SPOKANE, WA - A federal inspection completed March 6, 2025, at Sullivan Park Care Center revealed widespread deficiencies across multiple care areas, including untracked controlled substances from discharged residents, repeated medication errors, food safety violations, and systemic failures in infection control practices.
Controlled Medications Left Untracked for Months
One of the most concerning findings involved controlled medications belonging to residents who had been discharged months earlier remaining in the facility's medication storage without proper documentation or disposal.
During an inspection of the North Hall medication room on February 24, 2025, surveyors discovered multiple controlled substances in the locked narcotic box inside the refrigerator. These included an unopened bottle of liquid Morphine, a powerful narcotic pain medication, and an unopened bottle of liquid Lorazepam, a controlled anti-anxiety medication, both belonging to a resident who had discharged nearly five months earlier. Additionally, a medication card containing 10 Dronabinol capsules, used to treat nausea and stimulate appetite, was found with an expiration date that had already passed.
A second discharged resident's liquid Lorazepam was also discovered in the same location. That resident had left the facility over seven months prior.
The tracking failures were substantial. According to facility protocol, all medications in the narcotic box should have a page number written on them corresponding to an entry in the narcotic book, with counts performed every shift. However, none of the bottles of Lorazepam or Morphine had page numbers, and reviews of the narcotic books dating back months showed no entries for these medications.
A Licensed Practical Nurse told surveyors that "if for some reason a refrigerated narcotic was not in the log book, the mistake probably wouldn't be caught."
The Director of Nursing acknowledged during an interview that staff had not been checking the narcotic box in the medication refrigerator for discharged resident medications, especially those not documented in the medication books. The Director admitted that without proper tracking in the narcotic books, "there was a risk of drug diversion and the facility staff would not even know it."
Controlled substance diversion in healthcare settings represents a serious concern for multiple reasons. Untracked narcotics like Morphine and Lorazepam can be stolen and sold illegally or abused by staff members. Proper chain-of-custody documentation exists specifically to detect when medications go missing and to hold individuals accountable. When facilities fail to maintain accurate narcotic counts and promptly dispose of discharged residents' medications, they create opportunities for diversion that may never be detected.
Critical Medication Errors Affect Resident Care
The inspection revealed medication administration failures affecting two residents with serious medical conditions.
Resident 95, diagnosed with lupus, a condition where the immune system attacks healthy tissues causing pain and inflammation, experienced repeated gaps in receiving Cellcept, a medication designed to reduce overactive immune system activity. According to records, the resident missed doses on nine separate dates across January and February 2025, with documentation indicating the medication was unavailable, had been ordered from the pharmacy, had not been delivered, and was not available in the facility's backup medication storage.
The resident reported to surveyors that "several times during their stay, the facility had run out of the medication and it caused them to have more pain." The resident stated the longest period without the medication was four days.
A Resident Care Manager explained that when doses of Cellcept are missed, "it could cause a flare-up of their lupus and that could cause the resident increased pain, inflammation, fatigue, or many other concerns." The manager also noted there should have been better documentation showing nurses contacted the pharmacy or notified the provider when medication was unavailable.
For patients with autoimmune conditions like lupus, consistent medication adherence is essential for disease management. Immunosuppressive medications work by maintaining steady levels in the bloodstream to control the immune system's overactivity. Missed doses can trigger disease flares characterized by joint pain, fatigue, skin rashes, and potentially organ damage. The fact that this resident experienced multiple multi-day gaps in medication represents a significant care failure.
Resident 102, who had been hospitalized after a stroke and diagnosed with rapid atrial fibrillation, faced a different type of medication error. The resident's order for amiodarone, a heart rate control medication, included specific instructions to hold the medication if blood pressure readings fell below certain parameters and to notify the provider.
Records showed that on six dates in February 2025, the resident's systolic blood pressure readings were below the hold parameter of 110, yet the medication was still administered. A nurse who had recently begun employment at the facility stated they "did not realize the amiodarone was to be held" when blood pressure was low and had not discussed the low readings with the provider.
Heart rate medications like amiodarone carry parameters for good reason. Administering medications that further lower heart rate or blood pressure when readings are already low can cause dangerous drops in blood pressure, leading to dizziness, falls, fainting, or inadequate blood flow to vital organs. The hold parameters exist to allow providers to reassess whether the medication dose needs adjustment.
Widespread Food Safety and Quality Failures
Multiple residents and the Resident Council expressed concerns about food quality during the inspection. The Council reported that "the food was only good maybe two days a week," citing overcooked vegetables, lack of menu variety, and particularly poor weekend meals.
Individual resident complaints painted a consistent picture. One resident described meat that was "extremely overcooked and so tough they could not chew it" and vegetables that were "mushy." Another resident stated their cheese ravioli "had been cooked for so long that the sauce soaked completely into the pasta" and described the cheese inside as "rubbery" with "no taste."
A third resident reported that chicken served for dinner was "so dry they could not swallow it" and the meal was "inedible," leading them to instead eat a vegetable tray they had ordered from a local grocery store.
When surveyors sampled a test tray directly from the kitchen steam table, they found the temperature "lukewarm" and the appearance "unappetizing with dull colors." The fish and potatoes "tasted bland" with no lemon or almond flavoring as the menu suggested. The Dietary Manager acknowledged they had eaten the same meal and "had to add seasoning" because it lacked lemon flavor.
Beyond palatability concerns, surveyors identified multiple food safety violations:
- Expired foods: Four opened bags of cereal with expired dates and a container of rice past its use-by date were found in dry storage - Unlabeled items: Numerous opened foods in refrigerators lacked required date labels, including precooked sausage patties, sliced turkey, pickles, mayonnaise, salad dressing, and salsa - Temperature monitoring failures: Staff did not check food temperatures during tray line service until prompted by surveyors, and a fruit parfait was found at 46 degrees Fahrenheit when cold foods must be kept at or below 41 degrees - Thickened liquid preparation errors: A dietary aide was observed using incorrect amounts of thickener, using 3 pumps for honey-thick consistency when 4 pumps were required - Missing cleaning documentation: The facility lacked a documented cleaning schedule, and reviewed schedules showed tasks not completed for the majority of days
The Dietary Manager, who was also a Registered Dietitian, was found to lack a required Washington State Food Worker Card, which demonstrates competency in food safety practices.
For nursing home residents, many of whom have difficulty swallowing or are already at nutritional risk, food quality and safety are directly tied to health outcomes. Improper thickened liquid preparation can lead to aspiration, where liquids enter the airway and lungs, potentially causing pneumonia. Food temperature violations create conditions for bacterial growth that can cause foodborne illness, which is particularly dangerous for elderly individuals with compromised immune systems.
Infection Control Breakdown Across Multiple Units
Surveyors documented numerous failures in infection prevention practices throughout the facility.
During wound care for one resident, a Licensed Practical Nurse was observed removing soiled dressings, changing gloves without performing hand hygiene, applying new dressings, touching their uniform pocket for a pen, reapplying the resident's incontinence brief, and then physically checking the resident's gastrostomy tube site, all without washing hands between these activities.
The facility also failed to implement Contact Precautions when residents developed gastrointestinal symptoms. Two residents on the same unit experienced nausea, vomiting, and diarrhea, yet neither had contact precaution signage on their doors. A nurse acknowledged the residents "probably needed contact precautions" but had not notified the Infection Preventionist about the symptoms.
Enhanced Barrier Precautions, which require gowns and gloves during high-contact care activities for residents with wounds or medical devices, were inconsistently followed. Staff members were observed providing care without required protective equipment on multiple occasions. Even the Infection Preventionist was observed performing wound care without wearing a gown.
Multiple additional observations documented staff entering rooms with contact precaution signage without donning required protective equipment, staff transporting used protective equipment through hallways instead of disposing of it properly, and a mechanical lift being used and then parked without being cleaned.
The Infection Preventionist acknowledged there was "no formal monitoring of staff compliance" with Enhanced Barrier Precaution requirements.
Additional Issues Identified
The inspection also cited the facility for:
- Incomplete medical records: A resident who was transferred to the hospital after vomiting blood had no documentation in their record of the events leading to their decline, provider notifications, or interventions attempted - COVID-19 vaccination documentation failures: A newly hired nurse reported being offered a COVID vaccine during orientation but receiving no education and signing no consent or declination form, with employee files lacking required vaccination documentation
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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