SPOKANE, WA - Federal inspectors found significant staffing deficiencies at Sullivan Park Care Center that compromised resident safety and care quality, according to a March 2025 inspection report that documented inadequate supervision of cognitively impaired residents and delayed response times to emergency calls.
Critical Staffing Shortages Documented Across Units
The Centers for Medicare & Medicaid Services inspection revealed that Sullivan Park Care Center failed to maintain adequate staffing levels to meet the complex needs of its 120 residents, particularly those with cognitive impairments and behavioral challenges housed in the facility's secured South unit. The facility's staffing model, which relied on state minimum requirements rather than actual resident acuity levels, created dangerous gaps in supervision and care delivery.
The South unit, designed for residents with dementia and wandering behaviors, operated with just one registered nurse overseeing 61 residents during night shifts, along with approximately three nursing assistants managing 20 residents each. This unit housed the facility's most vulnerable population - residents with severe cognitive impairment who required constant supervision to prevent wandering, falls, and resident-to-resident altercations.
Multiple staff members interviewed during the overnight inspection confirmed the staffing crisis. "The facility did not have enough staff on night shift," reported one nursing assistant, explaining that staff were unable to take required lunch breaks and struggled to complete basic care duties while managing residents with complex behavioral needs.
Dangerous Wandering Incidents Left Unmonitored
The inspection documented multiple instances where residents with documented wandering behaviors and aggressive tendencies were observed moving throughout the facility without staff supervision, creating significant safety risks. One resident with severe cognitive impairment and a history of entering other residents' rooms was repeatedly observed wandering unsupervised despite having a care plan requiring constant supervision.
This resident's medical record revealed an escalating pattern of concerning behaviors between August and November 2024, including finding them in another resident's bed, involvement in multiple altercations where they struck peers with objects, biting a staff member, and threatening to throw objects. Despite these documented incidents and a care plan requiring supervision, inspectors observed this resident wandering alone on multiple occasions, even taking and consuming another resident's beverage.
Medical protocols for dementia care emphasize that residents with severe cognitive impairment and aggressive behaviors require continuous monitoring to prevent injuries to themselves and others. When supervision breaks down, the risk of serious incidents increases exponentially, particularly in residents who have already demonstrated patterns of entering other residents' rooms and engaging in physical altercations.
Emergency Response Times Exceed Safe Standards
Perhaps most critically, the inspection revealed dangerous delays in responding to resident emergency calls, with documented response times exceeding one hour in some cases. One cognitively intact resident reported waiting 75 minutes for staff to respond to their call light after an incontinence episode, forcing them to remain in soiled conditions.
During the inspection, surveyors documented multiple instances of delayed responses to call lights, including a 21-minute delay for a bathroom emergency and a 26-minute wait for general assistance. In one particularly concerning incident, a resident requiring oxygen had to yell for help after their call light went unanswered, with staff observed at the nursing station during the delay.
Emergency response standards in nursing home care require immediate attention to call lights, particularly for residents with mobility limitations who cannot seek help independently. Extended delays not only cause physical discomfort but can lead to medical complications, falls from residents attempting to meet their own needs, and psychological distress from feeling abandoned.
Care Plan Violations Compromise Resident Safety
The inspection revealed systematic failures to follow established care plans designed to protect vulnerable residents. One resident required two staff members for all interactions following an alleged incident with a nurse, yet inspectors repeatedly observed single staff members entering the resident's room alone, violating the safety protocol.
This violation is particularly significant because care plans represent legally binding treatment protocols developed by interdisciplinary teams based on individual resident assessments. When facilities fail to follow these plans, they not only violate federal regulations but also expose residents to the specific risks the plans were designed to prevent.
Laundry Crisis Affects Resident Dignity
The staffing shortage extended beyond direct care to essential support services, with the facility's laundry department operating at critically low levels. Residents reported not receiving their personal clothing for up to three weeks, with one resident observed wearing only footwear due to lack of available clothing.
The laundry aide confirmed that resident clothing was taking approximately one week to be returned instead of the standard 24 hours, with facility linens prioritized over personal garments. This situation directly impacts resident dignity and comfort, as access to clean, personal clothing is considered a basic right in long-term care settings.
Medical Context: Why Adequate Staffing Matters
Proper staffing in nursing homes is not merely about convenience - it's a critical safety issue with direct medical implications. Residents with dementia require specialized care approaches that include predictable routines, consistent caregivers, and immediate intervention when behavioral symptoms arise. Insufficient staffing disrupts these essential elements of dementia care.
When nursing assistants are responsible for too many residents, they cannot provide the individualized attention needed to prevent behavioral escalations. This leads to increased use of psychotropic medications, higher rates of falls and injuries, and deterioration in residents' functional abilities and quality of life.
The delayed response times documented at Sullivan Park Care Center create multiple medical risks. Residents may develop urinary tract infections from prolonged exposure to incontinence, experience skin breakdown from remaining in wet conditions, or sustain injuries from attempting to meet their own needs when staff don't respond promptly.
Industry Standards and Best Practices
Federal nursing home regulations require facilities to have "sufficient nursing staff" to provide necessary care and services to residents according to their individual care plans. This means staffing must be based on resident acuity - the complexity and intensity of care needed - rather than simple ratios or state minimums.
Best practices in dementia care emphasize the importance of consistent staffing patterns, with the same caregivers working with the same residents to build familiarity and trust. The facility's reliance on agency staff and pulling nursing assistants from resident care to cover laundry duties directly contradicts these evidence-based approaches.
Additional Issues Identified
The inspection also documented problems with facility assessment processes, noting that while the facility claimed to have daily interdisciplinary team meetings to review resident acuity and adjust staffing, the actual staffing levels did not reflect the complex needs of residents in the secured dementia unit.
The facility's incident logs revealed concerning patterns of falls and resident-to-resident altercations, with multiple residents sustaining injuries in incidents that proper supervision might have prevented. The high frequency of these events suggests systemic issues with the facility's ability to provide adequate oversight of vulnerable residents.
Environmental factors also contributed to safety concerns, with inspectors noting strong urine odors in common areas and residents found in states of undress, indicating inadequate monitoring and timely assistance with personal care needs.
The combination of these violations suggests that Sullivan Park Care Center's staffing model was fundamentally inadequate for the resident population they served, creating an environment where basic safety and dignity could not be assured.
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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