SPOKANE, WA - Federal inspectors cited Sullivan Park Care Center for failing to prevent pressure injuries in residents and improperly managing wound care protocols during a March 2025 inspection.
Critical Equipment Misuse Identified
The inspection revealed serious deficiencies in how staff used specialized medical equipment designed to prevent pressure injuries. In one case, positioning wedges intended to help turn and reposition a resident were placed incorrectly under the mattress instead of under the bed sheet where they would be effective.
"The wedges should be placed under the bed sheet and not under the mattress," acknowledged an LPN supervisor during the inspection. The misplacement rendered the positioning devices ineffective for pressure relief.
Staff also failed to establish proper settings for specialty air mattresses. These mattresses require specific weight-based settings to provide appropriate pressure redistribution, but inspectors found no physician orders or care plan instructions specifying the correct settings for individual residents.
Resident Care Compromised
Three residents were specifically affected by the facility's pressure injury prevention failures. One resident admitted without pressure injuries developed a deep tissue injury to their sacrum after staff failed to address their refusal to turn and reposition. Despite early documentation that this resident "refused and resisted turning in bed," no interventions were implemented to address these refusals until after a wound developed.
Another resident's existing pressure injury worsened while receiving care at the facility. This resident had a documented history of moisture-associated skin damage that deteriorated into a Stage 3 pressure injury. The care plan indicated the resident refused skin integrity interventions, but medical records showed no documentation of required quarterly risk-versus-benefit discussions with the resident as specified in their care plan.
A third resident developed multiple new pressure injuries after admission, including a deep tissue injury to the coccyx and bilateral heel blisters. The resident complained their bed was "too hard and uncomfortable," but their air mattress was set based on comfort preferences rather than clinical requirements.
Medical Significance of Pressure Injuries
Pressure injuries represent a significant medical concern for nursing home residents. These wounds develop when sustained pressure restricts blood flow to skin and underlying tissues, typically over bony prominences. The injuries can progress through stages, from superficial skin redness to deep wounds exposing bone, muscle, or tendons.
Deep tissue pressure injuries, like those documented at Sullivan Park, indicate damage to deeper tissue layers even when the skin surface appears intact. These injuries often present as persistent red, maroon, or purple discoloration and can rapidly progress to more severe stages without proper intervention.
Prevention requires consistent repositioning to redistribute pressure, appropriate support surfaces like properly calibrated air mattresses, and prompt intervention when residents resist care. When residents refuse repositioning, facilities must implement alternative strategies rather than simply documenting the refusal.
Regulatory Requirements Not Met
Federal regulations require nursing homes to ensure residents who enter without pressure injuries do not develop them unless clinically unavoidable. The facility's own policy stated residents would receive weekly risk assessments and that licensed nurses would complete full body skin evaluations weekly.
However, inspectors found gaps in implementing these protocols. Staff lacked clear instructions for operating specialty equipment, care plans failed to address documented refusals, and there was inconsistent communication about equipment settings between shifts.
The inspection also revealed systemic issues with staff training and communication. Different staff members provided conflicting information about who was responsible for setting up air mattresses, with some citing maintenance staff and others indicating nursing staff handled the equipment.
Additional Care Deficiencies
Beyond pressure injury prevention, inspectors identified problems with basic activities of daily living. One resident reported not receiving scheduled showers twice weekly as planned, with shower aides frequently reassigned to other duties due to staffing shortages.
"Many times, the shower aide was removed from shower duties and given assignments on a different unit," the resident stated. Staff confirmed that evening shift residents "usually did not get" their scheduled showers due to insufficient staffing.
Another resident was observed with inadequate grooming, going several days without shaving despite requiring staff assistance with personal hygiene. When staff observed the resident's unkempt appearance during the inspection, they acknowledged he "should have been shaved" and that proper grooming was "important because they needed to be treated with dignity."
Facility Response Required
The violations were classified as causing minimal harm or potential for actual harm, but inspectors emphasized the risk these failures posed to resident quality of life and health outcomes. Pressure injuries can lead to serious complications including infections, prolonged healing times, and in severe cases, life-threatening conditions.
Sullivan Park Care Center must develop and implement a plan of correction addressing the identified deficiencies. This includes establishing clear protocols for specialty equipment use, ensuring adequate staffing for personal care services, and implementing systems to address resident refusals of care through alternative interventions rather than documentation alone.
The facility is required to demonstrate sustained compliance with federal regulations governing resident care and safety. Follow-up inspections will verify that corrective measures effectively address the systemic issues identified during the March 2025 survey.
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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