Sullivan County Adult Care Center: Abuse Unreported - NY
The resident, identified in inspection records only as Resident #1, had been admitted to the facility with dementia, depression, and anemia. A formal assessment completed the month before the incident found the resident had moderately impaired cognition. That matters because a person with moderately impaired cognition cannot easily advocate for themselves, cannot reliably report what happened to them, and cannot get up and walk away from a dining room table pressed against their wheelchair.
What happened on May 11 was witnessed by another aide.
According to that aide, Certified Nurse Aide #1, Resident #1 had been near the nurses' station, yelling and asking to be toileted, pants already down. Certified Nurse Aide #2 responded by yelling the same profanities back at the resident. Then, the aide said, CNA #2 aggressively pushed the resident back into the wheelchair. After that, CNA #2 wheeled the resident into the dining and dayroom area, positioned the wheelchair against the wall, and placed a dining room table directly in front of the resident, blocking any exit from the chair.
CNA #1 reported all of this, the same day it happened, to Licensed Practical Nurse #1 and Registered Nurse Supervisor #1.
Nobody called the state.
New York requires facilities to report abuse allegations to the Department of Health within 24 hours if there is no serious bodily injury, and within 2 hours if there is. Sullivan County Adult Care Center's own written policy, revised as recently as February 2026, spelled this out in plain language. The policy also required the facility to submit a full investigation summary to the state within five business days.
The facility met none of those deadlines.
The registered nurse supervisor confirmed, during an interview with inspectors on May 21, that CNA #1 had reported the alleged abuse on May 11 and that the Director of Nursing had been notified that same day. The chain of communication had worked, at least partway up the ladder. The Director of Nursing knew. The Director of Nursing did not report.
The Director of Nursing's explanation, offered during an interview on May 21, was direct: the allegations were not reported to the New York State Department of Health because it was not believed that abuse had occurred.
That is not how the reporting requirement works. The requirement is triggered by an allegation, not a conclusion. A supervisor deciding, on their own, that what a witness described did not rise to the level of abuse, and therefore that the state did not need to know about it, is not an investigation. It is a unilateral determination made by someone with an institutional interest in the outcome.
The Administrator learned about none of this until May 21, when the Attorney General's office contacted the facility. Not from the Director of Nursing. Not from the nursing supervisor. Not from anyone inside the building. From the Attorney General.
During interviews on May 21 and again on May 22, the Administrator described how reporting is supposed to work at Sullivan County Adult Care Center: when a supervisor receives a report of abuse, they call the Director of Nursing and the Administrator, and then the Administrator or Director of Nursing reports to the state. That is the process. On May 11, the supervisor called the Director of Nursing. The Director of Nursing did not call the Administrator. The Administrator was not told. The Administrator said the alleged incident should have been investigated and reported.
Ten days passed.
The inspection was a complaint survey, triggered by the allegation, and conducted on May 29, 2026. Inspectors reviewed four residents for abuse concerns and identified the reporting failure for Resident #1. The harm level was classified as minimal harm or potential for actual harm, which is the lower end of the regulatory scale. That classification reflects the inspection findings as documented, not a judgment about what the resident experienced in that dining room with a table pressed against their wheelchair.
What the inspection record does not contain is any documentation of what happened to CNA #2 in the ten days between the alleged incident and the state finding out about it. It does not say whether CNA #2 continued working during that period. It does not say whether anyone interviewed the resident. It does not say whether anyone interviewed CNA #2, or CNA #1 again, or the LPN who was also told about it on May 11. The investigation summary that was supposed to reach the state within five business days of the allegation, which would have been by May 16 at the latest, apparently did not exist in any form the facility could point to when inspectors arrived.
The Director of Nursing said that office staff who are mandated reporters know they are required to report allegations of abuse, and that staff are left with instructions regarding reporting requirements. That framing, staff left with instructions, suggests a system that runs on written guidance and assumed compliance rather than active oversight. When the Director of Nursing received a report of a resident being grabbed, screamed at, and physically restrained in a chair by a piece of dining furniture, the instructions did not produce a phone call to the state. They produced a judgment call. The judgment call produced silence for ten days.
Resident #1 was admitted to Sullivan County Adult Care Center in the weeks before this happened. The April assessment showing moderately impaired cognition was conducted less than a month before the incident. This was not a long-term resident with an established relationship with staff and a family that visited regularly and would notice changes. This was someone relatively new to the facility, with a condition that affects memory and judgment and the ability to communicate distress, in a place where the person responsible for protecting them from abuse decided, without investigation, that nothing worth reporting had taken place.
The facility's own policy said otherwise. The law said otherwise. The Attorney General's office, apparently, said otherwise too.
Whether Resident #1 understood what was happening when the table was pushed up against the wheelchair is not something the inspection report addresses. Whether the resident was frightened, or in pain from being grabbed and forced into the chair, is not something the inspection report addresses. The report addresses what the facility was required to do and what it failed to do.
What it was required to do was simple: report within 24 hours, investigate, and submit findings to the state within five business days. What it did was wait for someone else to make the call.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sullivan County Adult Care Center from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Sullivan County Adult Care Center in Liberty, NY was cited for abuse-related violations during a health inspection on May 29, 2026.
The resident, identified in inspection records only as Resident #1, had been admitted to the facility with dementia, depression, and anemia.
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.