Sullivan Park Care Center

In the surveyor’s words

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

• Actual harm, isolatedF697Sep 9, 2024

  Based on observation, interview, and record review, the facility failed to provide necessary pain management for 2 of 3 sampled residents (Resident 3 and 4), reviewed for pain. Resident 3 and 4 each experienced harm when the facility did not ensure they had the ordered pain medication, or another effective alternative, to treat the residents timely, which resulted in each resident requiring to transfer to the hospital to relieve their pain. This failure placed residents at risk of uncontrolled pain and diminished quality of life. Findings included . Review of the facility's policy titled, Controlled Substance Medication Orders, dated January 2023, showed a prescription required multiple components including a manual signature from the medical provider to be valid. […]

• Actual harm, isolatedF689Feb 29, 2024

  Based on observation, interview, and record review, the facility failed to provide the identified transfer assistance required to prevent injury for 1 of 3 sampled residents (Resident 1), reviewed for accidents and supervision. This failure resulted in actual harm to Resident 1, who sustained a fracture and pain during a transfer without utilization of a two-person assist and appropriate equipment, as required. Findings included . Review of the 01/02/2024 annual assessment showed Resident 1 was dependent on staff for transfers, had impaired mobility to one upper and one lower extremity, and had no falls since the previous assessment. […]

• Actual harm, isolatedF689Apr 23, 2021

  Based on observation, interview, and record review, the facility failed to provide adequate supervision for staff and residents to mitigate a hazardous environment and avoid accidents and incidents, for 1 of 3 sample residents (Resident 2) resulting in harm to the resident, when the resident fell asleep with hot coffee and subsequently spilled the coffee, sustaining second degree [CONDITION(S)]. In addition, the facility failed to evaluate and analyze the incident, to find root cause analysis to identify hazards and risks, and reduce the potential for similar accidents to protect residents. […]

• No harm, potential for more than minimal, patternF584Jun 25, 2026

  Based on observation, interview, and record review, the facility failed to maintain a clean, safe, and homelike environment for 2 of 3 residents (Residents 13 and 6) and 4 of 6 shower rooms (Halls 100, 200, 500, and 600), reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their living conditions. Findings included . Review of the facility's policy titled, Maintenance Service, dated 12/2009, showed the maintenance director was responsible for developing and maintaining a schedule of maintenance service to ensure that the building, grounds, and equipment are maintained in a safe and operable manner. The maintenance director was also responsible for maintaining the building in good repair and free of hazards. […]

• No harm, potential for more than minimal, patternF804Jun 25, 2026

  Based on observation, interview and record review, the facility failed to provide food at proper temperatures and palatable taste for 5 of 8 residents (Resident 4, 97, 92, 56 and 48) reviewed for food. This failure placed residents at risk for foodborne illness, decreased nutritional intake and weight loss. Findings included. Review of a policy titled, Food Safety, dated 02/2019, showed cold products will reach temperatures no greater than 41 degrees Fahrenheit (F-unit of measure). Review of a facility undated document titled Schedule of Mealtimes, showed Breakfast was served between 7:00 AM to 8:00AM, Lunch was served from 12:00 PM to 1:00PM and Dinner was served from 5:00 PM to 6:00 PM. […]