Sullivan Healthcare & Senior Living

Inspectors wroteBased on interview and record review, the facility failed to monitor vital signs and laboratory results and assess/monitor/document/report changes in condition for one of three residents (R1) reviewed for falls in the sample list of 16. This resulted in R1 being sent to the hospital 4 days after a fall, being diagnosed with a brain breed and later dying.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly trust fund statements for two of three residents (R12, R13) reviewed for resident funds in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to report a trust fund account met the Supplemental Security Income (SSI) limit which could affect eligibility for Medicaid or SSI for one of three residents (R15) reviewed for resident funds in the sample list of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent access to fluids to maintain adequate hydration for one (R9) of three residents reviewed for hydration on a sample of three. On 6/15/26 at 10:20 AM, R9 was observed sitting in a wheelchair in front of the television, calling out and asking for a drink of water. Due to R9's total visual impairment, R9 was unaware that the water cup on the over-bed table was half full. The over-bed table was pushed against the wall next to the bedside table, placing it completely out of R9's reach. Although the call light was resting in R9's lap, it was not used to summon assistance. R9's Minimum Data Set (MDS) documents the resident is cognitively intact with little to no cognitive impairment. The care plan, dated 5/19/26, identifies R9 as visually impaired and includes the following interventions: [...]

Inspectors wroteBased on interview and record review, the facility failed to administer resident showers to residents dependent on staff to receive showers. This failure affects four residents (R4, R5, R6, and R9) out of six reviewed for showers on the sample list of eighteen.

Inspectors wroteBased on interview and record review the facility failed to repeatedly prevent a significant medication error for one (R2) resident out of three residents reviewed for significant medication errors in a sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to initiate and update fall care plans, failed to implement fall interventions, failed to thoroughly investigate falls for two (R3 and R7) residents out of four residents reviewed for Accidents in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to maintain timely call lights response times. This failure affected three of four residents (R2, R3, R4) reviewed for call lights on the sample list of four. Findings Include: The facility's Call System, Residents policy dated September 2022 documents each resident is provided with a means to call staff for assistance through a communication system. Calls for assistance should be answered as soon as possible but no later than five minutes. Any urgent requests for assistance need to be addressed immediately. 1. R2's Medical Diagnoses List dated March 2026 documents R2 is diagnosed with Chronic Kidney Disease, Severe Protein Calorie Malnutrition, Adult Failure to Thrive, Rheumatoid Arthritis, Malaise, and Pressure Ulcer of the Sacral Region Stage II. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member. This failure affects one (R2) of three residents reviewed for abuse in the sample list of 10.

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to be free from physical abuse by another resident for two of five residents (R2, R3) reviewed for abuse in the sample list of 17. This failure resulted in R2 obtaining lacerations to his Left Face, Left Upper Lip and Left Ear requiring treatment in the emergency room and experiencing pain and fear after R3 punched R2 in the face.

Inspectors wroteBased on observation, interview and record review the facility failed to employ a Certified Dietary Manager (CDM). This failure has the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain kitchen sanitation, failed to obtain temperatures of cold stored foods and foods prepared for meal service. These failures have the potential to affect all 71 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the dignity of three (R10, R11, R12) residents by not providing Activities of Daily Living (ADL) timely out of six residents reviewed for ADL's in a sample list of 17 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely and complete incontinence care for three residents (R9, R10, R13) out of six residents reviewed for Activities of Daily Living (ADL) in a sample list of 17 residents.

Inspectors wroteBased on interview and record review the facility failed to report a resident's allegation of staff to resident abuse for one of five residents (R1) reviewed for Abuse in a sample list of 17 residents.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a Registered Nurse (RN) eight consecutive hours a day, seven days a week. This failure has the potential to affect all 70 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 70 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for physical cross-contamination of food and failed to maintain sanitary walk-in cooler floor surfaces. These failures have the potential to affect all 70 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the Director of Nursing, (required personnel) attended the quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 70 residents residing in the facility. Findings Include:The facility QAPI (Quality Assurance and Performance Improvement) Plan for (the facility name) dated 5/19/24 documents, At minimum the Regional Team and Facility Management team, along with the QAPI Steering Committee, will conduct a facility-wide system evaluation utilizing QAPI Self-Assessment. The facility provided accompanying document states the QAA meeting is conducted every three months and includes Key Personnel. A second document was provided with a list of Key Personnel. This list included V2, Director of Nursing. The facility QA Meeting typed sign-in sheet documents key personnel. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a homelike environment for two (R7, R25) residents out of two residents reviewed for homelike environment in a sample list of 35 residents. 1). R25's Minimum Data Set (MDS) dated [DATE] documents R25 as cognitively intact. On 8/12/25 at 1:00 PM R25 was laying on her bed directly on the fitted sheet. R25's fitted sheet had several brown colored stains and was worn through so that the mattress could be seen. On 8/14/25 at 10:40 AM R25 was laying on her bed directly on her fitted sheet. R25's sheet was worn with three brown stains that were several inches in diameter. On 8/12/25 at 1:05 PM R25 stated the staff bring her clean sheets that are stained. R25 stated she would prefer to have sheets without 'someone else's stains' on them. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide bathing and timely incontinence cares for a resident dependent on staff for hygiene. This failure affects one resident (R21) of two reviewed for Activities of Daily Living on the sample list of 35.

Inspectors wroteBased on observation, interview and interview the facility failed to ensure the dignity of one (R7) resident out of three residents reviewed for dignity in a sample list of 35. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as severely cognitively impaired. This same MDS documents R7 is dependent on staff for transferring, toileting, bathing, dressing, bed mobility, eating and personal hygiene. 08/13/2025 8:00 AM R7 was reclined in her wheelchair in the resident lounge with other residents and staff present. R7 had a thick line of white mucous hanging from her Right lower cheek to the Right corner of her mouth. On 8/14/25 at 9:00 AM R7 was laying in her recliner in the resident lounge with other residents present. R7 had dried, thick white mucous on her lips and corners of her mouth. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to initiate a grievance report in a timely manner, resulting in a delay in resolving the resident grievance. This failure affects one of two residents (R37) reviewed for grievances on the sample list of 35.

Inspectors wroteBased on record review and interview, the facility failed to accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding falls. This failure affects one of two residents (R3) reviewed for falls/resident assessments on the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to identify, assess and provide treatment for pressure sores for one of one resident (R7) reviewed for pressure sores in a sample list of 35 residents. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as severely cognitively impaired. This same MDS documents R7 is dependent on staff for transferring, toileting, bathing, dressing, bed mobility, eating and personal hygiene. R7's Care plan intervention dated 3/28/23 instructs staff to float R7's heels in bed as needed, use pillows /cushions between to prevent skin to skin contact legs/ankles and feet, avoid pressure off feet against footboard, and avoid pressure of toes against mattress, rails, or footboard. R7's Physician Order Set (POS) dated August 2025 documents a physician order starting 11/01/2022 to complete a daily skin check. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor, and notify physician to obtain treatment orders timely and failed to implement care plan interventions for one (R2) resident's documented open buttock wounds out of three residents reviewed for incontinence care in a sample list of seven residents. This failure resulted in R2's reddened bilateral buttock areas to deteriorate to open wounds.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care and failed to provide timely incontinence care for one (R2) out of three residents reviewed for timeliness of incontinence cares in a sample list of seven residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide lifesaving equipment for emergency airway management, for a resident in cardiac and respiratory arrest. This failure affected one of 18 residents (R1) reviewed for advanced directives and has the potential to affect all 72 residents residing in the facility. R1 subsequently expired. The Immediate Jeopardy began on [DATE] when R1 was found to have no pulse or respirations and Cardiopulmonary Resuscitation (CPR) was initiated. Staff could not locate a functional bag valve mask (BVM) mask to provide a full seal over R1's nose and mouth, in order to provide effective ventilation during the medical emergency. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 1:58 pm. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement post fall interventions for (R2 and R3), and failed repeatedly to recognize, document and investigation falls from bed (R3). These failures affected two of four residents (R2, R3) reviewed for falls on the same list of 25.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from verbal and physical abuse by another resident. These failures affect four (R1, R2, R3, R4) residents out of four residents reviewed for abuse in a sample list of seven residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were informed of and understood their rights, while living in the nursing home. This failure has the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to deliver mail to residents on Saturdays. This failure has the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a qualified Director of Food and Nutrition Services. This failure has the potential to affect nearly all 71 residents residing in the facility, who consume food prepared in the facility kitchen (with the exception of four residents who receive nothing by mouth).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement food storage and leftover tracking processes, failed to maintain bulk food cleanliness, and failed to maintain kitchen equipment cleanliness to prevent the potential for food contamination. These failures affect nearly all 71 residents residing in the facility who consume food prepared in the facility kitchen (all with the exception of four residents who receive nothing by mouth).

Inspectors wroteBased on observation, interview and record review the facility failed to provided Activities of Daily Living assistance (ADL's) for six out of seven residents (R12, R17, R32, R38, R40 and R48) reviewed for ADL's assistance on the sample list of 28.

Inspectors wroteBased on observations, interviews and record review the facility failed to implement enhanced barrier precautions that required personal protective equipment to be used during care for residents with Tracheostomy airway access, Gastrostomy feeding tubes, pressure ulcers, urinary catheters and intravenous access port. This failure affected five of five residents (R12, R14, R15, R39 and R62) reviewed for enhanced barrier precautions on the sample list of 28.

Inspectors wroteBased on interview and record review the facility failed to notify a family representative of a decrease in dosage of antipsychotic medication. This failure affected one of one resident (R35) reviewed for family notification on the sample list of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to resolve a resident representative grievance to provide a specialized wheelchair in a timely manner. This failure affects one of one residents (R35) reviewed for grievances on the sample list of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to remove secured hand mitten restraints according to the plan of care, for one of one residents (R17) reviewed for restraint on the sample list of 28.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualize care plan to include an indwelling urinary catheter for a resident. This failure affects one (R39) of 20 residents reviewed for care plans in a sample of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to assess new, facility acquired Stage II pressure ulcers upon notification, resulting in a delay in initiating a pressure ulcer treatment in a timely manner. This failure affected one of two residents (R14), reviewed for pressure ulcers on the sample list of 28.

Inspectors wroteBased on observation and record review, the facility failed to maintain NPO (nothing by mouth) status by administering a medication to a resident with a tracheostomy. This failure affected one resident (R15) during medication pass observation.

Inspectors wroteBased on observation, interview and record review the facility failed to provide rehabilitation services to four (R1, R2, R3, R4) residents out of four residents reviewed for Rehabilitation Services in a sample list of four residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse for eight consecutive hours seven days per week. This failure has the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a Level 2 Pre-admission Screen to determine any needed psychiatric services. This failure affects one resident (R13) out of two reviewed for Pre-admission Screening on the sample list of 27.

Inspectors wroteBased on interview and record review, the facility failed to assist dependent residents with showering. This failure affected two of two residents (R23, R62) reviewed for Activities of Daily Living on the sample list of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change residents' oxygen tubing, nebulizer tubing, humidifier bottles and failed to provide sanitary storage for those items. The facility also failed to clean machines and provide sanitary storage for Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPap) machines. These failures affect three of four residents (R19, R62, R37) reviewed for respiratory care on the sample list of 27. Findings Include: The Oxygen Therapy Policy dated March 2019 documents staff are to change oxygen tubing/mask/cannula on a weekly basis. Date tubing changes and document on the treatment sheet. If using unfilled humidifier bottles; empty, rinse and refill daily with distilled water, and wash with soap and water as needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate resident medical records. This failure affected one of 27 residents (R25) reviewed for medical records on the sample list of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove contaminated gown and gloves before leaving a contact isolation room, during pressure ulcer treatment. This failure affected one of two residents (R2) reviewed for pressure ulcer/transmission-based precautions on the sample list of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 65 residents residing in the facility.