Sullivan County Health Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Jun 6, 2025

  Based on interview and record review, it was determined that the facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used a resident's insulin pen to administer insulin to another resident (Resident identifiers are #1 and #2.) Findings include: Interview on 6/6/25 at approximately 10:03 a.m. with Staff A (Licensed Practical Nurse (LPN)) revealed that on 6/3/25 he/she administered insulin to Resident #2 using Resident #1's used insulin pen. Interview on 6/6/25 at approximately 10:09 a.m. with Staff C (LPN) revealed that on 6/3/25 he/she received shift report from Staff A that Resident #2 ran out of insulin and Staff A used Resident #1's insulin pen to administer insulin to Resident #2. […]

• No harm, potential for more than minimal, patternF712Oct 19, 2023

  Based on interview and record review, it was determined that the facility failed to ensure that the residents were seen face-to-face by a physician, at least once every 30 days, for the first 90 days after admission, and at least every 60 days thereafter for 7 out of 7 residents reviewed for physician visits in a final sample of 25 residents (Resident Identifiers are #1, #40, #62, #73, #113 and #117). Findings include: Resident #1 Review on 10/18/23 of Resident #1's physician visit notes revealed the following encounters: On 1/10/23, a 60 day recertification telemedicine encounter; On 3/23/23, a 60 day recertification telemedicine encounter; On 5/18/23, a 60 day recertification telemedicine encounter; On 7/28/23, a 60 day recertification telemedicine encounter On 9/26/23, a 60 day… […]

• No harm, potential for more than minimal, patternF761Jun 24, 2021

  1.Based on observation, interview and policy review, the facility failed to ensure that drugs were labeled and stored in accordance with accepted professional standards for 2 out of 8 medication carts observed and 2 out of 3 medication rooms observed. Findings include: Observation on 6/22/21 at approximately 9:15 a.m. of 3rd floor North Side medication cart with Staff D (Registered Nurse) revealed 1 [MEDICATION(S)] Emergency 1 mg Kit with a manufacturer's expiration date of 5/2021. Further observation revealed 1 bottle of Mineral Oil Lubricant [MEDICATION(S)] with a manufacturer's expiration date of 5/2021. Observation of the 3rd floor medication room revealed 1 vial of [MEDICATION(S)] High-Dose Quadrivalent vaccine with a manufacturer's expiration date of 6/2/21. […]

• No harm, potential for more than minimal, patternF880Feb 3, 2021

  Based on record review and interview, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines for screening staff for signs and symptoms COVID-19 on 2 of 4 days reviewed. Findings include: Review on 2/3/21 of staff screening logs for 1/29/21 to 2/3/21 revealed 4 staff that answered yes to currently having cold and flu symptoms: Staff C (Nursing) on 1/29/21, Staff D (Housekeeping) on 1/29/21 (also wrote in headache and very tired), Staff E (Nursing) on 2/1/21 and Staff F (Nursing) on 2/1/21. There was no documentation of any evaluation or actions that had taken place. Interview with Staff A (Director of Nursing) and Staff B (Infection Preventionist) on 2/3/21 at approximatley 1:00 p.m. […]

• No harm, potential for more than minimal, isolatedF657Dec 11, 2025

  Based on interview and record review, it was determined that the facility failed to ensure resident care plans were revised for 2 residents in a final sample of 24 residents. (Resident Identifiers are #34 and #121). Findings include:Resident #34 Review on 12/10/25 of Resident #34's nursing notes revealed the following note dated 10/17/25: Spoke this shift with DPOA [Durable Power of Attorney] about this resident found in another male residents room lying on the bed with [pronoun omitted] pants off, still had a brief on and a bra half on . […]