SPOKANE, WA - Avalon Care Center at Northpointe received multiple citations following a federal inspection that documented significant nutrition failures and care violations affecting resident health and safety.
Serious Weight Loss Issues Documented
The most concerning findings involved two residents who experienced dangerous weight loss while under the facility's care. One resident lost 14.29% of their body weight over six months and 7.9% in approximately three months, meeting the criteria for significant weight loss. The second resident lost 8.51% of their body weight in just one month.
Weight loss of this magnitude creates serious health risks for nursing home residents. A loss of 5% in one month, 7.5% in three months, or 10% in six months is considered medically significant and requires immediate intervention. Unintentional weight loss in elderly residents can lead to decreased immune function, increased infection risk, slower wound healing, and higher mortality rates.
For the first resident, documentation showed they were consuming only 25-49.9% of their meals, yet proper nutritional interventions were not implemented until December 2024, after substantial weight loss had already occurred. During observations, inspectors noted the resident ate only small portions of meals and was not offered alternative foods or nutritional supplements as required by their care plan.
Systematic Failures in Basic Care
The inspection revealed widespread problems with basic resident care across multiple areas. Seven residents experienced failures in bowel care management, with staff not providing prescribed laxatives despite residents going days without bowel movements. One resident went seven consecutive days without a bowel movement while prescribed medications remained unadministered.
Constipation in nursing home residents can lead to serious complications including bowel obstruction, which can be life-threatening. Regular bowel function is essential for resident comfort and preventing medical emergencies.
Bathing care also fell below standards, with documentation showing one resident received proper bathing only five times over a four-month period. The resident's care plan specified showering one to two times weekly, but records indicated frequent missed opportunities and inadequate alternative care when showers were refused.
Wound Care and Safety Concerns
A particularly troubling case involved a resident who developed a Stage 4 pressure ulcer on their left heel. The wound, measuring 7.9 centimeters by 5 centimeters with a depth of 2.1 centimeters, was not identified by facility staff until the resident's family member brought it to their attention. Stage 4 pressure ulcers involve full thickness skin and tissue loss with exposed bone, tendon, or muscle.
The resident had a history of heel wounds that were previously documented as healed. However, weekly skin checks from January 2025 showed "no skin concerns" just days before a significant wound was documented. This represents a serious failure in the facility's wound monitoring protocols.
Pressure ulcers are largely preventable through proper positioning, nutrition, and skin assessment. When they do develop, early identification and treatment are crucial to prevent progression to deeper stages that can result in serious complications including bone infection.
Fall Prevention Failures
Multiple residents experienced falls due to inadequate safety measures. One resident sustained nine falls over a three-month period, including several that occurred even after one-on-one supervision was reportedly implemented. Another resident fell and hit their head in the same location as a previous injury that had required brain surgery, yet proper neurological monitoring protocols were not followed.
Neurological assessments after head injuries are critical for detecting complications such as brain bleeding, particularly in residents taking blood-thinning medications. The facility's monitoring protocol required checks every 15 minutes initially, then at specified intervals, but documentation showed significant gaps in required assessments.
Respiratory Care Deficiencies
Three residents receiving respiratory therapy experienced care failures. One resident used oxygen equipment without physician orders, while two others had CPAP machines for sleep apnea but lacked proper medical orders or care plans. One resident reported not wearing their CPAP machine for multiple nights due to falling asleep before applying it, yet staff documentation incorrectly indicated nightly compliance.
Sleep apnea treatment is essential for preventing serious health complications including heart problems and daytime fatigue that can increase fall risk. Proper medical supervision ensures equipment is used safely and effectively.
Medication and Treatment Errors
A dialysis patient's care plan and medical orders contained significant errors. The resident had a central venous catheter for dialysis access, but staff were documenting assessments for a fistula that the resident never had. This type of error indicates poor communication between the facility and the dialysis center, potentially compromising the resident's specialized care needs.
Staffing Concerns Identified
The inspection documented concerns about adequate staffing levels to meet resident needs. Multiple staff members expressed concerns about insufficient staffing, particularly during evening and weekend shifts. One resident reported waiting up to one hour and 40 minutes for call light responses.
Adequate staffing is fundamental to providing safe nursing home care. When staffing levels are insufficient, residents may experience delays in receiving assistance with activities of daily living, medication administration, and emergency response.
Regulatory Response and Industry Context
The violations identified at Avalon Care Center reflect broader challenges in the nursing home industry related to staffing, clinical oversight, and quality assurance. Federal regulations require nursing homes to provide services necessary for each resident to attain and maintain their highest level of physical, mental, and psychosocial well-being.
The Washington State Department of Social and Health Services will require the facility to submit a plan of correction addressing each citation. The facility must demonstrate how it will prevent similar problems from recurring and ensure resident safety.
Families with loved ones at nursing facilities should be aware of these quality indicators and advocate for proper care. Warning signs include unexplained weight loss, new wounds, frequent falls, and changes in a resident's overall condition or behavior.
The inspection findings underscore the importance of robust clinical oversight, adequate staffing, and systematic approaches to resident care in nursing home settings. Proper implementation of care plans, medication management, and safety protocols are essential components of quality long-term care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center At Northpointe from 2025-02-07 including all violations, facility responses, and corrective action plans.
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