SPOKANE, WA - Federal regulators found serious deficiencies in abuse prevention protocols at Sullivan Park Care Center following a March 6, 2025 inspection that revealed the facility failed to properly identify, report, and investigate potential allegations involving six residents.
Critical Failures in Abuse Prevention System
The investigation exposed systemic breakdowns in Sullivan Park Care Center's abuse prevention program, with inspectors documenting violations affecting residents' safety and quality of life. The facility's own policy, revised in April 2021, required staff to identify and report potential allegations within mandated timeframes while protecting residents from harm during investigations.
Despite having clear procedures in place, the facility repeatedly failed to recognize incidents as potential abuse or neglect allegations, delayed reporting to state authorities, and conducted inadequate investigations that left residents vulnerable.
The most significant issue involved delayed responses to resident call lights. One cognitively intact resident reported waiting over an hour for staff assistance after experiencing incontinence, turning on their call light at 9:45 PM but not receiving help until 11:00 PM. The resident indicated this lengthy delay had occurred on four other occasions.
This allegation wasn't identified as potential neglect until brought to administration's attention by surveyors during the inspection. A nursing assistant later confirmed the resident's account, documenting that the resident "was glad Staff I answered their call light because Resident 42 had waited for an hour to be changed."
Resident-to-Resident Altercations Go Unreported
The inspection revealed multiple incidents of physical aggression between residents that were not promptly reported to state authorities. One resident with severe cognitive impairment and documented wandering behaviors was involved in three separate altercations over a 12-day period in October and November 2024.
These incidents included: - Open-handed slapping of another resident on the back of their head, reported 23 hours after staff witnessed the incident - Hair pulling witnessed by staff but not reported for 24 hours - Striking with a hairbrush when the resident wandered into another's room
In another case involving two residents, facility staff documented a confrontation where one resident entered another's room and "placed their hand on their left arm." The affected resident later described being "yelled at" and said it was "the worst experience I had with them." However, this incident was never logged in the facility's February 2025 incident reports, and state authorities weren't notified as required.
Medical Significance of Reporting Delays
Healthcare facilities must report suspected abuse or neglect to state agencies within two hours under federal regulations. These strict timelines exist because vulnerable nursing home residents depend entirely on staff for protection and care. Delays in reporting can allow continued harm and prevent immediate protective interventions.
When call lights go unanswered for extended periods, residents face serious health risks. Prolonged exposure to incontinence can cause skin breakdown, urinary tract infections, and dignity-related psychological trauma. For residents with limited mobility, these delays can also prevent timely pain management or assistance with breathing difficulties.
Resident-to-resident altercations require immediate attention because individuals with dementia may not remember previous conflicts, leading to repeated incidents. Proper documentation and reporting enable facilities to implement targeted interventions, such as increased supervision or environmental modifications, to prevent future occurrences.
Inadequate Investigation Procedures
The inspection found that even when incidents were eventually reported, investigations lacked thoroughness. In the resident-to-resident altercation case, the initial investigation failed to include staff or resident interviews. No progress notes were written on the day of the incident, and monitoring for psychological impact didn't occur until the following day.
Federal standards require comprehensive investigations that include interviews with all relevant parties, documentation of findings, and implementation of protective measures. The facility's Director of Nursing acknowledged that "thorough investigations" were essential "to prevent harm or re-occurrence and to identify triggers to prevent future occurrences."
Missing Money Cases Unrecognized
Two separate residents reported missing money - $50 and $40 respectively - that the facility replaced when unable to locate the funds. However, these incidents were never logged in facility incident reports or reported to state authorities as potential theft allegations.
Staff interviews revealed confusion about reporting requirements for missing money. The administrator stated instances were reported "on a case-by-case basis, if it was over $100 or if theft was suspected." However, the facility's Resident Care Manager explained they "would not wait until they suspected theft prior to reporting missing money because the facility might not suspect theft until instances of missing money were investigated."
This inconsistency in understanding demonstrates the importance of clear policies. Missing personal funds can indicate staff theft, inadequate security measures, or exploitation of vulnerable residents who may not remember financial transactions.
Staff Knowledge Gaps Identified
Interviews with facility staff revealed concerning gaps in understanding about abuse prevention requirements. While some staff members correctly identified reporting timelines and investigation procedures, others were uncertain about key protocols.
A registered nurse was "unsure how abuse and/or neglect was ruled out," and there was inconsistency about when staff should be removed from direct care duties during investigations. The Director of Nursing noted that ideally, staff would be "immediately removed from direct resident care pending the results of the investigation" when allegations involved specific employees.
Industry Standards and Best Practices
Federal nursing home regulations require facilities to maintain comprehensive abuse prevention programs that include staff training, incident identification protocols, and timely reporting procedures. These standards recognize that nursing home residents are among society's most vulnerable populations, often unable to advocate for themselves or report mistreatment.
Best practice involves creating a culture where all staff understand their role as mandatory reporters and feel empowered to speak up about concerns. Effective programs also include regular training updates, clear escalation procedures, and systematic monitoring to ensure compliance.
The facility's policy correctly outlined many required elements, but implementation failures suggest gaps in staff education and oversight. Regular audits and training refreshers help ensure policies translate into consistent practice.
Additional Issues Identified
Beyond the major violations, inspectors documented related concerns including: - Delayed monitoring of residents for psychological harm following alleged incidents - Inconsistent documentation practices across different departments - Gaps in supervisor notification when potential allegations were identified - Need for additional education on Washington State reporting guidelines
The inspection resulted in required corrective action plans and re-education for key staff members. The facility's Regional Director of Clinical Services provided specific training on state reporting guidelines to prevent future incidents from going unreported.
Federal regulators classified these violations as causing "minimal harm or potential for actual harm" but affecting "some" residents, indicating systemic issues that could impact facility operations and resident safety if not addressed promptly and comprehensively.
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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