A list of the most recent deficiencies for Sullivan County Adult Care Center. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-18 | 2023-12-18 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-07-07 | 2023-07-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-05 | 2023-03-05 | 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 | 2023-01-05 | 2023-03-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-05 | 2023-03-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-01-05 | 2023-03-05 | 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 | 2023-01-05 | 2023-03-05 | 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 | 2023-01-05 | 2023-03-05 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-05 | 2023-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-05 | 2023-03-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-05 | 2023-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-05 | 2023-03-05 | 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 | 2023-01-05 | 2023-03-05 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-01-05 | 2023-03-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-05 | 2023-03-05 | 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 | 2023-01-05 | 2023-03-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-05 | 2023-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-05 | 2023-03-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-05 | 2023-03-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-18 | 2023-01-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-18 | 2023-01-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-01 | 2022-09-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-01 | 2022-09-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-01 | 2022-09-29 | Y |
| 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 | 2019-09-04 | 2019-11-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-04 | 2019-11-01 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-04 | 2019-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-04 | 2019-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-04 | 2019-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-04 | 2019-11-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-04 | 2019-11-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-04 | 2019-11-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-09-24 | 2019-10-24 | 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 | 2019-09-24 | 2019-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-09-24 | 2019-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-11-02 | 2017-12-27 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2017-11-02 | 2017-12-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-11-02 | 2017-12-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-11-02 | 2017-12-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-11-02 | 2017-12-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-11-02 | 2017-12-27 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2017-11-02 | 2017-12-16 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-02 | 2017-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-11-02 | 2017-12-15 | N |
