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Deficiency Records for Sullivan Park Care Center
View the most recent health deficiencies and inspection results for Sullivan Park Care Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Sullivan Park Care Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-03-06 | 2025-04-11 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2025-03-06 | 2025-04-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-03-06 | 2025-04-11 | 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 | 2025-03-06 | 2025-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-03-06 | 2025-04-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-03-06 | 2025-04-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2025-03-06 | 2025-04-11 | 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 | 2025-03-06 | 2025-04-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-03-06 | 2025-04-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-03-06 | 2025-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-06 | 2025-04-11 | 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 | 2025-03-06 | 2025-04-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2025-03-06 | 2025-04-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2025-03-06 | 2025-04-11 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2025-03-06 | 2025-04-11 | 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 | 2025-03-06 | 2025-04-11 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-03-06 | 2025-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-06 | 2025-04-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-03-06 | 2025-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-06 | 2025-04-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-03-06 | 2025-04-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-03-06 | 2025-04-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-03-06 | 2025-04-11 | 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 | 2025-03-06 | 2025-04-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-03-06 | 2025-04-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-03-06 | 2025-04-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-03-06 | 2025-04-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-06 | 2025-04-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-03-06 | 2025-04-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-06 | 2025-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-06 | 2025-04-11 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-03-06 | 2025-04-11 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-03-06 | 2025-04-04 | 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 | 2025-03-06 | 2025-04-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-03-06 | 2025-04-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2025-02-14 | 2025-03-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-01-16 | 2024-12-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-09-09 | 2024-10-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-09 | 2024-10-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-10-08 | 2024-10-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-10-08 | 2024-10-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-08 | 2024-10-29 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-09-09 | 2024-10-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-09 | 2024-10-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-09 | 2024-10-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-09 | 2024-10-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-09-09 | 2024-10-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-09 | 2024-10-29 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-09-09 | 2024-10-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-09 | 2024-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-09 | 2024-10-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-29 | 2024-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-29 | 2024-03-21 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-29 | 2024-03-21 | Y |
| 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 | 2023-12-21 | 2024-01-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-21 | 2024-01-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-21 | 2024-01-29 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-21 | 2024-01-29 | 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 | 2023-12-21 | 2024-01-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-21 | 2024-01-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-21 | 2024-01-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-21 | 2024-01-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-01-29 | 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 | 2023-12-21 | 2024-01-29 | 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 | 2023-12-21 | 2024-01-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-21 | 2024-01-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-21 | 2024-01-29 | N |
| Establish methods for sharing information. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-21 | 2024-01-22 | 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 | 2023-12-21 | 2024-01-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-21 | 2024-01-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-06 | 2023-11-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-06 | 2023-11-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-06 | 2023-11-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-12 | 2023-11-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-12 | 2023-11-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-12 | 2023-11-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-11-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-22 | 2023-09-15 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Meet other general requirements. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-17 | 2022-07-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-17 | 2022-06-27 | 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 | 2022-06-17 | 2022-06-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-17 | 2022-06-27 | 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 | 2022-06-17 | 2022-06-27 | 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 | 2022-06-17 | 2022-06-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-17 | 2022-06-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-17 | 2022-06-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-17 | 2022-06-27 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-06-17 | 2022-06-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-17 | 2022-06-27 | 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 | 2022-06-17 | 2022-06-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-17 | 2022-06-27 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-17 | 2022-06-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-17 | 2022-06-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-17 | 2022-06-27 | 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 | 2022-06-17 | 2022-06-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-17 | 2022-06-27 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-17 | 2022-06-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-17 | 2022-06-27 | N |