SPOKANE, WA - Federal inspectors documented widespread medication administration failures, food safety violations, and infection control breaches at Avalon Care Center at Northpointe during a February 2025 inspection that identified risks to resident health and safety across multiple care areas.
Critical Medication Errors Endanger Diabetic Residents
The facility failed to properly administer insulin and monitor blood sugar levels for multiple diabetic residents, creating dangerous health risks. Three residents experienced significant medication errors that could have resulted in serious medical complications.
For one resident with diabetes receiving dialysis treatments three times weekly, staff repeatedly failed to administer prescribed insulin doses. The resident's medication records showed they missed their 11:30 AM insulin on eight separate occasions and their 4:30 PM dose on twelve occasions during January and February 2025. Each dialysis day, when the resident left the facility at 10:20 AM and returned after 6:00 PM, staff marked medications as omitted rather than adjusting administration schedules or sending medications with the resident.
Blood sugar monitoring, essential for diabetes management, was also neglected. The same resident had blood sugar checks and insulin coverage doses omitted on multiple dates between 10:00 AM and 6:00 PM timeframes. Additionally, their phosphorous-lowering medication sevelamer, crucial for kidney disease management, went unadministered on ten separate January dates.
Another diabetic resident experienced gaps in both their fast-acting and long-acting insulin administration. On January 11, 2025, neither blood sugar checks nor any insulin doses were given throughout the entire day. On January 24, blood sugar monitoring wasn't performed before breakfast or lunch, and neither type of insulin was administered as prescribed.
The facility also failed to follow physician-ordered parameters for blood pressure medications. Two residents received their blood pressure medication metoprolol despite having heart rates below the threshold requiring the medication to be held. One resident received the medication on January 26 and 27 with documented heart rates below 50 beats per minute. Another received it on six occasions in January when their systolic blood pressure fell below 120, contrary to physician orders.
Food Safety Violations Threaten Resident Health
Inspectors discovered expired food and improper temperature monitoring in the facility kitchen that placed all residents at risk for foodborne illness. A crate containing approximately 36 expired eggs was found in the walk-in refrigerator and only discarded after inspectors pointed out the expiration date.
Temperature monitoring, critical for preventing bacterial growth in food, was inconsistently performed. While staff checked food temperatures in the dining room steam table, they failed to monitor temperatures for cold items like salads brought directly from refrigeration. More concerning, no temperature checks occurred at the kitchen steam table where the majority of resident meals were served.
Review of temperature logs from January through February 2025 revealed no documentation of temperature monitoring for the kitchen tray line service. This represents a fundamental breakdown in food safety protocols that could allow contaminated food to reach vulnerable residents.
Multiple residents reported the food was inedible, overly salty, and lacked proper seasoning. Five residents interviewed expressed consistent dissatisfaction with meal quality. One stated "the food was not good, that the vegetables were mushy and any chicken they got was a processed patty." Another reported eggs at breakfast were "not edible" with a terrible smell and taste.
Survey team testing confirmed resident complaints. A lunch meal sampled consisted of items that were bland, unappetizing in appearance, and poorly prepared. A breakfast tray obtained from the last cart being served contained lukewarm food with multiple quality issues including flavorless scrambled eggs with large mushy curds and unripe mangos with no fruit flavor.
Infection Control Failures During COVID-19 Outbreak
During an active COVID-19 outbreak at the facility, multiple staff members improperly wore N95 respirator masks, compromising protection for themselves and residents. Seven staff members were observed wearing N95 masks incorrectly, with straps positioned improperly, preventing the seal necessary for effective filtration.
One nursing assistant wore both N95 straps on top of their head over a winter hat, with the bottom strap over a scarf. When asked about proper positioning, the staff member stated they hadn't realized wearing the mask over other items could interfere with creating a proper seal. Another staff member acknowledged knowing the correct positioning but stated it was "inconvenient" because of their hair clip.
The facility also failed to implement enhanced barrier precautions for residents with draining wounds. Two residents with actively draining wounds lacked the required signage and personal protective equipment outside their rooms. One resident had yellow drainage from a heel wound visible on their pillowcase, while another had bloody drainage on their shirt from an armpit wound, yet neither had enhanced barrier precautions in place.
Hand hygiene protocols were violated during wound care and meal service. During one wound treatment observation, a nurse wore the same pair of gloves while touching the resident's boot, adjusting bed controls, handling treatment supplies, and applying medication to the wound - actions that could spread infection between contaminated and clean surfaces.
Medication Storage and Monitoring Deficiencies
The facility failed to maintain proper temperature controls for medication storage areas. Two of three medication rooms lacked thermometers to monitor room temperature where medications were stored. The East medication room refrigerator, containing insulin and other temperature-sensitive medications, showed significant gaps in temperature monitoring with only 13 of 31 days documented in January 2025.
A medication used to prevent blood clots was inconsistently monitored for adverse effects. For one resident taking the blood thinner Xarelto, documentation of required monitoring for bleeding, bruising, or breathing difficulties was blank for multiple dates across all shifts in January and February 2025. This monitoring helps detect potentially life-threatening complications from anticoagulation therapy.
Additional Issues Identified
The inspection revealed numerous other violations affecting resident care and safety. Staff performance reviews required annually were not completed for nursing assistants, potentially allowing inadequately trained staff to provide care. Three severely cognitively impaired residents with dementia diagnoses signed binding arbitration agreements instead of their legal representatives, waiving their right to jury trials for disputes.
Equipment maintenance issues created safety hazards, with four resident beds having exposed wiring and peeling electrical tape on bed controls. Call bell systems failed to function properly for two residents, leaving them without means to summon help in emergencies. Personal refrigerators in resident rooms contained expired food items and lacked temperature monitoring.
The facility's infection prevention policies had not been updated since 2022, and a water management plan to prevent Legionnaires' disease remained incomplete. These systemic failures in policy maintenance and implementation demonstrate organizational lapses extending beyond individual care delivery issues.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center At Northpointe from 2025-02-07 including all violations, facility responses, and corrective action plans.
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