A list of the most recent deficiencies for Life Care Center of Sullivan. 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? |
|---|---|---|---|---|
| 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 | 2023-08-17 | 2023-10-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-17 | 2023-10-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-17 | 2023-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-17 | 2023-10-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-17 | 2023-10-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-17 | 2023-10-01 | N |
| Post nurse staffing information every day. | Health | 2023-08-17 | 2023-10-01 | 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 | 2023-08-17 | 2023-10-01 | 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 | 2023-08-17 | 2023-10-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-17 | 2023-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-10-01 | 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 | 2023-08-17 | 2023-10-01 | N |
| Use approved construction type or materials. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-17 | 2023-10-01 | 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 | 2023-08-17 | 2023-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-08-17 | 2023-10-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-02 | 2023-06-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-20 | 2022-06-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-20 | 2022-06-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-10 | 2022-03-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-02-10 | 2022-03-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-10 | 2022-03-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-02-10 | 2022-03-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-10 | 2022-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-10 | 2022-03-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-05 | 2021-07-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-05 | 2021-07-06 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-08 | 2019-09-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-08 | 2019-09-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-08 | 2019-09-20 | 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 | 2019-08-08 | 2019-09-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-08-08 | 2019-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-08 | 2019-09-20 | N |
