey conducted from 12/27/2022 -1/5/2023, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident population in accordance with resident needs identified in the facility assessment. Specifically, three of four resident care units reviewed for sufficient staff did not consistently have adequate staff to meet the needs of the residents as per the facility staffing minimum. In addition, during a Resident Counsel meeting held on 1/3/23, four residents (#38, 63, 37, and 75) verbalized that staffing was inadequate.

Inspectors wroteBased on observation, record review and interview conducted during Recertification Survey, the facility did not ensure that care was provided in a manner to maintain dignity for 2 of 2 residents (#23 and #72) reviewed for dignity. Specifically, the urinary foley catheter tubing and drainage collection bag for Resident #23 and #72 were not covered with a privacy cover to prevent direct observation by other residents and their families.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey conducted from 12/27/22 to 1/05/2023, the facility did not ensure that a resident's representative was made aware of the facility's bed hold policy before and upon transfer to a hospital for 1 of 3 residents reviewed for Closed Record Review. Specifically, Resident #62 was transferred to the hospital on [DATE] for an evaluation and the facility did not give advance notice of the bed hold policy to the resident/resident's representative prior to the transfer.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey conducted from 12/27/2022 -1/5/2023, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for 1 of 3 residents (Resident #63) reviewed for ADL's. Specifically, Resident # 63 did not consistently receive twice a week showers as per the CNA (Certified Nursing Assistant) Accountability and the unit shower schedule.

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey, the facility did not ensure a resident with limited range of motion (ROM) and mobility received appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. Specifically, a splint device was not provided to the resident as per physician order. This was evident in 1 of 1 resident (Resident #66) reviewed for ROM care and services. The findings Are: The facility policy and procedure titled Splint, Braces, Casts and Immobilizers (assistive devices) undated documented the following: the facility will access each splint, brace, cast and immobilizer to ensure proper placement fitting, minimal pressure and proper placement and cleaning. Nursing and rehab will collaborate as necessary for resident safety and comfort. [...]

Inspectors wroteBased on interview and record review during the Recertification Survey conducted between 12/27/2022-1/5/2023, the facility failed to employ qualified staff with the appropriate competencies and skills to carry out the function of the food and nutrition services. Specifically, the Diet technician was a full-time employee at the facility, but did not have a certification and the Registered Dietician was remotely employed 8 hours per week and did not report to the facility.

Inspectors wroteBased on observations, record review, and interviews during a Recertification Survey conducted from 1/27/2022-1/4/2023 the facility did not ensure that each resident received, and was provided food that accommodated resident allergies, intolerances, and preferences, for one Resident (#95) of three residents reviewed for nutrition. Specifically, the facility did not ensure Resident #95 who was allergic to pineapple was not given pineapple on their meal tray.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 12/27/22-1/05/23, the facility did not ensure that food was prepared and served in accordance with professional standards for food safety. This was evident during the Kitchen Task observation. Specifically, the cook and 2 food service technicians were observed in the kitchen with their face masks pulled down off their noses and mouths, the cook, who is bearded, was observed without a beard cover, and the Maintenance Assistant was observed in the kitchen without a hair net.

Inspectors wroteBased on interviews and record review during a Recertification Survey the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Nursing Staff documented on two occasions in medical record assistive devices were applied to prevent further decrease in range of motion when they were not being provided. This was evident for 1 of 1 resident (Resident #66) reviewed for Positioning and Mobility. The finding is: The facility policy and procedure titled Splint, Braces, Casts and Immobilizers (assistive devices) undated documented the following: the facility will access each splint, brace, cast and immobilizer to ensure proper placement fitting, minimal pressure and proper placement and cleaning. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 12/27/2022-1/4/2023 the facility did not ensure that an infection prevention and control program was established and maintained to prevent the transmission of a Multi Drug Resistant Organism for 1 of 1 (#47) resident reviewed for Infection Control. Specifically PTA #1 ( Physical Therapist Aide) did not use appropriate Personal Protective Equipment (PPE) when providing services for Resident # 47, who had a Multi Drug resistant Organism and was on contact precautions.

Inspectors wroteBased upon observations, interview and record review conducted during the recertification survey, the facility did not ensure that information regarding resident Advance Directive (a legal document in which a person specifies what actions should be taken if they are no longer able to make decisions for themselves because of illness or incapacity) was consistently and accurately documented for 1 (Resident #6) of 2 residents reviewed for Advance Directives. Specifically, the residents' physician's orders, certified nurse's aide care guide, and the hard copy medical record all documented the resident's Advance Directive status as Do Not Resuscitate (DNR; [...]

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that an allegation of staff to resident abuse was fully investigated. Specifically, the facility did not conduct a full investigation regarding an allegation of staff to resident abuse made by the resident's family member. This was evident for one resident (Resident # 60) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that an allegation of staff to resident abuse was fully investigated. Specifically, the facility did not conduct a full investigation, including but not limited to resident assessment and staff interviews, regarding an allegation of staff to resident abuse made by the resident's family member, to determine if abuse occurred or if the incident should have been reported to the State. This was evident for one resident (Resident # 60). In addition, the facility did not ensure that an allegation of resident to resident abuse was fully investigated for 2 of 2 residents (#39 and #58).

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey the facility did not ensure that residents or their representatives were given timely written notification of the transfer and the reasons in a language and manner they understood. This was evident for 2 of 2 residents (#107 and #6) reviewed for hospitalization.

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that interventions were implemented according to the plan of care. This was evident for 2 of 3 residents reviewed for implementation of the care plan. Specifically, 1. there was no documented evidence that a urinalysis (U/A) and culture and sensitivity (C/S) were obtained for a resident with symptoms of urinary tract infection ( UTI ) (Resident #102) 2. there was no documented evidence that a dialysis site was assessed for signs of infection. (Resident #108).

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that care and treatment was provided for a resident with a history of urinary tract infection (UTI). This was evident for 1 of 3 residents reviewed for urinary tract infection. (Resident #102).

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure for 1 of 1 resident (Resident #108) reviewed for dialysis that 1.there was ongoing communication between the dialysis center and the facility regarding the resident's response to dialysis treatment and 2. that nurses were assessing the dialysis site for signs and symptoms (s/s) of infection, bleeding, and the presence of bruit and thrill.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure for 1 of 6 residents reviewed for unnecessary medications (#26) that the monthly medication regimen reviews (MMR) were consistently conducted by the consultant pharmacist. The finding is: Resident #26 was admitted to the facility on [DATE] with diagnoses including Non Alzheimer Dementia, Anxiety, and Depression. The 3/31/19 Annual MDS (Minimum data Set: an assessment tool), revealed the resident had severe cognitive impairment. The MDS further revealed the resident was prescribed an antipsychotic (Abilify), antidepressants (Trazadone and Celexa), an anticoagulant (Coumadin) and a diuretic (Lasix). Review of the record revealed the MMR reviews for the last 6 months were only completed on 2/28/19, 3/28/19 and 8/14/19. [...]