A list of the most recent deficiencies for Sullivan Park 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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| Provide activities to meet all resident's needs. | 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 enough food/fluids to maintain a resident's health. | Health | 2023-12-21 | 2024-01-29 | 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 | 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 |
| Ensure medication error rates are not 5 percent or greater. | 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 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 |
| 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 |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Establish methods for sharing information. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-18 | 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 | 2023-12-18 | 2024-01-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-18 | 2024-01-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-12-18 | 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 |
| Provide and implement an infection prevention and control program. | Health | 2023-04-17 | 2023-05-08 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Meet other general requirements. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-14 | 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 | 2022-06-14 | 2022-07-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-06-14 | 2022-07-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-08 | 2022-06-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-08 | 2022-06-27 | Y |
| 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 |
| Respond appropriately to all alleged violations. | 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| Provide activities to meet all resident's needs. | 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 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 |
| 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 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-23 | 2022-04-18 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-23 | 2022-04-18 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-23 | 2022-04-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-23 | 2022-04-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-07 | 2021-06-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-23 | 2021-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-06-23 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-18 | 2019-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-18 | 2019-06-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-04-18 | 2019-06-14 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-18 | 2019-06-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-18 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-18 | 2019-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-22 | 2019-05-24 | N |
