Sullivan County Adult Care Center

In the surveyor’s words

From the most serious findings on record at Sullivan County Adult Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610May 29, 2026

  Based on observations, record review, and interviews conducted, the facility failed to investigate an allegation of abuse and implement appropriate corrective actions to protect a resident from further abuse. This was evident for one resident (Resident #1) of four residents reviewed for abuse. Specifically, on 05/11/2026, Certified Nurse Aide #1 reported to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 that they observed Certified Nurse Aide #2 forcibly grab Resident #1 and push the resident into a wheelchair, then use the dining room table as a barrier preventing Resident #1 from getting out of the wheelchair. Certified Nurse Aide #1 also reported that they heard Certified Nurse Aide #2 repeatedly use profanities toward Resident #1. […]

• Immediate jeopardy, isolatedF678Jul 7, 2023

  Based on record review and interview conducted during an abbreviated survey (NY00319128), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had a Full Code status with Advance Directives in place. This was evident for 1 of 3 residents (Resident #1) reviewed for CPR. Specifically, on [DATE] at 5:00 AM Resident #1 was found in their bed unresponsive with no pulse by a Training Nurse Assistant (TNA) #1. The Registered Nurse (RN ) #1 on duty was summoned to the resident's room and did not initiate CPR. The facility did not activate their Medical Emergency Services Protocol (Code Blue) and did not call 911(Emergency Medical Service). Subsequently, Resident #1 was pronounced dead by the RN #1 at 5:04 AM. […]

• Actual harm, patternF689Feb 2, 2026

  Based on record review and staff interviews conducted during a survey, the facility failed to ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for three (3) of six (6) residents reviewed for accidents (Resident #1, #2, & 3). Specifically, 1) On 11/01/2024, Certified Nurse Assistant #2 did not follow the care plan and attempted to transfer Resident #1 by themself as a stand pivot and the resident fell, hit their head, and subsequently required transfer to the hospital. 2) On 12/26/2025, Resident #2 was provided with morning care, was unable to walk and had a significant bruise on their right hip. […]

• Actual harm, isolatedF689Sep 27, 2024

  Based on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY00333577 and NY00320085) from [DATE] to [DATE], the facility did not ensure that the residents environment remained as free of accident hazards as possible for 2 (Residents #219 and #95) of 7 residents reviewed for accidents. Specifically, 1. Resident #219 who- was being transferred via Mechanical lift by two certified nurse aides, fell from the mechanical lift due to the battery dying and Certified Nurse Aides #20 and #23 unhooking the straps instead of using the emergency lower button, subsequently causing a hematoma (large pool of blood under the skin resulting from injury) to the back of Resident #219's head which resulted in them having to be transferred to the emergency… […]

• No harm, potential for more than minimal, widespreadF812Sep 27, 2024

  Based on observations and interviews conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food safety practice, and essential equipment was not in safe operating condition. Specifically, 1. Food was stored in the walk-in freezers and refrigerators that was unlabeled, undated and without expiration dates. 2. Expired foods were stored in refrigerators and the dry storage room. 3. Freezers #6 and #7's insulation door seals were not attaching properly causing the formation of ice on the ceiling and walls inside the freezers. 4. Damaged tile flooring next to the dishwashing machine formed an uneven and wobbly surface. […]