SPOKANE, WA - A federal inspection at Sullivan Park Care Center revealed significant gaps in care planning and wound prevention that placed residents at risk for continued injuries and complications.
Hip Fracture Fall Not Addressed in Care Plans
The most serious violation involved a resident with dementia who fell and fractured their right femur but did not receive updated care planning for over three months. Resident 44 broke their hip on August 10, 2024, when they attempted to transfer from their wheelchair to bed without assistance. Despite this major injury, the facility failed to revise the resident's fall prevention care plan until November 18, 2024.
During this period, the resident experienced multiple additional falls: - September 19: Found walking out of bathroom after falling - November 17: Slid out of recliner in common area - November 21: Fell in room with no injury - December 4: Fell in room, sustained skin tears - December 27: Fell in room with no injury - January 13: Fell in room with no injury
The initial basic care plan from August only included standard fall prevention measures like keeping call lights within reach and using non-skid footwear. After the hip fracture and repeated falls, staff should have implemented enhanced interventions such as increased monitoring, behavioral assessments, or environmental modifications.
Staff member acknowledged the oversight: "If a resident fell and broke their leg, they would expect to see changes to the resident's plan of care," stated the Director of Nursing during the inspection.
A nursing assistant noted the resident's impulsive behavior: "The resident used to be and was still impulsive and tried to sit on the edge of the bed and holler. If they do not get there timely the resident tried to get up."
Addison's Disease Management Gaps
Inspectors also found the facility failed to address a rare but serious medical condition in another resident's care plan. Resident 35, who has Addison's disease, expressed concerns about staff knowledge regarding their condition during medical crises.
Addison's disease occurs when adrenal glands fail to produce adequate hormones to regulate blood pressure, water balance, and stress response. During adrenal crises, patients require emergency hormone injections to prevent life-threatening complications.
The resident described a 48-hour crisis that required two injections before subsiding. They stated concern that "nursing staff were not educated on how to address it" and reported difficulty convincing new nurses of their need for emergency medication.
Medical records showed the resident received emergency hydrocortisone injections on six occasions between December 2024 and March 2025, yet no specific interventions for Addison's disease appeared in their care plan as of December 5, 2024.
A Resident Care Manager acknowledged the oversight: "The disease should have been added to the resident's care plan with special instructions/interventions. This was important because it would ensure staff provided the appropriate care and management of their condition."
Personal Care Deficiencies Impact Dignity
The inspection revealed additional concerns about basic personal care services. Resident 52 reported not receiving scheduled twice-weekly showers due to staffing shortages, with shower aides frequently reassigned to other duties.
Documentation showed gaps in shower provision, with no recorded showers after February 28, 2025. The resident stated they were often told there was insufficient staff to provide evening showers.
Another resident, requiring assistance with personal grooming due to stroke and cognitive impairment, was observed with an unkempt beard multiple times during the inspection period. Staff acknowledged the resident should have been shaved regularly for dignity and hygiene.
Wound Prevention Protocol Failures
Perhaps most concerning were violations related to pressure injury prevention. The facility failed to properly implement wound prevention protocols for multiple residents, leading to avoidable pressure ulcers.
Two residents with physician orders for constipation management did not receive prescribed bowel medications when indicated. Resident 18 went without bowel movements for periods of three to five days on multiple occasions without receiving ordered interventions. Constipation can significantly increase pressure injury risk through immobility and straining.
Pressure Injury Equipment Misuse
Inspectors found improper use of pressure-relieving equipment that could compromise effectiveness. Blue foam wedges intended for positioning were placed under the mattress rather than under bed sheets as designed. Staff lacked clear instructions on specialty mattress settings, with some residents experiencing discomfort from inappropriate firmness levels.
One resident with multiple pressure injuries had an air mattress but no documented provider orders specifying proper settings. Staff reported adjusting equipment "based on resident comfort" rather than clinical guidelines, which inspectors noted was inadequate practice.
Medical Standards for Care Planning
Federal regulations require nursing homes to develop comprehensive care plans within seven days of admission and revise them as residents' conditions change. Care plans must address all identified risks and include specific interventions to prevent complications.
For fall-prone residents, evidence-based interventions may include hourly rounding, alarm systems, physical therapy evaluation, medication review, and environmental modifications. When residents sustain major injuries like hip fractures, care plans should immediately incorporate lessons learned and enhanced protective measures.
Pressure injury prevention requires systematic risk assessment, appropriate support surfaces, repositioning schedules, nutrition optimization, and skin monitoring protocols. Equipment like specialty mattresses must be properly calibrated according to manufacturer specifications and resident-specific factors.
Industry Context and Consequences
Nursing home care planning violations reflect broader challenges with staff training, documentation systems, and interdisciplinary communication. When care plans fail to address changing conditions, residents face increased risk of preventable injuries, infections, and functional decline.
Hip fractures in nursing home residents carry particularly serious consequences, including prolonged pain, reduced mobility, increased fall risk, and higher mortality rates. Proper post-fracture care planning is essential to prevent additional injuries and optimize recovery.
Addison's disease affects only 1 in 10,000 people, making staff education crucial for proper crisis recognition and response. Adrenal crises can be fatal without prompt treatment, making care plan inclusion of emergency protocols a patient safety imperative.
The Centers for Medicare & Medicaid Services classified these violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the cumulative impact of multiple care planning failures suggests systemic issues requiring comprehensive corrective action.
Sullivan Park Care Center must now submit a plan of correction detailing how they will address these deficiencies and prevent recurrence. The facility's response and implementation will be subject to ongoing federal oversight to ensure resident safety and regulatory compliance.
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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