A list of the most recent deficiencies for Sullivan Rehab and Hlth Care Ctr. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-04 | 2023-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-04 | 2023-08-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-04 | 2023-08-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-04 | 2023-08-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-04 | 2023-08-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-04 | 2023-08-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-04 | 2023-08-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-01 | 2023-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-01 | 2023-08-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-14 | 2023-08-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-14 | 2023-08-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-06 | 2023-04-23 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-04-06 | 2023-04-23 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-05 | 2022-10-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-02 | 2022-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-02 | 2022-09-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-02 | 2022-09-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-04 | 2022-01-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-18 | 2021-12-01 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-06-25 | 2021-07-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-06-25 | 2021-07-12 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-06-25 | 2021-07-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-25 | 2021-07-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-25 | 2021-07-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-06-17 | 2021-07-05 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-06-17 | 2021-07-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-06-25 | 2021-06-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-06-25 | 2021-06-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-25 | 2021-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-25 | 2021-06-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-17 | 2021-06-26 | N |
| Provide or obtain dental services for each resident. | Health | 2021-06-17 | 2021-06-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-17 | 2021-06-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-17 | 2021-06-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-17 | 2021-06-25 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-17 | 2021-06-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-17 | 2021-06-25 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-17 | 2021-06-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-17 | 2021-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-17 | 2021-06-25 | Y |
