Deficiency Records for Sullivan Rehab and Hlth Care Ctr
Updated as of May 01, 2022
This is not the most recent data for Sullivan Rehab and Hlth Care Ctr. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-04 | 2021-02-15 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-02-04 | 2021-02-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-24 | 2020-01-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-30 | 2019-11-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-30 | 2019-11-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-30 | 2019-11-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-08 | 2019-10-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-08 | 2019-10-30 | N |
| Have enough space near smoke barriers to protect residents. | Fire Safety | 2019-10-08 | 2019-10-30 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-11 | 2019-10-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-07-10 | 2019-07-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-24 | 2018-09-10 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-08-24 | 2018-09-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-08-24 | 2018-09-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-08-24 | 2018-09-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-24 | 2018-09-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-08-24 | 2018-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-24 | 2018-09-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-08-24 | 2018-09-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-24 | 2018-09-10 | 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 | 2018-08-24 | 2018-09-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-08-24 | 2018-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-24 | 2018-09-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-08-24 | 2018-09-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-08-24 | 2018-09-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-08-24 | 2018-09-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-08-28 | 2018-09-10 | 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 | 2018-08-28 | 2018-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-28 | 2018-09-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-28 | 2018-09-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-28 | 2018-09-10 | N |
