Sullivan Healthcare & Senior Living

In the surveyor’s words

From the most serious findings on record at Sullivan Healthcare & Senior Living, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Dec 20, 2024

  Based on observation, interview and record review the facility failed to provide lifesaving equipment for emergency airway management, for a resident in cardiac and respiratory arrest. This failure affected one of 18 residents (R1) reviewed for advanced directives and has the potential to affect all 72 residents residing in the facility. R1 subsequently expired. The Immediate Jeopardy began on [DATE] when R1 was found to have no pulse or respirations and Cardiopulmonary Resuscitation (CPR) was initiated. Staff could not locate a functional bag valve mask (BVM) mask to provide a full seal over R1's nose and mouth, in order to provide effective ventilation during the medical emergency. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 1:58 pm. […]

• Actual harm, isolatedF684Jun 19, 2026

  Based on interview and record review, the facility failed to monitor vital signs and laboratory results and assess/monitor/document/report changes in condition for one of three residents (R1) reviewed for falls in the sample list of 16. This resulted in R1 being sent to the hospital 4 days after a fall, being diagnosed with a brain breed and later dying. Findings include: R1's Care Plan (undated) documents V16 as R1's legal appointed Guardian and includes interventions to advocate and discuss the best interest of R1; encourage appointed responsible party to discuss options, advanced directives and wishes with R1; and inform V16 of changes in R1's condition. R1's diagnoses include Hypertension and Atrial Fibrillation. […]

• Actual harm, isolatedF600Nov 25, 2025

  Based on interview and record review the facility failed to protect resident's right to be free from physical abuse by another resident for two of five residents (R2, R3) reviewed for abuse in the sample list of 17. This failure resulted in R2 obtaining lacerations to his Left Face, Left Upper Lip and Left Ear requiring treatment in the emergency room and experiencing pain and fear after R3 punched R2 in the face. Findings include:R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively intact. This same MDS documents R2 requires moderate assistance with toileting, dressing, personally hygiene and transfers. R2's Physician Order Sheet (POS) dated November documents a physician order for Xarelto 20 milligrams (mg) daily (anticoagulant). […]

• Actual harm, isolatedF684Jan 10, 2025

  Based on observation, interview and record review the facility failed to assess, monitor, and notify physician to obtain treatment orders timely and failed to implement care plan interventions for one (R2) resident's documented open buttock wounds out of three residents reviewed for incontinence care in a sample list of seven residents. This failure resulted in R2's reddened bilateral buttock areas to deteriorate to open wounds. Findings include: R2's undated Face Sheet documents medical diagnoses of Quadriplegia, Diabetes Mellitus Type II, Spinal Stenosis, Arthrodesis, Cervicalgia, Obesity, Radiculopathy Cervical Region, Sensorineural Hearing Loss, Neuropathy, Retention of Urine, Depression, Syndrome of Inappropriate secretion of Antidiuretic Hormone and Anxiety. […]

• Actual harm, isolatedF689Jun 17, 2021

  Based on observation, interview, and record review, the facility failed to provide a safe transfer, failed to implement interventions or increase supervision after a change in condition, to prevent falls, and failed to properly secure a wheelchair in the facility van impacting 3 of 4 residents (R53, R36, and R37) reviewed for accidents in the sample of 41. These failures resulted in R53 sustaining a fracture to the left humerus which required surgical repair and in R36 sustaining a right clavicle fracture. Findings include: 1. On 6/14/21 at 10:15 AM, R53 was sitting in a wheelchair in the room. R53's left arm was in a sling. R53's emergency room notes dated 6/1/21 documents R53 was in the emergency roiagnom on [DATE] due to discomfort in the upper extremity. […]