SPOKANE, WA - A March 2025 state inspection at Sullivan Park Care Center revealed several safety violations that placed residents at risk, including unsafe storage of smoking materials, improper medical device maintenance, and inadequate trauma-informed care protocols.
Fire Safety Concerns with Smoking Materials and Electrical Appliances
Inspectors identified significant fire safety risks involving both smoking materials and electrical heating devices. Resident 18, a stroke survivor with hemiplegia who required smoking materials to be secured per their care plan, was repeatedly observed keeping cigarettes and a lighter in an accessible wheelchair cup rather than locked in the medication cart as required.
The situation became more concerning given the presence of wandering residents on the unit. Resident 63, described as cognitively impaired, was observed multiple times wandering onto Resident 18's hallway, entering rooms, and taking items from other residents. Staff confirmed that wandering residents regularly accessed other residents' rooms despite attempts to prevent entry, including placing stop signs on doors.
"There were two residents that wandered on 400 hall and three residents wandered from the other two halls on the secured unit that wandered onto 400 hall," a nursing assistant reported. One resident had already reported missing cigarettes from their room in previous months.
The fire risk was compounded by Resident 18's roommate being on oxygen therapy. When questioned about the safety implications, the Director of Nursing acknowledged that smoking supplies needed to be secured and stated, "it was important that smoking supplies were kept in the nurse's cart for safety reasons."
A separate electrical safety issue involved Resident 78, who used a heating pad brought by family members without proper medical assessment or monitoring. The heating pad was observed being used at 100 degrees for extended periods, with no physician orders, care plan documentation, or safety protocols in place. Staff expressed uncertainty about the device's safety, with one nurse asking inspectors, "Should I get rid of it? I'll double check with my boss."
Critical Medical Device Maintenance Failures
The inspection revealed serious deficiencies in the management of a PICC line (peripherally inserted central catheter) for Resident 52, who had been receiving antibiotic treatment for empyema, a serious lung infection. PICC lines are sophisticated medical devices that require precise maintenance to prevent life-threatening complications including bloodstream infections and blood clots.
The facility failed to follow established protocols in multiple ways. The transparent dressing covering the PICC insertion site was left unchanged beyond the required seven-day interval, with inspectors observing the same dressing from February 16 still in place on February 25 - nine days later with edges peeling off. Mandatory saline flushes ordered every eight hours were completely omitted from February 25 through March 1, creating risk for line occlusion.
When the PICC line became blocked on March 2, the ordered clot-dissolving medication (Cathflo Activase) was not administered due to unavailability. The blocked catheter remained in place for several additional days before removal on March 4, despite having no medical purpose after antibiotic treatment ended February 20.
Medical standards require PICC lines to be removed promptly when no longer medically necessary, as they create ongoing infection risk for patients already being treated for serious infections. The Centers for Disease Control and Prevention guidelines emphasize daily assessment of catheter necessity and prompt removal to prevent complications.
The facility's Resident Care Manager acknowledged the oversight, stating "We do not do competencies that I am aware of. That would be a good one," referring to the lack of specialized training for nurses managing PICC lines.
Respiratory Care Equipment Neglect
Two residents requiring continuous oxygen therapy experienced compromised care due to poorly maintained equipment. Resident 74, diagnosed with chronic obstructive pulmonary disease (COPD), was found receiving oxygen at incorrect flow rates - 4 liters per minute instead of the prescribed 3 liters per minute. More concerning was the condition of the oxygen concentrator's filter, which was observed to be thick with dust debris on multiple inspection days.
The facility's own policy required weekly cleaning of oxygen concentrator filters to maintain proper function, yet this basic maintenance was not being performed consistently. An oxygen equipment supplier confirmed that dirty filters "could clog the airway for the flow of air into the concentrator and would impact the flow of oxygen."
Resident 35 faced similar issues with unclean oxygen equipment, including tubing dated from August 2024 that showed dried blood and had not been changed despite the resident's requests. The resident told inspectors they had asked for new nasal cannula "because it was dirty with blood on it" and that tubing was "supposed to be changed weekly but had to request that it be done."
Proper oxygen delivery is critical for residents with respiratory failure, as inadequate oxygen levels can lead to serious complications including organ damage and death. Clean equipment is essential to prevent respiratory infections in already vulnerable patients.
Systemic Failure in Trauma-Informed Care
Perhaps most concerning was the facility's widespread failure to provide trauma-informed care for residents with Post-Traumatic Stress Disorder (PTSD). Inspectors identified six residents with PTSD diagnoses who received no specialized trauma-informed care planning.
The facility's screening process was fundamentally flawed. Instead of asking residents whether they had experienced traumatic events, staff only asked if residents wanted to discuss trauma - marking "Not sure" for all trauma history questions when residents declined to elaborate. This approach prevented identification of potential triggers that could retraumatize vulnerable residents.
Resident 6, who had experienced gunshot wounds and sudden deaths of relatives, received no trauma-informed care planning despite clear PTSD diagnosis. Staff caring for these residents were unaware of their trauma histories and had no guidance on avoiding potential triggers.
One resident with trauma history from physical abuse expressed fear about head injuries after an alleged incident with facility staff, but this information was not incorporated into care planning. The Social Services Director acknowledged the screening inadequacy, stating it "would be better practice to ask the resident if they experienced trauma prior to asking them if they would like to talk about trauma."
Medical Consequences and Industry Standards
These violations represent significant departures from accepted healthcare standards. Fire safety protocols exist because nursing home residents often have limited mobility and cognitive impairments that prevent self-evacuation during emergencies. The combination of unsecured smoking materials, wandering residents, and oxygen therapy creates multiple ignition sources and fuel for potential fires.
PICC line maintenance protocols are based on extensive research showing that each day a catheter remains in place increases infection risk. Bloodstream infections from contaminated central lines have mortality rates of 10-25% and can cost healthcare systems hundreds of thousands of dollars per case.
Respiratory care standards emphasize equipment cleanliness because residents with breathing problems are highly susceptible to infections. Compromised oxygen delivery can lead to hypoxemia, organ dysfunction, and respiratory failure requiring emergency intervention.
Trauma-informed care has become a recognized healthcare standard as research demonstrates that retraumatization can worsen mental health conditions, increase behavioral problems, and reduce treatment effectiveness. Proper screening and care planning can prevent psychological harm and improve overall health outcomes.
Additional Issues Identified
The inspection also documented problems with medication administration timing, inadequate documentation of safety assessments, and staff knowledge gaps regarding specialized medical equipment. Multiple staff members expressed uncertainty about proper protocols for managing medical devices and safety equipment.
Sullivan Park Care Center must address these systematic failures to ensure resident safety and comply with federal healthcare standards. The violations indicate broader issues with staff training, policy implementation, and quality assurance processes that require comprehensive correction.
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.
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