Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Sullivan during CMS and state inspections, most recent first.
A resident admitted with a recent toe amputation and gangrene did not have specific surgical wound care or follow-up orders obtained by facility staff, despite policy requiring detailed physician-directed treatment orders. Hospital discharge paperwork lacked wound care instructions, and the physician order obtained only directed wound care to "evaluate and treat" without specifics. For approximately a week, the TAR and nursing notes showed no wound treatment orders or documented assessments of the surgical site, while staff relied on the resident’s statement that the dressing should remain intact until a follow-up visit. An LPN documented this based solely on the resident’s report, passed the concern about missing orders in shift report, but did not notify the physician, and another LPN later noted the foot appeared to be "dying" with no wound orders in the chart. The resident was ultimately sent to the hospital after family removed the dressing and contacted the surgeon, and the hospital documented worsened chronic right foot wound with tissue necrosis requiring a right trans metatarsal amputation.
A resident with moderate cognitive impairment sustained a burn from spilled hot coffee, but staff failed to provide timely treatment or notify the physician, only documenting and treating the injury two days later when blisters developed. The care plan lacked interventions for hot liquid safety, and the facility did not have a policy for addressing burn injuries.
A resident with moderate cognitive impairment sustained a burn injury after spilling hot coffee on their leg. Initial assessment by an LPN noted redness but no blistering, and neither the physician nor the resident's representative was notified at that time. Notification occurred two days later when blisters developed, despite the physician's expectation for earlier communication. The facility lacked a policy specifying notification requirements for such incidents.
Staff did not update the care plans for two residents after significant events: one resident sustained a burn from a hot liquid, and another regularly participated in smoking breaks. In both cases, the care plans lacked necessary interventions for burn care and smoking, despite facility policy requiring updates after such changes. Interviews confirmed that the responsibility to update care plans was not fulfilled by the IDT or nursing staff.
Two residents with cognitive impairment and behavioral risks were involved in repeated physical altercations, with one resident striking the other on two occasions. Despite care plans directing staff to separate them during verbal conflicts, staff failed to consistently implement or communicate effective interventions, resulting in repeated incidents of physical abuse.
The facility staff failed to properly wash and sanitize dishes, with the dish machine not reaching the required temperature and staff not following correct procedures in the three-compartment sink. The sanitizing solution was too concentrated, and dishes were not air-dried before storage. Waste containers were left uncovered, and staff were inadequately trained on proper sanitation practices.
The facility failed to document restorative therapy for two residents, despite referrals and care plans indicating the need for such services. One resident required assistance with ADLs and walking, while another needed help with ambulation using a wheeled walker. Interviews revealed that no restorative services were provided, and the facility lacked an active restorative nursing program due to insufficient trained staff.
The facility staff did not serve meals according to the nutritionally calculated recipes and menus, providing smaller portions than required to residents on regular and easy to chew diets. The cook did not review the recipe, leading to incorrect portion sizes, despite training to follow menus and recipes.
The facility failed to educate and offer the COVID-19 vaccine to three residents as per guidelines. The policy requires screening for prior vaccination status and contraindications, along with providing education on benefits and side effects. However, documentation for these residents was lacking since November 2022. Interviews revealed that the Infection Preventionist was responsible for ensuring vaccinations but was unsure why these residents were missed.
The facility failed to maintain a clean and safe environment in three shower rooms, with observations of dust, black substances, and maintenance issues. Staff interviews revealed a lack of awareness and action, with no work orders submitted for the issues. The administrator acknowledged the responsibility for cleaning but was unaware of the lack of a deep cleaning schedule.
Two nurse aides, NA M and NA N, continued to work in their roles without completing the required nurse aide training within four months of their hire dates. Despite failing the CNA test, they were allowed to perform all duties of a CNA, including providing care without supervision, as they were considered proficient after completing competency checklists. The facility's policy mandates that individuals should not work as nurse aides for more than four months without completing the necessary training.
The facility did not ensure that the three most recent years of survey results were accessible to residents and their families, as required by policy. Observations over several days confirmed the absence of survey results in accessible areas. Interviews revealed that both the administrator and the DON were unaware of the requirement, with the results being kept in the Business Office instead.
Failure to Obtain Orders and Assess Surgical Foot Wound
Penalty
Summary
Facility staff failed to obtain specific physician orders and complete assessments for a resident’s surgical foot wound following admission. The facility’s policies required that treatment orders be written per physician direction, including wound site, cleanser, ointment, dressing type, and treatment frequency, and that a physician, PA, or NP provide orders for immediate and ongoing care. The resident was admitted with a recent toe amputation and a diagnosis of gangrene, but the hospital discharge summary did not include surgical wound care orders or a follow-up appointment. On admission and in the days following, staff relied on the resident’s report that the surgical dressing was not to be removed until a follow-up visit, without obtaining clarifying orders from the surgeon, hospital, or wound care provider. Review of the physician orders dated shortly after admission showed only a directive for a wound care provider to “evaluate and treat,” with no specific surgical wound care orders or post-operative follow-up appointment documented. The Treatment Administration Record for the first week after admission contained no treatment orders or documentation that staff provided care to the surgical site. Nursing notes from that same period did not document any assessment of the dressing or surgical site. One LPN documented that the bandage was to remain intact until the surgeon follow-up based solely on what the resident reported, and stated that the hospital discharge paperwork lacked treatment orders. This LPN reported passing the concern about missing wound orders to the oncoming nurse but did not notify the physician directly. Interviews with the administrator, DON, LPNs, and the physician confirmed that no formal orders were obtained to either maintain or change the surgical dressing, and that no wound assessments were documented during the week after admission. The administrator and DON both stated that their understanding of leaving the dressing in place came from what the resident told the admitting nurse, and the DON later confirmed that no order could be found to keep the dressing intact. An LPN who worked the day the resident was sent to the hospital reported that the resident’s foot looked like it was “dying” and that there were no wound or treatment orders in the chart. The physician stated that he ordered wound care to evaluate and treat because there were no existing orders, and that the facility should have followed up with wound care or the private surgeon to obtain them, noting that in an ideal situation orders would have been in place within a few days. The resident was ultimately sent to the emergency room after family removed the dressing and contacted the surgeon, and hospital records documented worsened chronic right foot wound with tissue necrosis and a right trans metatarsal amputation.
Failure to Provide Timely Burn Treatment and Inadequate Care Planning
Penalty
Summary
Facility staff failed to provide timely treatment to a resident who sustained a burn injury to the right thigh after spilling hot coffee. The incident was documented by an LPN, who noted redness but no blistering and decided to monitor the area without administering any treatment or notifying the physician. No treatment interventions were documented until two days later, when staff observed fluid-filled blisters and applied Silvadene cream after notifying the physician. The care plan did not include interventions for providing or monitoring hot liquids, and there was no documentation of assessment regarding the resident's consumption of hot liquids in the electronic medical record. The facility did not have a policy addressing changes in a resident's condition following a burn injury. Interviews revealed that staff did not initiate immediate treatment, such as applying a cool compress or contacting the physician, as would have been expected. The resident, who had moderate cognitive impairment and was independent with eating and mobility, was not provided with timely care or documentation following the burn, and staff failed to update the care plan with appropriate interventions related to hot liquid safety.
Failure to Timely Notify Physician and Representative After Resident Burn Injury
Penalty
Summary
Facility staff failed to notify the physician and resident representative in a timely manner after a resident spilled hot coffee on their right leg, resulting in a significant burn injury. The initial documentation by an LPN noted a red, blotchy area with no blistering and indicated continued monitoring, but did not include notification to the physician or the resident's responsible party. Two days later, staff documented the presence of fluid-filled blisters on the resident's right inner knee and thigh, at which point the physician and resident representative were notified. The facility did not have a policy specifying when to notify the physician or resident representative of an injury or change in condition. Interviews revealed that both the administrator and the ADON did not expect staff to notify the physician or resident representative for what they considered a minor injury without significant pain, based on the initial assessment. However, the resident's physician stated that notification should have occurred shortly after the injury or within 24 hours. The LPN involved acknowledged that notification should have been made but was not due to being busy and forgetting. The resident was assessed as having moderate cognitive impairment and was independent with eating, bed mobility, and transfers at the time of the incident.
Failure to Update Care Plans After Resident Injury and Smoking Behavior
Penalty
Summary
Facility staff failed to review and revise comprehensive care plans for two residents following significant changes in their conditions and behaviors. For one resident with moderate cognitive impairment, staff documented a burn injury to the right thigh caused by a coffee spill, with subsequent treatment and physician notification. However, the care plan was not updated to include interventions for hot liquids or burn treatment. Interviews with the ADON, DON, and Care Plan Coordinator revealed that the incident was not communicated to the interdisciplinary team (IDT), and the care plan was not revised as required by facility policy. For another resident, also assessed with moderate cognitive impairment and a history of smoking, staff documented the resident's participation in scheduled smoke breaks. Despite this, the care plan did not include interventions related to smoking. The Care Plan Coordinator acknowledged missing the addition of smoking interventions during the quarterly care plan update. Staff interviews confirmed that care plans are expected to be updated by any nurse or IDT member following changes in a resident's condition or behavior, but this process was not followed in these cases.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when another resident struck them in the face on two separate occasions. Both residents involved were assessed as cognitively intact and had diagnoses of Alzheimer's disease, with one also having an unspecified mental disorder. The care plans for both residents identified risks for behavioral issues and directed staff to separate them if yelling occurred to prevent altercations. Despite these care plan directives, staff did not consistently implement or communicate effective interventions to prevent further incidents. The first incident occurred when one resident approached the other in the hallway, leading to a verbal exchange and a slap to the face. Staff separated the residents after the altercation, but interviews revealed uncertainty among staff and administration regarding additional interventions to ensure ongoing safety. Several staff members reported being unaware of any specific measures put in place to protect the resident who was struck, aside from separating the residents at the time of the incident. A second altercation occurred a few days later, during which the same resident struck the other twice in the face at the nurse's station. Again, staff separated the residents immediately, but interviews with multiple staff members, including CNAs, LPNs, and the DON, indicated a lack of awareness or implementation of further interventions to prevent recurrence. The facility's failure to consistently assess, communicate, and implement appropriate interventions resulted in repeated physical abuse between the two residents.
Improper Dishwashing and Sanitation Practices
Penalty
Summary
The facility staff failed to properly wash and sanitize soiled dishes, leading to potential cross-contamination. Observations revealed that the high-temperature dish machine was not functioning correctly, with the rinse cycle temperature measuring only 118 degrees Fahrenheit instead of the required 180 degrees. The booster heater was leaking, and despite the Dietary Manager's repeated requests for repair, no action had been taken to fix or replace it. The staff continued to use the malfunctioning dishwasher without adhering to the facility's policy of using disposable dinnerware or washing dishes in the three-compartment sink when the dishwasher was not working as designed. Additionally, staff did not follow proper procedures for washing dishes in the three-compartment sink. They failed to rinse dishes with clean potable water before placing them in the sanitizing solution and did not allow the dishes to remain in the solution for the required time. The concentration of the sanitizing solution was not checked, resulting in a solution that was too strong, exceeding 500 parts per million, which is above the recommended range of 150-400 ppm. Staff were inadequately trained, as evidenced by their lack of knowledge about the correct procedures and concentration levels. Furthermore, the facility staff did not ensure that dishes and utensils were air-dried before storage, leading to wet-nesting, which can promote bacterial growth. Observations showed that wet dishes and utensils were stacked and stored without proper drying. Waste containers in food preparation and utensil washing areas were also left uncovered when not in use, contrary to the facility's sanitation policy. The Dietary Manager and administrator were aware of these issues but failed to ensure compliance with the facility's policies and procedures.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to document the provision of restorative therapy for two residents, leading to a deficiency in maintaining or improving their range of motion and mobility. The facility's policy on Restorative Nursing, dated 11/30/23, outlines the need for interventions to promote residents' independence and optimal functioning, with documentation required by trained CNAs and evaluations by licensed nurses. However, the medical records for Resident #9 and Resident #41 lacked documentation of restorative nursing services, despite referrals and care plans indicating the need for such services. Resident #9 was assessed as cognitively intact but required varying levels of assistance for activities of daily living (ADLs) such as dressing, toileting, and transfers. An occupational therapy discharge summary indicated a prognosis to maintain the current level of functioning with consistent staff follow-through. Despite a referral for restorative nursing services to assist with walking and ADLs, the resident's medical record did not show evidence of these services being provided. The resident expressed a desire for assistance with walking and transfers, noting that staff did not have time to help, which affected their abilities. Resident #41, assessed as moderately cognitively impaired, also required assistance with ADLs and had a referral for restorative nursing to ambulate with a wheeled walker. The resident's care plan aimed to maintain or attain the highest level of function, but the medical record lacked documentation of restorative services. The resident and their spouse expressed concerns about the lack of assistance with walking. Interviews with the Rehabilitation Director and the Director of Nursing revealed that no restorative services had been provided, and the facility did not have an active restorative nursing program due to a lack of trained staff.
Failure to Serve Meals According to Nutritional Guidelines
Penalty
Summary
The facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents receiving regular and easy to chew (EC) diets. The facility's policy required that menus be planned in advance and followed as written to meet the nutritional needs of residents. However, during the lunch meal service, the staff served portions that were smaller than those directed by the menus. Specifically, residents on regular diets received six sweet and sour meatballs instead of the ten required, a #16 scoop of steamed rice instead of a #8 scoop, and four ounces of Soup Da Jour instead of six ounces. Similarly, residents on EC diets received a #16 scoop of steamed rice and four ounces of soup, both less than the menu specifications. The cook responsible for the meal service admitted to not reviewing the recipe for the sweet and sour meatballs and was unaware of the correct portion sizes. The dietary manager confirmed that staff are trained to serve meals according to the menus and recipes, and the administrator reiterated that staff should adhere to these requirements. Despite this training, the staff did not follow the established guidelines, resulting in the deficiency noted by the surveyors.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility staff failed to educate and offer the COVID-19 vaccination to eligible residents in accordance with current guidelines and policy. Specifically, three residents, identified as Residents #39, #57, and #61, did not receive the necessary education or offer for the COVID-19 vaccine. The facility's policy, in conjunction with CDC guidelines, mandates that residents be screened for prior vaccination status and medical contraindications before being offered the vaccine. Additionally, education regarding the benefits and potential side effects of the vaccine must be provided, allowing residents or their representatives the opportunity to refuse. However, the medical records for these residents lacked documentation of such education or offers since November 2022. Interviews with facility staff revealed a lack of adherence to the vaccination policy. The Infection Preventionist (IP) acknowledged that residents are typically offered vaccinations each season but was unsure why these residents were missed. The Director of Nursing (DON) and the facility administrator both indicated that it is the responsibility of the IP to ensure vaccinations are provided according to the season. The administrator expressed an expectation that the vaccination policy be followed, noting that the residents had missed opportunities to receive the COVID-19 vaccines.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment in three of the four shower rooms, as observed by surveyors. The facility's policies required regular cleaning and disinfection of high-touch surfaces and a deep cleaning schedule, but these were not adequately implemented. Observations revealed thick layers of dust on vents, unknown black substances on vents and shower stalls, cracked and missing tiles, and black stains on toilets. These conditions were consistent across multiple observations on consecutive days. Interviews with staff, including LPNs, NAs, CNAs, housekeepers, and supervisors, revealed a lack of awareness and action regarding the cleanliness and maintenance of the shower rooms. Staff were aware of the procedure to report maintenance issues via work orders, but none had been submitted for the shower rooms. The housekeeping supervisor admitted to not having a deep cleaning schedule and was unaware of the dirty vents and black substances. The maintenance director also did not have a deep cleaning schedule and was unaware of the shower room conditions. The administrator acknowledged the responsibility of housekeeping to clean the shower rooms daily and expected a deep cleaning schedule to be in place, which was not. Despite attempts to clean the areas, the administrator and housekeeping supervisor were unable to remove the black substances effectively. The administrator was aware of the black substances but not the dirty vents and had not submitted any work orders for the shower rooms. The facility had recently invested in new flooring, which may have influenced the decision not to remodel the shower rooms.
Nurse Aides Worked Without Completing Training
Penalty
Summary
The facility failed to ensure that two nurse aides, referred to as NA M and NA N, completed their nurse aide training program within four months of their hire dates. According to the facility's policy, individuals should not work as nurse aides for more than four months without completing the required training. NA M was hired on February 20, 2024, and NA N on January 11, 2024, yet both were still working without having passed their Certified Nurse Aide (CNA) test. Interviews revealed that both aides were scheduled to retake the test, but were allowed to continue working in their roles despite not having passed. The Staffing Coordinator and the Director of Nursing (DON) confirmed that NA M and NA N were performing the duties of a CNA, including providing all cares, without any limitations. The DON stated that the aides were given 90 days to retake the test and were supposed to be supervised by qualified staff until they were proficient. However, it was later mentioned that both aides had completed competencies in all resident care areas and were considered proficient and safe to care for residents without supervision. The facility administrator also confirmed that the aides were allowed to perform resident care in areas where they had completed competency checklists.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the three most recent years of survey results were posted and readily accessible to residents, family members, or representatives of residents. The facility's policy, dated 05/23/19, required that survey results be available in a location easily accessible to residents and visitors, such as a lobby or other common area, without the need to request access. Observations on three consecutive days showed that the facility did not have copies of the federal survey results accessible to residents, family members, or representatives. During interviews, both the administrator and the Director of Nursing were unaware that the survey results needed to be available in an accessible area, with the administrator noting that the results were kept in the Business Office instead.
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Illustrative
What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sullivan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meramec Nursing | 0.9 mi | ★★★★★ | 1 | 0 |
| St Clair Nursing Center | 15.1 mi | ★★★★★ | 1 | 0 |
| Cuba Manor Inc | 15.2 mi | ★★★★★ | 0 | 0 |
| Steelville Senior Living | 19 mi | ★★★★★ | 2 | 0 |
| Sunset Health Care Center | 19.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.