The March inspection revealed the facility's systematic failure to address residents' fundamental needs. Two newly admitted residents never received baseline care plans addressing their serious medical conditions, while established residents went without proper assistance for hearing loss, vision problems, and safety concerns.
Resident 78 was almost completely deaf and relied on hearing aids, lip reading, and sign language to communicate. During multiple observations in February, inspectors watched the resident struggle with a single hearing aid, often placing it incorrectly or leaving it on the bedside table.
"Just so you know, [Resident 78] is very hard of hearing, even with a hearing aid," a licensed practical nurse told inspectors on February 27.
The resident's family representative explained the communication challenges: "It's difficult to have conversations with Resident 78." The representative said the resident was "very hard of hearing, almost 100% deaf" and used hearing aids, lip reading, and sign language.
Staff acknowledged the communication barriers but weren't equipped to help. One nursing assistant said they relied on the resident to read lips, then would "put [their] hearing aid in, and just watching your face." When lip reading failed, staff resorted to written communication.
The facility's care plan for Resident 78 was completely inadequate. It incorrectly stated the resident had "mild hearing loss with HA and moderate loss without" and claimed they used hearing aids in both ears. The plan made no mention of sign language, lip reading, or written communication methods that both the resident and staff actually used.
Staff F, a resident care manager, admitted to inspectors: "Not to my knowledge does [Resident 78] wear any hearing aids." The manager acknowledged the care plan failed to show "resident-centered alternative communication techniques, like sign language, lip reading, or written communication."
Another resident faced a different but equally serious problem. Resident 62 had alleged being struck in the head by a nurse three months earlier. Following a facility investigation in August 2024, administrators updated the resident's care plan to require two staff members for "all interactions including medication administration and conversations."
The safety measure was routinely ignored.
Inspectors observed Staff J, a nursing assistant, entering Resident 62's room alone multiple times on March 3 and March 4 to answer call lights and deliver crackers. A registered nurse also administered medications alone, directly violating the care plan.
"Resident 62 was two person assist when care was provided but did not require two staff to answer the call light," Staff J told inspectors, misunderstanding the care plan requirements.
When shown the medical record, the same nursing assistant acknowledged Resident 62 required two staff for all interactions and admitted "that would be hard to do."
Staff H, the registered nurse who gave medications alone, reviewed the record and conceded that "having a conversation with a person was an interaction so technically Resident 62 required two staff to talk with them."
The resident confirmed the lapses: "They do not send two staff in here all the time."
Vision problems plagued another resident without proper care planning. Resident 41 had adequate vision with glasses and enjoyed reading books, newspapers and magazines, according to their quarterly assessment. They were scheduled for cataract surgery in March 2025.
But inspectors found no documentation about the resident's vision needs in their November 2024 care plan.
During multiple observations from February 25 through March 4, Resident 41 was repeatedly seen without their glasses, struggling to read letters and surrounded by unopened mail at their desk. On February 25, the resident held a typed letter and told inspectors they "should be wearing their glasses." They tried to read the first sentence aloud but gave up and put the letter down.
"They needed their glasses to read the letter and reminders to wear them daily," the resident told inspectors on March 4.
When Resident 41 finally appeared wearing glasses on March 5, the right lens was missing.
Staff FF, a registered nurse, claimed the resident "wore glasses daily" and that staff would help find them when misplaced. But the resident care manager acknowledged the obvious gap: Resident 41 "required glasses for their activities of daily living and should have been documented in their care plan."
The failures extended to new admissions. Resident 6 entered the facility with heart failure, high blood pressure, and atrial fibrillation, plus legal blindness. Their baseline care plan contained no goals or interventions for either the cardiovascular conditions or vision impairment.
Resident 411 arrived with chronic obstructive pulmonary disease and asthma but received a baseline care plan with no respiratory interventions.
Staff G, the resident care manager, acknowledged both baseline care plans failed to identify "the residents' nursing needs, interventions, or goals related to the active or treated diagnoses."
The inspection found a facility that wrote policies but failed to implement them. A June 2017 policy required quarterly care plan reviews to ensure plans reflected residents' current needs. Yet residents sat with outdated, inaccurate, or missing care plans that ignored their daily struggles.
Administrator Staff A told inspectors they "expected staff to follow care planned interventions." But the gap between expectation and reality left residents isolated by communication barriers, unsafe due to ignored precautions, and unable to participate in activities they valued because of untreated impairments.
The March 6 inspection documented a systematic breakdown in individualized care planning, the foundation of nursing home services that federal regulations require within 48 hours of admission and updated as residents' needs change.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sullivan Park Care Center from 2025-03-06 including all violations, facility responses, and corrective action plans.