Inspection Reports for
Life Care Center of Sullivan
875 DUNSFORD DR, SULLIVAN, MO, 63080-1238
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
15.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
182% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
56% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Census: 67
Deficiencies: 3
Date: Jun 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements following an incident where a resident sustained a burn injury from hot coffee and to evaluate the facility's care planning and treatment related to this injury and other resident care issues.
Findings
The facility failed to timely notify the physician and resident representative of a burn injury, did not update the resident's care plan to include interventions for the burn or smoking, and delayed treatment for the burn injury. Staff did not document treatment until two days after the injury, and care plans lacked necessary interventions.
Deficiencies (3)
F 0580: Facility staff failed to notify the physician and resident representative in a timely manner of a burn injury sustained by a resident. Notification occurred two days after the injury despite policy guidance.
F 0657: Facility staff failed to review and revise comprehensive care plans to include interventions for burns and smoking for two residents. Care plans were not updated after the burn injury or to address smoking.
F 0684: Facility staff failed to provide timely treatment to a resident's burn injury and did not document treatment interventions until two days after the injury. The care plan lacked guidance on hot liquid consumption monitoring.
Report Facts
Residents present: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in failure to notify physician and resident representative and failure to initiate treatment for burn injury |
| Assistant Director of Nursing | Interviewed regarding expectations for notification and care plan updates | |
| interim Director of Nursing | Interviewed regarding care plan update responsibilities | |
| Care Plan Coordinator | Interviewed regarding care plan update responsibilities and missed interventions | |
| Certified Nursing Assistant A | CNA | Interviewed regarding care plan usage and resident care |
| Certified Nursing Assistant B | CNA | Witnessed coffee spill incident and notified nurse |
| Resident's physician | Interviewed regarding notification expectations and treatment approval |
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 2
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to investigate allegations of abuse and neglect involving resident altercations and to assess compliance with abuse prevention and protective oversight regulations.
Findings
The facility failed to ensure a resident was free from physical abuse when one resident struck another in the face. Staff interventions to separate residents during altercations were inconsistent, and protective oversight procedures for residents on voluntary leave were not met.
Deficiencies (2)
F600 Freedom from Abuse and Neglect: The facility failed to prevent physical abuse when Resident #2 struck Resident #1 in the face. Staff did not consistently implement interventions to separate residents during altercations.
A4074 Protective Oversight, Voluntary Leave: The facility did not have a minimum procedure to inquire about the resident's whereabouts and estimated length of absence while on voluntary leave.
Report Facts
Facility census: 66
Plan of correction completion date: Completion date set for 2025-04-18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Mayfield | Executive Director | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Mar 24, 2025
Visit Reason
The inspection was conducted following a complaint regarding physical abuse between two residents at the facility.
Complaint Details
The complaint investigation found substantiated physical abuse where Resident #2 slapped Resident #1 multiple times. Staff separated the residents but lacked clear interventions to ensure Resident #1's safety. Multiple staff interviews confirmed limited or no additional protective measures were implemented.
Findings
The facility failed to ensure one resident remained free from physical abuse when another resident struck him in the face. Staff separated the residents after the incidents but were unclear or unaware of additional interventions to keep the assaulted resident safe.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Resident #2 struck Resident #1 in the face, and staff did not implement sufficient interventions to prevent further altercations.
Report Facts
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Present during the altercation on 3/20/25 and reported on interventions |
| RN A | Registered Nurse | Documented the initial incident and updated care plans |
| NA D | Nurses Aide | Witnessed second altercation and reported on interventions |
| CNA E | Certified Nurse Aide | Present during the first altercation and reported no instructions given |
| RN C | Registered Nurse | Reported staff were told to keep Resident #2 away from nurse's station |
| CNA F | Certified Nurse Aide | Responded to first altercation and removed Resident #2 |
| CNA G | Certified Nurse Aide | Unaware of interventions to keep Resident #1 safe |
| Director of Nursing | Director of Nursing | Aware of the first altercation and staff instructions |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 16
Date: Oct 4, 2024
Visit Reason
Annual inspection survey conducted at Life Care Center of Sullivan to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including failure to post survey results, inadequate housekeeping and maintenance of shower rooms, failure to provide restorative nursing services documentation, improper hiring and use of nurse aides, food safety violations, and incomplete COVID-19 immunization education and documentation.
Deficiencies (16)
F577: Facility failed to post and make accessible the three most recent years of survey results to residents and family members.
F584: Facility failed to maintain a clean, safe, and homelike environment, evidenced by unclean shower rooms with dust, black substances, cracked tiles, and lack of maintenance work orders.
F688: Facility failed to provide restorative nursing services documentation and ensure residents received restorative therapy as ordered.
F728: Facility failed to ensure nurse aides completed training within four months of hire and used nurse aides who had not passed certification tests.
F803: Facility failed to serve food in accordance with nutritional guidelines and failed to follow menus and recipes properly.
F812: Facility failed to properly wash and sanitize dishes, maintain dishwasher temperature, and follow sanitation policies.
F887: Facility failed to provide adequate COVID-19 immunization education and documentation for residents and staff.
A3001: Building was not substantially constructed and maintained in good repair, violating physical plant requirements.
A4023: Nurse aide training program requirements were not met, including failure to complete basic training within four months.
A4081: Facility failed to provide restorative nursing to residents as ordered, including encouraging independence and activity.
A5001: Facility failed to meet nutritional needs of residents by not properly preparing and seasoning food according to physician orders.
A6031: Waste containers in food preparation areas were not kept covered when not in use.
A7073: Equipment cleaning sequence in sink was not properly followed, risking contamination.
A7076: Hot water sanitizing temperature was not maintained at required levels for dishwashing.
A7086: Utensils and equipment were not air dried or stored in a self-draining position after sanitization.
A8002: Facility failed to post noncompliance notices in a conspicuous location as required.
Report Facts
Facility census: 69
Plan of Correction completion date: Nov 12, 2024
Nurse Aide training timeframe: 4
Dishwasher sanitizing temperature: 180
Sanitizer concentration range: 150-400 ppm
Booster heater temperature: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Mayfield | Executive Director | Signed report and Plan of Correction |
| Director of Nursing | Interviewed regarding restorative nursing and nurse aide certification | |
| Licensed Practical Nurse B | LPN | Interviewed about shower room maintenance and work orders |
| Nurse Assistant E | NA | Interviewed about shower room cleaning responsibilities |
| Certified Nurse Assistant D | CNA | Interviewed about shower room cleaning and sanitizing |
| Housekeeper G | Interviewed about shower room cleaning schedule and conditions | |
| Housekeeping Supervisor | Interviewed about housekeeping responsibilities and schedules | |
| Maintenance Director | Interviewed about shower room maintenance and work orders | |
| Staffing Coordinator | Interviewed about nurse aide certification testing | |
| Dietary Manager | DM | Interviewed about food service and dishwasher issues |
| Cook O | Observed preparing and serving food | |
| Cook R | Observed washing dishes and food preparation | |
| Infection Preventionist | IP | Interviewed about COVID-19 vaccination policies |
Inspection Report
Life Safety
Census: 69
Capacity: 120
Deficiencies: 10
Date: Oct 4, 2024
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and emergency preparedness at the Life Care Center of Sullivan.
Findings
The facility was found deficient in developing and maintaining an emergency preparedness plan and communication plan, and in maintaining and testing the fire alarm system and fire drills. Deficiencies included failure to inspect and test smoke detectors, incomplete fire drill documentation, and failure to maintain generator testing and emergency power systems according to standards.
Deficiencies (10)
E006: The facility failed to develop and maintain an emergency preparedness plan based on a documented risk assessment including missing residents and emergency events.
E030: The facility failed to develop and maintain an emergency preparedness communication plan including names and contact information for staff, physicians, and other entities.
E031: The facility failed to include contact information for state licensing and certification agencies and the long-term care ombudsman in the emergency preparedness communication plan.
K345: The facility failed to inspect, test, and maintain the fire alarm system and smoke detectors in accordance with NFPA standards, including missing documentation and untested detectors.
K712: The facility failed to conduct required fire drills at various times and shifts, including failure to conduct a simulated resident evacuation drill annually.
K918: The facility failed to maintain and test the emergency generator and electrical systems according to NFPA standards, including missed inspections and incomplete documentation.
A2019: The facility failed to maintain complete fire alarm systems and testing in accordance with NFPA 72, 1999 edition.
A2058: The facility failed to have a written plan for fire drills and emergency preparedness including annual consultation with the local fire unit.
A2061: The facility failed to conduct a minimum of twelve fire drills annually including unannounced drills and simulated resident evacuation.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, 1999 edition.
Report Facts
Facility census: 69
Total capacity: 120
Deficiencies cited: 10
Inspection Report
Routine
Census: 69
Deficiencies: 7
Date: Oct 4, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident rights, environment, restorative care, staffing, nutrition, sanitation, and vaccination.
Findings
The facility failed to post survey results accessibly, maintain clean shower rooms, provide restorative nursing services, ensure nurse aide training compliance, serve food according to menus, properly sanitize dishes, and offer COVID-19 vaccinations to eligible residents.
Deficiencies (7)
F 0577: Facility staff failed to ensure the three most recent years of survey results were posted and accessible to residents and representatives.
F 0584: Facility staff failed to maintain a clean, safe, and homelike environment by inadequately cleaning and maintaining three of four shower rooms with dust, black substances, and damaged tiles.
F 0688: Facility staff failed to document provision of restorative therapy for two residents, and the facility lacked an active restorative nursing program.
F 0728: Facility staff failed to ensure two nurse aides completed required training within four months of hire and allowed them to provide care without passing CNA tests.
F 0803: Facility staff failed to serve food in accordance with nutritionally calculated recipes and menus for regular and easy to chew diets.
F 0812: Facility staff failed to properly wash and sanitize dishes, allow dishes to air dry before storage, and cover waste containers in food preparation areas.
F 0887: Facility staff failed to educate and offer COVID-19 vaccination to three sampled residents according to current guidelines and policy.
Report Facts
Facility census: 69
Number of meatballs served: 6
Dishwasher wash cycle temperature: 170
Dishwasher rinse cycle temperature: 118
Sanitizer concentration: 500
Nurse Aides not trained within 4 months: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA M | Nurse Aide | Failed CNA test but continued to provide care |
| NA N | Nurse Aide | Failed CNA test but continued to provide care |
| Director of Nursing | Director of Nursing | Acknowledged lack of active restorative nursing program and nurse aide training issues |
| Dietary Manager | Dietary Manager | Reported dishwasher issues and improper dishwashing practices |
| Administrator | Administrator | Acknowledged issues with survey posting, shower room cleaning, dishwasher repair, and vaccination policy adherence |
| Infection Preventionist | Infection Preventionist | Responsible for vaccination education and offering, acknowledged missed opportunities |
Inspection Report
Routine
Census: 69
Deficiencies: 11
Date: Aug 17, 2023
Visit Reason
Routine inspection of Life Care Center of Sullivan to assess compliance with regulatory standards including environment, resident care, medication management, staffing, infection control, and safety.
Findings
The facility was found deficient in maintaining a clean and homelike environment, timely and accurate resident assessments, medication management, staffing adequacy, infection control practices, and bed rail safety assessments. Multiple residents were affected by these deficiencies.
Deficiencies (11)
F 0584: Facility staff failed to maintain a clean, homelike, and comfortable environment with multiple areas of broken tiles, stained carpets, and strong odors observed throughout the facility.
F 0644: Facility staff failed to accurately complete or update PASARR documentation for two residents with serious mental illness, affecting care planning.
F 0658: Facility staff failed to obtain labs timely for one resident, failed to document pharmacist interventions for another, and performed blood sugar tests improperly for four residents.
F 0689: Facility staff failed to ensure resident safety by leaving disposable razors unsecured and improperly propelling residents in wheelchairs without foot pedals, risking injury.
F 0698: Facility staff failed to provide adequate nursing staff to meet resident care needs, resulting in missed showers, delayed assistance to bed, and inadequate meal assistance for several residents.
F 0732: Facility failed to post required nurse staffing information daily including total licensed and unlicensed staff per shift and resident census.
F 0758: Facility staff failed to perform gradual dose reductions on psychotropic medications for one resident and failed to limit PRN psychotropic medication orders to 14 days for two residents without documented rationale.
F 0761: Facility staff failed to ensure medications were stored safely with loose pills found in medication carts and expired medications found in storage rooms and over-the-counter cabinets.
F 0804: Facility staff failed to prepare pureed foods according to standardized recipes, resulting in inconsistent preparation and potential nutritional compromise.
F 0880: Facility staff failed to follow infection prevention and control procedures including hand hygiene, glove use, wound care, glucometer cleaning, and medication administration for multiple residents.
F 0909: Facility staff failed to complete entrapment assessments, obtain physician orders, and update care plans for residents using bed rails. Bed rails were used for a resident who declined them.
Report Facts
Facility census: 69
Staffing counts: 3
Staffing counts: 4
Staffing counts: 14
Staffing counts: 3
Staffing counts: 6
Staffing counts: 15
Staffing counts: 3
Staffing counts: 6
Staffing counts: 12
Staffing counts: 7
Staffing counts: 7
Staffing counts: 15
Expired medication: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN I | Licensed Practical Nurse | Named in findings related to improper blood sugar testing and insulin administration |
| CNA C | Certified Nurse Aide | Named in findings related to improper perineal care and wheelchair propulsion |
| LPN F | Licensed Practical Nurse | Named in findings related to wound care and medication pass |
| CMT G | Certified Medication Technician | Named in findings related to perineal care, medication cart maintenance, and staffing |
| RN A | Registered Nurse | Named in findings related to staffing, medication pass, and resident care |
| Administrator | Named in multiple interviews regarding facility policies, staffing, and deficiencies | |
| Director of Nursing | DON | Named in multiple interviews regarding staffing, infection control, and medication management |
| Maintenance Director | Named in findings related to entrapment assessments and facility maintenance | |
| Dietary Manager | Named in findings related to food preparation and pureed diet recipe adherence |
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 24
Date: Aug 17, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Sullivan following a survey completed on 08/17/2023. It addresses multiple regulatory deficiencies identified during the inspection.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment; coordination of PASARR and assessments; meeting professional standards for services provided; free of accident hazards; dialysis care; sufficient nursing staff; medication management; infection control; and resident care including use of bed rails and psychotropic medication management.
Deficiencies (24)
F584 Safe/Clean/Comfortable/Homelike Environment. Facility staff failed to maintain a clean, homelike, and comfortable environment as evidenced by broken floor and wall tiles, missing trim, large stains and odors throughout the facility, and damaged resident room features.
F644 Coordination of PASARR and Assessments. Facility staff failed to accurately complete or update PASARR documentation and incorporate recommendations into resident assessments and care plans for sampled residents.
F658 Services Provided Meet Professional Standards. Facility staff failed to obtain timely labs, produce pharmacist interventions, and perform blood sugar tests accurately for multiple residents.
F689 Free of Accident Hazards/Supervision/Devices. Facility staff failed to ensure resident environment was free of accident hazards including improperly stored disposable razors and inadequate supervision in spa rooms.
F698 Dialysis. Facility failed to ensure residents receiving dialysis care were provided care consistent with professional standards including communication, monitoring, and documentation.
F725 Sufficient Nursing Staff. Facility failed to provide sufficient nursing staff to meet resident care needs and maintain highest practicable well-being.
F732 Posted Nurse Staffing Information. Facility failed to post required nurse staffing information daily in a clear and accessible manner.
F758 Free from Unnecessary Psychotropic Meds/PRN Use. Facility failed to ensure psychotropic medications were limited to 14 days unless clinically justified and properly documented.
F761 Label/Store Drugs and Biologicals. Facility failed to store medications securely, discard expired medications, and maintain medication storage areas properly.
F780 Infection Prevention & Control. Facility failed to maintain an effective infection prevention program including hand hygiene, cleaning, and disinfection procedures.
F804 Nutritive Value/Appear, Palatable/Prefer Temp. Facility failed to prepare pureed foods according to standardized recipes ensuring nutritive value, flavor, and appearance.
F909 Resident Bed. Facility failed to conduct regular inspection and maintenance of bed frames, mattresses, and bed rails, and failed to ensure proper use of bed rails for residents.
A3001 Constructed/Maintained. The building was not maintained in good repair with multiple physical plant deficiencies noted.
A4033 Employee Hours Documented. Facility failed to maintain written documentation of actual hours worked by each employee.
A4055 Safe/Effective Medication System. Facility failed to maintain a safe and effective medication distribution and administration system.
A4064 Medication Storage. Facility failed to store medications at appropriate temperatures and secure medications properly.
A4074 Protective Oversight, Voluntary Leave. Facility failed to provide adequate protective oversight and supervision for residents on voluntary leave.
A4108 Clinical Records - assessment/interventions. Facility failed to maintain sufficient clinical records including assessments and interventions.
F758 Free from Unnecessary Psychotropic Meds/PRN Use. Facility failed to limit psychotropic medication PRN orders to 14 days and ensure proper documentation and review.
F880 Infection Control and Communicable Disease. Facility failed to implement effective infection control procedures including hand hygiene and cleaning protocols.
F725 Sufficient Staff. Facility failed to provide sufficient nursing staff to meet resident care needs and maintain highest practicable well-being.
F644 Clinical Records - assessments/interventions. Facility failed to complete and update assessments and care plans for residents with serious mental illness or intellectual disability.
F804 Foods-Nutritive Value/Flavor/Appearance. Facility failed to prepare and serve foods that conserve nutritive value, flavor, and appearance according to prescribed diets.
F909 Resident Bed. Facility failed to conduct regular inspection and maintenance of bed frames, mattresses, and bed rails, and failed to ensure proper use of bed rails for residents.
Report Facts
Facility census: 69
Deficiencies cited: 23
Inspection Report
Annual Inspection
Census: 69
Capacity: 120
Deficiencies: 9
Date: Aug 16, 2023
Visit Reason
Annual survey conducted to assess compliance with life safety and fire safety codes at Life Care Center of Sullivan.
Findings
The facility was found deficient in maintaining fire safety features including fire-rated construction, egress door accessibility, hazardous area enclosures, fire alarm system testing and maintenance, electrical system safety, and oxygen storage. Several deficiencies had the potential to affect all residents and occupants.
Deficiencies (9)
K161 Building Construction Type and Height 2012 EXISTING: Facility failed to maintain one-hour fire rating on type V 111 buildings, with multiple penetrations and holes in walls and ceilings.
K222 Egress Doors: Facility staff failed to maintain doors in a means of egress readily accessible at all times, including issues with magnetic locking devices and failure to provide codes for unlocking.
K321 Hazardous Areas - Enclosure: Facility failed to maintain rated and sealed walls around the boiler room, allowing gaps around pipes that compromised fire barriers.
K345 Fire Alarm System - Testing and Maintenance: Facility failed to ensure only authorized personnel could access and reset the fire alarm panel and lacked documentation of qualified service technicians.
K362 Corridors - Construction of Walls: Facility staff failed to ensure corridor walls maintained fire resistance and smoke barrier integrity, with unsealed glass panels allowing smoke passage.
K363 Corridor Doors: Facility failed to maintain corridor doors to resist smoke passage and ensure proper closing and latching, including kitchen corridor door issues.
K918 Electrical Systems - Essential Electric System: Facility failed to inspect, test, and maintain emergency generator and electrical wiring, including lack of remote manual stop station and improper power strip wiring.
K920 Electrical Equipment - Power Cords and Extension Cords: Facility staff failed to maintain electrical wiring and power strips in patient care areas, with unsafe extension cord use and daisy chaining.
K929 Gas Equipment - Precautions for Handling Oxygen: Facility failed to store oxygen cylinders properly secured, with unsecured cylinders in the shower room affecting at least 45 residents.
Report Facts
Facility census: 69
Facility capacity: 120
Inspection date: Aug 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany E. Hunter | Executive Director | Named as provider/supplier contact and signatory on plan of correction |
| Maintenance Director | Interviewed regarding fire safety and maintenance issues | |
| Maintenance Supervisor | Interviewed regarding maintenance and repair status |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Jun 2, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's belongings by a nursing assistant.
Complaint Details
The complaint was substantiated based on video surveillance showing the nursing assistant removing the resident's body spray and not returning it. The nursing assistant was suspended and terminated. The facility conducted abuse and neglect in-services following the incident.
Findings
The facility failed to prevent the misappropriation of a resident's fragrance spray by a nursing assistant who took the item and did not return it. The nursing assistant was suspended and terminated after video evidence confirmed the incident, and the facility conducted in-services on abuse and neglect focusing on theft.
Deficiencies (1)
F 0602: Facility staff failed to protect a resident from misappropriation when a nursing assistant took the resident's fragrance spray and did not return it. The item remains missing despite searches and video evidence confirmed the nursing assistant's actions.
Report Facts
Facility census: 62
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 1
Date: Jun 2, 2023
Visit Reason
The visit was conducted to address a deficiency related to misappropriation/exploitation of a resident's property and to review the facility's corrective actions following a prior non-compliance.
Findings
The facility failed to prevent misappropriation of a resident's fragrance spray by a Nursing Assistant. The administrator took corrective actions including staff termination, in-services on abuse and neglect, and replacement of the missing item.
Deficiencies (1)
CFR 483.12: The resident was not free from misappropriation as a Nursing Assistant took the resident's fragrance spray and did not return it. The facility census was 62.
Report Facts
Facility census: 62
Inspection Report
Plan of Correction
Census: 69
Deficiencies: 2
Date: May 20, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to notification of changes in resident condition and infection prevention and control at Life Care Center of Sullivan.
Findings
The facility failed to notify the family/responsible party in a timely manner about significant changes in a resident's condition, including weight loss and pressure ulcers. The facility also failed to implement proper infection control procedures, including staff not wearing gloves during wound care for three residents.
Deficiencies (2)
F580 Notification of Changes: Facility staff failed to notify the family/responsible party timely about a resident's significant change in condition including weight loss, worsened pressure ulcer, and decreased mobility.
F880 Infection Prevention & Control: Facility staff failed to use appropriate infection control procedures, including failure to wear gloves during wound care for three residents.
Report Facts
Facility census: 69
Deficiencies cited: 2
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 6
Date: Feb 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, bed hold policies, oxygen use, bed rails, food safety, infection control, and other care standards at Life Care Center of Sullivan.
Findings
The facility was found deficient in multiple areas including failure to notify the State Long-Term Care Ombudsman of resident transfers and discharges, failure to provide written bed hold policy information, failure to obtain physician orders for oxygen use and label oxygen tubing, incomplete entrapment assessments for bed rails, inadequate hand hygiene and food safety practices, and insufficient infection prevention and control measures.
Deficiencies (6)
F623 Notice Requirements Before Transfer/Discharge. Facility staff failed to notify the State Long-Term Care Ombudsman of resident transfers and discharges for four of five sampled residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer. Facility staff failed to provide written information about the bed hold policy to residents or their representatives for four sampled residents.
F658 Services Provided Meet Professional Standards. Facility staff failed to obtain physician orders for oxygen use and failed to label oxygen tubing for two residents.
F700 Bedrails. Facility staff failed to complete entrapment assessments and update care plans for residents using bed rails.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. Facility staff failed to wash hands properly and allow sanitized dishes to air dry, leading to potential cross-contamination.
F880 Infection Prevention & Control. Facility staff failed to follow infection control protocols including hand hygiene and use of PPE, increasing risk of communicable disease transmission.
Report Facts
Facility census: 67
Number of sampled residents with transfer notification issues: 4
Number of sampled residents with bed hold policy notification issues: 4
Number of residents with incomplete bed rail entrapment assessments: 5
Inspection Report
Life Safety
Census: 67
Capacity: 120
Deficiencies: 2
Date: Feb 10, 2022
Visit Reason
The inspection was conducted to evaluate compliance with the Life Safety Code of the National Fire Protection Association (NFPA) 2012 edition, specifically regarding fire drills and emergency preparedness.
Findings
The facility failed to meet the applicable provisions of the 2012 Life Safety Code related to fire drills. Deficiencies included failure to conduct fire drills under varying conditions on each shift quarterly, incomplete documentation of simulated fire conditions, and failure to conduct silent fire drills only between 9:00 PM and 6:00 AM as required.
Deficiencies (2)
K712 Fire Drills: Facility staff failed to conduct fire drills under varying conditions on each shift quarterly from February 2021 through January 2022. Staff also failed to ensure silent fire drills were only conducted between 9:00 PM and 6:00 AM as required by policy.
A2061 Fire Drill Requirements, Evacuation: The facility did not conduct the minimum required twelve fire drills annually with at least one every three months on each shift. At least four drills must be unannounced and include a simulated resident evacuation involving local emergency services.
Report Facts
Facility census: 67
Total capacity: 120
Number of fire drills required annually: 12
Number of fire drills conducted: 10
Silent drill documented time: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Taylor | Executive Director | Signed the statement of deficiencies and plan of correction; educated Maintenance Director on fire drill requirements |
| Maintenance Director | Interviewed regarding fire drill procedures and knowledge of silent drill timing requirements | |
| Administrator | Interviewed regarding responsibility for fire drills and documentation requirements |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 6
Date: Feb 10, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to notify the State Long-Term Care Ombudsman of resident transfers and discharges, failure to provide written bed hold policy information to residents, failure to obtain physician orders and label oxygen tubing for oxygen use, failure to complete entrapment assessments and update care plans for residents using bed rails, failure to follow proper hand hygiene and infection control protocols by staff.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify the State Long-Term Care Ombudsman of resident transfers and discharges, failure to provide bed hold policy information, failure to obtain physician orders and label oxygen tubing, failure to complete entrapment assessments and update care plans for bed rail use, and failure to follow proper hand hygiene and infection control protocols including mask handling and incontinence care.
Findings
The facility failed to notify the State Long-Term Care Ombudsman of resident transfers and discharges, failed to provide written bed hold policy information to residents, failed to obtain physician orders and label oxygen tubing for oxygen use, failed to complete entrapment assessments and update care plans for residents using bed rails, and failed to follow proper hand hygiene and infection control protocols including handwashing and mask handling.
Deficiencies (6)
F 0623: Facility staff failed to notify a representative of the State Long-Term Care Ombudsman of resident transfers and/or discharges for four of five sampled residents.
F 0625: Facility staff failed to provide written information to residents or their representatives about the bed hold policy for four sampled residents.
F 0658: Facility staff failed to obtain physician orders for oxygen use for two residents and failed to label oxygen tubing for two residents.
F 0700: Facility staff failed to complete entrapment assessments and update care plans for five residents using bed rails as required by policy.
F 0812: Facility staff failed to wash their hands as often as necessary using approved techniques and failed to allow sanitized dishes to air dry prior to storage and use.
F 0880: Facility staff failed to follow infection control protocols for COVID-19 by not performing hand hygiene after touching face masks and failed to use appropriate infection control during incontinence care for two residents.
Report Facts
Facility census: 67
Residents affected: 4
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 2
Inspection Report
Plan of Correction
Census: 60
Deficiencies: 2
Date: May 5, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care and notification of changes, as well as professional standards of quality in services provided.
Findings
The facility failed to promptly notify a resident's physician of urinalysis results, resulting in delayed antibiotic treatment. Additionally, the facility did not consistently carry out physician orders for skin treatments and failed to provide timely hospice evaluations and shingles vaccinations.
Deficiencies (2)
F580 Notification of Changes. The facility failed to notify a resident's physician in a timely manner about urinalysis results, causing a delay in antibiotic treatment.
F658 Services Provided Meet Professional Standards. The facility failed to consistently carry out physician orders for skin treatments and did not provide timely hospice evaluations or shingles vaccinations.
Report Facts
Facility Census: 60
Inspection Report
Routine
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 5
Date: Aug 8, 2019
Visit Reason
Annual inspection of Life Care Center of Sullivan to assess compliance with federal regulations including resident assessments, care planning, medication storage, and nutritional adequacy.
Findings
The facility failed to provide required documentation for resident assessments and care plans, including missing dates and signatures on Care Area Assessment summaries and baseline care plans. Medication storage and labeling deficiencies were also noted, along with failures in menu planning and food service compliance.
Deficiencies (5)
F636: The facility failed to provide the location and date on the Care Area Assessment Summary for four residents, missing required documentation for comprehensive MDS assessments.
F655: The facility failed to develop and implement a baseline care plan within 48 hours of admission and communicate it with the resident or representative for two residents.
F657: The facility failed to revise the plan of care with changes in resident needs for seven residents, including failure to update side rail use and other care plan elements.
F761: The facility failed to ensure medications were monitored, stored safely, and properly labeled, including expired and improperly labeled medications in medication carts.
F803: The facility failed to serve food items in accordance with nutritionally calculated recipes and menus, including incorrect utensil sizes for mechanical soft and pureed diets.
Report Facts
Facility census: 65
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned in interviews regarding expectations for MDS Coordinator and care plan completion |
| MDS Coordinator | MDS Coordinator | Interviewed regarding completion of MDS assessments and care plans |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed about medication dating and labeling |
| Certified Medication Tech (CMT) B | Certified Medication Technician | Interviewed about medication labeling and dating |
| Cook C | Cook | Observed serving food and interviewed about menu preparation |
| Dietary Manager (DM) | Dietary Manager | Interviewed about menu preparation and food service compliance |
Inspection Report
Life Safety
Census: 65
Capacity: 120
Deficiencies: 7
Date: Aug 8, 2019
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and building codes, including sprinkler system maintenance, smoke barrier integrity, and oxygen storage safety.
Findings
The facility failed to maintain the sprinkler system free from obstruction, corrosion, and damage, maintain smoke barriers free of holes and breaches, and properly store combustible materials away from oxygen cylinders. Night lights were also not maintained in seven resident rooms.
Deficiencies (7)
K353 The facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25 Standards, exhibited by obstruction of sprinklers and keeping sprinklers free from foreign materials, corrosion and damage.
K372 The facility failed to maintain subdivision of building spaces - smoke barriers in accordance with NFPA 101, evidenced by holes and breaches in smoke barrier walls allowing smoke to pass between fire zones.
K923 The facility failed to maintain the oxygen storage room in accordance with NFPA 99 Code, evidenced by storage of combustible materials within five feet of oxygen cylinders.
A1132 Facility failed to provide night lights as required by 19 CSR 30-85.012(125) in seven resident rooms.
A2010 Facility failed to maintain oxygen cylinders with safety caps intact and supported by collars or stable carts to prevent accidental damage or dislocation.
A2034 Facility failed to inspect, maintain, and test sprinkler systems as required by 19 CSR 30-85.022(11)(C).
A2054 Facility failed to maintain smoke section walls and doors with one-hour fire-rated walls continuous from outside wall to outside wall and floor to roof deck.
Report Facts
Facility census: 65
Total capacity: 120
Inspection Report
Plan of Correction
Census: 68
Deficiencies: 3
Date: Sep 28, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding restorative nursing services, drug regimen review, and communicable disease policies at Life Care Center of Sullivan.
Findings
The facility failed to provide adequate restorative nursing services to maintain or improve residents' mobility for six residents. Additionally, the facility failed to communicate pharmacy recommendations for two residents and failed to implement policies ensuring new employees were screened for tuberculosis.
Deficiencies (3)
F688 The facility failed to provide restorative nursing service to maintain or improve the resident's ability to function for six residents (Resident #25, #42, #50, #58, #65 and #66).
F756 The facility failed to communicate pharmacy recommendations to physicians for two residents (Resident #18 and #59) to prevent or minimize adverse consequences related to medication therapy.
A4029 The facility failed to implement policies and procedures to ensure that all new hire employees who work 10 or more hours per week were screened appropriately for Tuberculosis. Staff failed to ensure that the two-step PPD was completed within the required time frame.
Report Facts
Facility census: 68
Residents affected: 6
Residents affected: 2
Inspection Report
Annual Inspection
Census: 68
Capacity: 120
Deficiencies: 6
Date: Sep 28, 2018
Visit Reason
Annual inspection of Life Care Center of Sullivan to assess compliance with federal and state regulations including emergency preparedness and life safety code.
Findings
The facility failed to provide adequate emergency preparedness information and training to residents and staff. The facility also did not maintain doors in a means of egress readily accessible at all times in accordance with the 2012 Edition of NFPA 101 Life Safety Code.
Deficiencies (6)
E035: The facility failed to develop and implement a method for sharing emergency preparedness information with residents and their families. The facility census was 68 with a capacity of 120.
E037: The facility failed to provide initial and ongoing emergency preparedness training to all staff, including education on policies and procedures for severe weather and other emergencies.
K222: The facility failed to maintain doors in a means of egress readily accessible at all times, including failure to provide access codes and removal of deadbolt locks, violating the 2012 Edition of NFPA 101 Life Safety Code.
A2041: Door locks did not meet requirements; only one lock permitted per door and must be operable from inside by simple device or knob.
A2058: The facility lacked a written fire drill and emergency preparedness plan reviewed annually with local fire unit consultation.
A4022: The facility failed to provide an in-service orientation and continuing education program for staff including emergency preparedness training.
Report Facts
Facility census: 68
Total capacity: 120
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