SPOKANE, WA - Federal inspectors cited Sullivan Park Care Center for multiple care plan deficiencies during a March 6, 2025 inspection, finding the facility failed to properly develop and implement essential care plans for residents with complex medical needs including heart conditions, respiratory diseases, and sensory impairments.
Baseline Care Plans Missing Critical Medical Interventions
The inspection revealed significant gaps in the facility's initial care planning process, with two residents receiving incomplete baseline care plans within the required 48-hour admission window. These deficiencies left residents without proper protocols for managing serious medical conditions.
Resident 6 was admitted with multiple cardiovascular conditions requiring medications for heart failure, high blood pressure, and atrial fibrillation - a potentially dangerous irregular heart rhythm. Despite being legally blind, the resident's baseline care plan contained no goals or interventions addressing either the cardiovascular diagnoses or vision impairment.
Similarly, Resident 411 was admitted with chronic obstructive pulmonary disease and asthma, both serious respiratory conditions that can lead to breathing difficulties and medical emergencies. The facility's baseline care plan failed to include any interventions for managing these lung diseases.
Baseline care plans serve as the foundation for a resident's treatment during their most vulnerable period following admission. These plans must identify immediate care needs and establish protocols to prevent medical complications. When facilities fail to address critical diagnoses like heart failure or respiratory disease, residents face increased risks of emergency situations, medication errors, and delayed interventions.
The facility's Resident Care Manager acknowledged during the inspection that both residents' baseline care plans failed to identify nursing needs, interventions, or goals related to their active medical diagnoses.
Communication Care Plan Failures for Hearing-Impaired Resident
Inspectors documented serious deficiencies in care planning for Resident 78, who had significant hearing loss and relied on multiple communication methods. The resident was observed struggling with a hearing aid that was frequently placed incorrectly or left on the bedside table.
During observations, Resident 78 stated: "the staff use a little bit of both writing or use of pictures to communicate with them." The resident's family representative confirmed the individual was "very hard of hearing, almost 100% deaf" and used hearing aids, lip reading, and sign language to communicate.
Despite these complex communication needs, the facility's care plan was dated and inaccurate. It incorrectly stated the resident used hearing aids in both ears when observations showed only one functioning device. More critically, the plan failed to document essential alternative communication methods including sign language, lip reading, and written communication that staff and the resident actually used.
Effective communication is fundamental to all aspects of nursing home care, from medication administration to emergency response. When care plans fail to accurately reflect a resident's communication needs and methods, it creates risks for misunderstood medical requests, improper care delivery, and social isolation.
Safety Protocol Violations in Resident Interactions
The inspection revealed concerning failures to implement safety protocols for Resident 62, who had a documented care plan requiring two staff members for all interactions following an alleged incident in August 2024. The facility's investigation had resulted in an updated care plan mandating this safety measure for all interactions, including medication administration and conversations.
However, inspectors observed multiple violations of this protocol. Staff members were documented entering the resident's room alone to answer call lights, provide requested items, and administer medications on multiple occasions during the inspection period.
When questioned, nursing staff acknowledged the two-person requirement but expressed difficulty implementing it consistently. One nursing assistant stated that following the care plan "would be hard to do," while a registered nurse confirmed that "having a conversation with a person was an interaction" requiring two staff members.
This type of safety protocol typically results from documented behavioral concerns or incident investigations. Consistent implementation protects both residents and staff by ensuring proper witnesses to interactions and reducing potential for conflicts or misunderstandings.
Vision Care Planning Deficiencies
Inspectors found inadequate care planning for Resident 41, who required glasses for daily activities and had an upcoming cataract surgery scheduled. Despite the resident's documented vision needs and the importance of reading to their quality of life, the care plan contained no documentation related to vision care.
Multiple observations showed the resident without glasses while attempting to read correspondence and perform daily activities. On one occasion, the resident was observed wearing glasses with a missing lens. When asked, Resident 41 stated: "they needed their glasses to read the letter and reminders to wear them daily."
Vision care in nursing homes extends beyond medical treatment to encompass safety during daily activities, medication management, and maintaining cognitive engagement through reading and other visual activities. Residents with cataracts face particular challenges as their vision deteriorates, requiring enhanced monitoring and adaptive interventions.
Medical Context and Industry Standards
These violations represent fundamental failures in nursing home care planning, which serves as the roadmap for meeting each resident's individual needs. Federal regulations require facilities to develop comprehensive care plans that address all identified health conditions and update them as needs change.
Proper care planning involves ongoing assessment of residents' physical, cognitive, and psychosocial needs, with specific interventions designed to maintain or improve function. For residents with multiple chronic conditions, coordinated care planning becomes critical to prevent complications and ensure quality of life.
Additional Issues Identified
The inspection also documented concerns about quarterly care plan reviews and staff understanding of care plan requirements across multiple departments.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.