SPOKANE, WA - Federal inspectors cited Sullivan Park Care Center for failing to complete mandatory mental health evaluations before admitting residents with serious psychiatric conditions, potentially leaving vulnerable individuals without appropriate specialized care.
Critical Mental Health Screening Violations
The March 6, 2025 inspection revealed Sullivan Park Care Center violated federal regulations governing Pre-Admission Screening and Resident Review (PASRR) requirements. These screening protocols are designed to identify residents with serious mental illness, intellectual disabilities, or developmental conditions who require specialized services.
Inspectors documented that the facility failed to ensure completion of required PASRR Level 2 evaluations for two residents before their admission, despite clear indicators of serious mental illness. Additionally, the facility failed to implement recommended specialized behavioral health services for a third resident who had already received a Level 2 evaluation.
The violations affected residents with conditions including: - Post-traumatic stress disorder and depression - Delusional disorder and major depressive disorder - Borderline personality disorder requiring specialized behavioral health services
Resident Cases Reveal Systematic Failures
Resident with Multiple Mental Health Conditions
One resident admitted with depression, anxiety disorder, and post-traumatic stress disorder had been identified by the hospital as requiring a PASRR Level 2 evaluation due to serious mental illness indicators. The hospital completed a Level 1 screening on December 6, 2024, and sent a referral for the required Level 2 evaluation. However, inspectors found no documentation that Sullivan Park Care Center ensured this evaluation was completed before the resident's admission.
When questioned about the missing evaluation, the facility's Social Services Director acknowledged the violation, stating "PASRRs from the hospitals are a mixed bag."
Resident with Delusional Disorder
Another case involved a resident with delusional disorder and major depressive disorder who required daily antipsychotic and antidepressant medications. The hospital discharge summary documented that this resident "exhibited paranoid delusions while hospitalized, particularly with regards to his neighbors, and had some hallucinations."
A PASRR Level 1 screening dated January 2, 2025 clearly indicated this resident required a Level 2 evaluation due to their history of delusions and psychotic disorder. When inspectors requested documentation of the completed Level 2 evaluation, the Administrator responded in an email that "the facility did not have a level II evaluation for Resident 102 yet, the evaluator was behind."
Failure to Implement Required Services
The inspection also revealed that even when proper evaluations were completed, the facility failed to implement recommended services. One resident's PASRR Level 2 evaluation determined they required specialized behavioral health services due to an existing behavioral health diagnosis and borderline personality disorder.
Despite this clear recommendation, the resident had not received any behavioral health services. A February 4, 2025 progress note documented the resident experienced suicidal ideation and agreed to a behavioral health consultation. However, when inspectors requested any behavioral health provider progress notes on March 3, 2025, none were provided.
During an interview, the resident confirmed "someone had recently asked them about seeing a behavioral health provider about it," indicating the services had been discussed but not delivered.
Medical Significance of PASRR Violations
PASRR evaluations serve as a critical safeguard to ensure nursing home residents receive appropriate psychiatric care. These screenings identify individuals who may need specialized mental health services that typical nursing home care cannot adequately provide.
When facilities admit residents with serious mental illness without proper evaluations, several risks emerge. Residents may not receive necessary psychiatric medications, therapeutic interventions, or specialized behavioral health services. This can lead to worsening mental health symptoms, increased behavioral incidents, and inadequate treatment of underlying psychological conditions.
The failure to complete timely evaluations is particularly concerning for residents with conditions like delusional disorder, where untreated symptoms can significantly impact their quality of life and ability to participate in their own care decisions.
Regulatory Requirements and Best Practices
Federal regulations require nursing homes to coordinate with PASRR programs to ensure residents with mental illness receive appropriate services. Level 1 screenings must accurately identify residents with potential mental health conditions, while Level 2 evaluations provide comprehensive assessments to determine specific service needs.
When a Level 1 screening indicates potential serious mental illness, facilities must ensure Level 2 evaluations are completed before admission. If evaluations recommend specialized services, facilities must implement these services or demonstrate why nursing home placement remains appropriate.
The facility's own policy, dated March 2019, stated that social workers would ensure residents were evaluated within a timely period when Level 2 evaluations were indicated. However, the inspection revealed this policy was not consistently followed.
Inaccurate Screening Documentation
Beyond missing evaluations, inspectors found systematic problems with the accuracy of PASRR screenings. Three residents had Level 1 screenings that contained significant inaccuracies or omissions regarding their mental health diagnoses.
One resident's PASRR Level 1 screening listed post-traumatic stress disorder but failed to include documented diagnoses of anxiety disorder and depression. Another resident's screening incorrectly indicated schizophrenia symptoms despite no such diagnosis in their medical record, while omitting documented conditions including PTSD, depression, anxiety, and borderline personality disorder.
A third case involved a resident with depression who was taking antipsychotic and antidepressant medications, yet their PASRR screening indicated no mood or psychotic disorders and determined a Level 2 evaluation was not needed.
Administrative Response and Acknowledgment
When presented with these findings, facility leadership acknowledged the violations. The Social Services Director stated regarding inaccurate screenings: "That would be good to double check on these on admission. We would do a new PASRR that is more accurate."
The Director also acknowledged they "were not aware that if a level II evaluation was recommended that it was required to be completed prior to admission to the facility" and admitted they "were not involved with the PASRR process until after residents had already arrived at the facility."
The Administrator stated they expected staff to follow appropriate PASRR processes and that social services should review screenings for accuracy and make corrections as needed.
Impact on Resident Care and Safety
These violations represent more than administrative oversights. Residents with serious mental illness require specialized assessment and care planning to address their unique needs. When proper screenings are not completed or implemented, residents may experience inadequate psychiatric care, inappropriate medication management, or lack of access to therapeutic services.
The inspection findings suggest a pattern of insufficient attention to mental health screening requirements, potentially affecting the facility's ability to provide appropriate care for its most vulnerable residents. Federal regulations classify these violations as having minimal harm or potential for actual harm, but they indicate systematic problems that could lead to more serious consequences if not addressed.
Sullivan Park Care Center must now develop and implement a plan of correction to address these deficiencies and demonstrate compliance with federal PASRR requirements. This includes ensuring all current and future residents receive appropriate mental health screenings and that recommended services are implemented in a timely manner.
The facility has 60 days to submit a plan of correction detailing how it will prevent similar violations and ensure proper mental health screening and service coordination for all residents requiring PASRR evaluations.
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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