Sullivan Healthcare: Residents Left Soiled 4 Hours - IL
Inspectors who arrived at Sullivan Healthcare & Senior Living on November 25, 2025, documented what they found in that lounge: three residents, identified in the report as R9, R10, and R13, all cognitively impaired, all incontinent of both bladder and bowel, sitting in the same position for four hours without a single staff member attending to them.
The licensed practical nurse stationed at the desk facing the lounge confirmed it. She told inspectors that R9, R10, and R13 are not capable of recognizing when they need to use the restroom, and cannot tell staff when they need care. They depend entirely on staff to check them, change them, and move them. On this afternoon, staff did not.
The facility's own Director of Nurses laid out exactly what should have happened. Speaking with inspectors at 2:40 that afternoon, the DON said dependent residents should receive incontinence care at least every two hours. They should be repositioned. They should be well groomed. She said staff should never assume they know a resident's bladder and bowel habits, because those habits can change from one day to the next.
Then she confirmed that R9, R10, and R13 had been sitting in that lounge for four hours without any attention from staff at all.
Sitting for hours in a soiled brief is not merely uncomfortable. The DON described the clinical consequences directly: pressure ulcers, urinary tract infections, and what she called a negative psychosocial impact. Pressure ulcers develop when skin stays pressed against wet, soiled material. They can begin as redness and progress to open wounds that reach muscle and bone. Urinary tract infections in elderly residents with cognitive impairment can trigger sudden and severe confusion, hospitalization, and in some cases death. The DON knew the risks. She listed them for inspectors without being asked.
When inspectors pressed on whether the facility had a written policy governing incontinence care intervals, the DON said she was not certain one existed. What she said instead was that the expectation is to provide the standard of care, which she defined as incontinence care at least every two hours.
The gap between that expectation and what happened in the lounge that afternoon was four hours wide.
The deficiency was cited under F0690, covering the treatment and prevention of urinary incontinence and related care. Inspectors classified the level of harm as minimal harm or potential for actual harm, affecting some residents. The complaint inspection covered nine pages.
Three people who could not speak up for themselves, could not stand up and walk to a bathroom, could not flag down a nurse or press a call button with any reliable effect, sat in a common room in a facility that employed staff specifically to care for them. The nurse at the station could see the lounge from where she stood. Four hours passed.
The Director of Nurses, when asked to account for it, said she could not confirm there was even a policy requiring what she herself described as the basic standard of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sullivan Healthcare & Senior Living from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SULLIVAN HEALTHCARE & SENIOR LIVING in SULLIVAN, IL was cited for violations during a health inspection on November 25, 2025.
The licensed practical nurse stationed at the desk facing the lounge confirmed it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.