Sullivan Park Care Center

F-F607 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 505383

F-F656 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297

Residents Affected - Few Based on observation, interview and record review the facility failed to ensure smoking materials were secured as care planned for 1 of 3 sampled residents (Resident 18), reviewed for smoking. In Addition, the facility failed to assessed and monitored for the safe use of an electrical heating appliance for 1 of 5 sampled residents (Resident 78), reviewed for accident hazards. These failures placed residents at risk for potentially avoidable accident and placed the facility at risk of fire.

Findings included .

<Electrical Appliances>

Review of a 12/16/2024 admission assessment showed Resident 78 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment further showed Resident 78's cognition as intact and had both vision and hearing impairment. Resident 78 required assistance from the staff to complete Activities of Daily Living.

An observation on 02/25/2025 at 10:19 AM showed Resident 78 in bed, head slightly up, and a heating pad to their right side. When asked about its use, Resident 78 stated, I just put it on there. Resident 78 stated their family brought the heating pad in and they used it when they get cold at night.

An observation on 02/27/2025 at 10:08 AM showed Resident 78 in bed with the heating pad observed to the left side of the head of the bed. Resident 78 stated they used the heating pad, This morning. When touched,

the heating pad was warm to touch and set at 100 degrees for 45 minutes.

Review of Resident 78's physician orders showed no instructions for the use of a heating pad.

Review of Resident 78's care plan showed no documentation of the heating pad, its purpose or interventions for its safe use.

An observation on 02/28/2025 at 8:32 AM, showed Resident 78 in bed on their left side with a heating pad on edge of the bed next to them. On 02/28/2025 at 8:35 AM, Staff T, Licensed Practical Nurse (LPN), identified

the appliance as a hot pad. Staff T stated, I think [Resident 78's] family brought it in. [Resident 78] is using it for just relaxing. Staff T then asked Resident 78 why they used the hot pad, and Resident 78 stated, When I get pain to the side and pointed to the left stomach area. Staff T then asked the Surveyor, Do we need to get rid of that [the hot pad]? Staff T stated they knew of no other residents that used a hot pad and confirmed

they were aware Resident 78 used the hot pad prior to 02/28/2025. Staff T stated, I thought it was just for comfort to be honest. Staff T stated that some of the risks of using heating pads without monitoring included,

They get too hot if they turn it up too high. Burns from not checking it often. Staff T stated they, Usually make sure the aides are aware of [the hot pad] and check on it a lot make sure it's not too hot. Find out if [Resident 78] is physically able to manage it. Staff T again asked the Surveyor, Should I get rid of it? I'll double check with my boss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In an interview on 02/28/2025 at 8:41 AM, Staff BB, Nursing Assistant (NA), familiar with Resident 78's care, was asked if they were aware of any residents that used electrical heating appliances or a heating pad. Staff Level of Harm - Minimal harm or BB stated, I have not seen any of those on my hallway. Staff BB stated the risks involved with the use of potential for actual harm electrical heating pads included, The cords can be frail and catch on fire if it's plugged improperly, and just getting too hot for the patient and causing burns. Staff BB stated that if they observed a resident with a Residents Affected - Few heating pad they would, Ask them if they made sure it was okay to have in their room and double check with nurse and ask if it's okay with them and if they feel it's not safe then take it out and [the resident] can use it when in public view.

The above findings were shared with Staff A, Administrator, on 02/28/2025 at 8:46 AM. Staff A stated that

they were unaware of any resident that used an electric heating pad. Staff A stated the use of an electric heating pad could cause a burn or thermal injury if it got too warm. Staff A stated they expected staff to, Notify management and unplug [the appliance], if staff saw residents using these appliances. No further information was provided.

46115

<Smoking>

Per the 12/26/2024 quarterly assessment, Resident 18 had diagnoses which included a stroke, hemiplegia (paralysis that affected only one side of your body), diabetes and was able to make decisions regarding their care.

During an observation and interview on 02/24/2025 at 9:29 AM, Resident 18 stated they smoked and always kept their cigarettes and lighter with them. Resident 18 had a cup that was attached to their wheelchair and there was a pack of cigarettes and a lighter in it.

The 05/19/2022 smoking care plan documented Resident 18's smoking materials were to be kept locked in

the medication cart.

In an observation on 02/24/2025 at 4:00 PM, a cognitively impaire resident from another hall (Resident 63) wandered down to the 400 hall (the hall Resident 18 lived on) in their wheelchair. Resident 63 picked up another resident's drink and wheeled off while they drank from it. At 4:02 PM, Staff R, Licensed Practical Nurse, came out of a room and took the cup away from Resident 63 and escorted them back to their own hall.

In an observation on 02/26/2025 at 9:11 AM, Resident 63 again wandered onto the 400 hall and was tampering with the lift that assisted residents to stand.

In an interview on 02/26/2025 at 9:36 AM, Resident 70, another resident that smoked and lived on 400 hall, stated a month or two ago they had cigarettes that went missing. At 10:19 AM Resident 70 stated they kept their cigarettes and lighter in a basket that was attached to their wheelchair.

During an interview on 02/26/2025 at 10:26 AM, Resident 18 stated there were two residents on the 400 hall that wandered into rooms. Resident 18 stated the one resident wandered in their room about twice a week. Resident 18 stated they had taken some candy out of their room and if the resident saw something they liked

they would take that too. Resident 18 stated staff had attempted to put a stop sign on their door but that did not keep the wandering residents out of their room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Subsequent observations of Resident 18 with their cigarettes and lighter in their wheelchair cup were made

on 02/25/2025 at 2:22 PM, 02/27/2025 at 11:43 AM and 2:57 PM. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/26/2025 at 9:12 AM, Staff S, NA, stated there were two residents that wandered on 400 hall and three residents wandered from the other two halls on the secured unit that wandered onto 400 hall. Residents Affected - Few Staff S stated Resident 63 went into the other resident's rooms, took items, and held them in their lap.

During an interview on 02/26/2025 at 9:40 AM, Staff M, Registered Nurse, stated there were three residents

on the 400 hall that wandered and two residents from other halls on the secured unit wandered onto 400 hall. Staff M stated there was one resident on 400 hall that would take things out of resident rooms. Staff M stated

they told Resident 18 today they had onto hold their lighter.

In an interview on 02/26/2025 at 1:26 AM, Staff B, Director of Nursing, stated they had residents that wandered into other resident's rooms and took things. When Staff B was asked if they felt it was safe for Resident 18 to have their smoking supplies on them when they had a roommate on oxygen. Staff B stated Resident 18's supplies needed to be kept in the nurse's cart as care planned. Staff B added it was important that smoking supplies were kept in the nurse's cart for safety reasons. Staff B acknowledged the concern about the residents who wandered and the unsecured smoking supplies and agreed this was unsafe.

Reference: WAC 388-97-1060(3)(g)

50027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297 potential for actual harm Based on interview and record review, the facility failed to ensure 6 of 6 sampled residents (Resident 6, 23, Residents Affected - Some 411, 416, 417, and 62) reviewed for trauma informed care, received culturally competent, trauma-informed care in accordance with professional standards of practice. The failure of the facility to adequately screen, assess, identify potential triggers (a psychological stimulus that prompts recall of a previous traumatic event), and develop and implement a Trauma Informed Care Plan to help limit the residents' exposure to potential trauma triggers, placed the residents at risk for re-traumatization and a diminished quality of life.

Findings included .

Review of the [DATE REDACTED] facility policy titled, Trauma-Informed Care showed, the facility screened residents for indications of trauma for newly admitted residents and as part of the comprehensive care plan process, and developed appropriate interventions based upon the screening responses and resident observations. The facility interviewed the resident and/or their representative as part of the screening process and care plan development.

<Resident 6>

Review of a [DATE REDACTED] admission assessment showed Resident 6 admitted to the facility on [DATE REDACTED] with the diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event). The staff assessed Resident 6 as cognitively intact.

Review of a [DATE REDACTED] hospital History and Physical document showed Resident 6 experienced sudden losses of relatives or spouse at a young age. Resident 6 also experienced gunshot wounds to the chest which left

the resident unable to perform their job any longer.

Review of a [DATE REDACTED] facility Social History Assessment showed a questionnaire for Significant Life Events.

The questionnaire asked about a number of difficult or stressful things that sometimes happen to people. All

the events, to include, Assault with a weapon and Sudden, unexpected death of someone close to you were marked as Not sure.

Review of the medical record showed four emergency contacts and relatives of Resident 6 listed. Progress notes review showed no indication the facility made additional efforts to collaborate with family members to determine the type of PTSD Resident 6 experienced and its possible triggers. Additionally, no care plan development for Trauma Informed Care was noted to help direct the staff on preventing re-traumatization of Resident 6.

On [DATE REDACTED] at 9:04 AM, Staff PP, Nursing Assistant (NA), stated that they were familiar with Resident 6, a resident on the 300 Hall. Staff PP stated that they knew if a resident was a trauma survivor by, I would hope that the nurses would articulate that to the aides to let us know because we do not have access to their personal record. Sometimes the admission person would let us know.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 On [DATE REDACTED] at 9:24 AM, Staff QQ, Licensed Practical Nurse (LPN), stated that they were familiar with Resident 6 as they were a primary nurse assigned to the 300 Hall. Staff QQ stated that they did not know of Level of Harm - Minimal harm or any residents on the 300 Hall with the diagnosis of PTSD or were trauma-survivors. Staff QQ stated that they potential for actual harm knew a resident was a trauma-survivor by, sometimes when they are admitted I will look at admission documents from hospital. Staff QQ stated that they knew what triggers to avoid to prevent re-trauma by Residents Affected - Some asking the resident, reviewing the progress notes and, some of it is common sense thing.

The above information was shared with Staff Q, Social Services Director, on [DATE REDACTED] at 8:19 AM. Staff Q stated he was unaware of Resident 6's history of PTSD as stated in the hospital records of [DATE REDACTED], It should be in the care plan but to be honest I don't think it got seen in those documents when [the resident] got here but that warrants a follow up. We would start with reaching out to a POA [Power of Attorney], always be our first step, spouse or child, any direct contacts.

<Resident 23 and 417>

Review of a Diagnosis Report showed Residents 23 and 417 resided on the 300 Hall and both carried the diagnosis of PTSD from admission. Record review showed Resident 23 admitted to the facility on [DATE REDACTED] and Resident 417 on [DATE REDACTED]. Neither resident's medical record showed the development of a Trauma Informed Care Plan to help direct the staff on recognizing triggers and preventing re-traumatization of the residents. Review of Resident 417's [DATE REDACTED] and Resident 23's [DATE REDACTED] Social History Assessments showed

the answer of Not sure to all the Significant Life Events questionnaire.

<Resident 411>

Review of the medical record showed Resident 411 admitted to the facility on [DATE REDACTED] with a diagnosis of PTSD. Review of an undated hospital admission referral showed, Pt [patient] requesting [their] door be left open and reports [their] father passed away while hospitalized . Review of a [DATE REDACTED] Social History Assessment showed the answer of Not sure to all the Significant Life Events questionnaire. Resident 411 resided in the 200 Hall.

<Resident 416>

Review of the medical record showed Resident 416 admitted to the facility on [DATE REDACTED] with a diagnosis of PTSD. Review of a [DATE REDACTED] Social History Assessment showed the answer of Not sure to all the Significant Life Events questionnaire. Resident 416 resided in the 200 Hall.

Neither Resident 411 or 416's medical record showed the development of a Trauma Informed Care Plan to help direct the staff on recognizing triggers and preventing re-traumatization of the residents.

On [DATE REDACTED] at 9:02 AM, Staff BB, Nursing Assistant stated that they were a primary aide on the 200 Hall. Staff BB stated that they became aware a resident was a trauma survivor by, It should come with their admission paperwork so we get that information in report. I don't remember if I've ever taken care of a resident with PTSD before. Staff BB stated that it was difficult for them to know what triggers to avoid for a resident with a history of trauma unless they know the type of trauma. Staff BB mentioned there might be a resident on the 200 Hall with PTSD because the resident, was telling me [they] had trauma. It just came in conversation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 On [DATE REDACTED] at 8:52 AM, Staff T, LPN, stated they were a 200 Hall primary nurse. Staff T stated that they knew a resident was a trauma survivor and what triggers to avoid through, report when they get here. Like in Level of Harm - Minimal harm or their History and Physical [from the hospital]. Find out from the family. Staff T was unaware of any residents potential for actual harm on the 200 Hall with the diagnosis of PTSD.

Residents Affected - Some The above findings were shared with Staff Q on [DATE REDACTED] at 9:01 AM. Staff Q stated that since nothing triggered secondary to the Not Sure answers throughout the Significant Life Events questionnaire, it did not trigger a Trauma informed Care Plan for the residents.

47328

<Resident 62>

According to the [DATE REDACTED] quarterly assessment, Resident 62 had diagnoses including anxiety and depression. The assessment further showed Resident 62 was able to clearly verbalize their needs.

Review of the [DATE REDACTED] behavior care plan showed Resident 62 rejected care, became mute, and made accusations. The care plan instructed staff to re-approach, create a calming environment, and inform social services of any new accusations. No documentation was found to show Resident 62 experienced trauma or any identified trauma triggers for staff to avoid.

Review of the [DATE REDACTED] trauma screen showed no documentation Resident 62 was asked if they had experienced any traumatic events.

Review of the facility [DATE REDACTED] facility incident investigation showed Resident 62 alleged being hit in the head by the nurse around midnight when they requested pain medications.

In an interview on [DATE REDACTED] at 2:56 PM, Resident 62 stated approximately three months ago, a night shift staff knocked me on the head with a bottle of roll-on pain relief lotion that was on the bedside table. Resident 62 explained they had concerns with being hit in the head because they previously lived in California, where the culture was different, and they were beat with a baseball bat. Resident 62 stated they were aware of the potential risk of death secondary to a head injury and explained they knew someone who died from a ruptured aneurysm (bulge or ballooning of a blood vessel) after they sustained a head injury.

In an interview on [DATE REDACTED] at 11:15 AM, Staff J, NA, was unsure if Resident 62 had experienced any traumatic events.

In an interview on [DATE REDACTED] at 12:19 PM, Staff E, Resident Care Manager, was unsure if Resident 62 had experienced any traumatic events.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 In an interview on [DATE REDACTED] at 1:42 PM, Staff Q, Social Service Director, stated residents were screened for trauma upon admission but if they were not willing to talk about trauma experienced or if they state they did Level of Harm - Minimal harm or not experience trauma then the conversation stopped. Staff Q reviewed Resident 62's trauma screen. Staff potential for actual harm Q acknowledged the trauma screen did not ask the resident if they had experienced any traumatic events,

the screen only asked the resident if they wanted to talk about trauma experienced. Staff Q further Residents Affected - Some acknowledged it would be better practice to ask the resident if they experienced trauma prior to asking them if they would like to talk about trauma because that way the facility could identify/be aware the resident experienced trauma so staff could be on the lookout for potential unidentified trauma triggers to avoid and/or verbalizations of trauma details.

In an interview on [DATE REDACTED] at 11:07 AM, Staff A, Administrator, stated they expected staff to appropriately screen residents for trauma to identify potential triggers to avoid.

No associated WAC

Refer to

F-F686 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 46033 potential for actual harm Based on observation, interview and record review, the facility failed to ensure that residents requiring Residents Affected - Few assistance with their activities of daily living (ADLs), were provided timely assistance according to their needs and preference for 2 of XXX sampled residents (Residents 52 and 41) reviewed for ADLs. Specifically, Resident 52 was not provided showers per their preference and Resident 41 was not shaved when indicated.

This failure put residents at risk for decreased quality of life.

Findings included .

<Resident 52>

The 12/26/2024 admission assessment documented Resident 52 had diagnoses that included empyema (pockets of infection that build up in the space between the lung and the chest wall) and fractured ribs. The resident was cognitively intact and required substantial assistance of 1 to 2 staff for showering.

The 12/28/24 care plan revised on 01/30/2025 documented Resident 52 was at risk for skin breakdown related to incontinence. Staff were instructed to keep the skin clean and dry, and minimize exposure to moisture from incontinence, wounds, and perspiration.

Nursing Assistance shower task documentation reviewed on 03/04/2025 documented the resident received showers on 02/06/2025, 02/08/20258, then not again until 02/15/2025; then again 02/19/2025, 02/22/2025, 02/26/2025 and 02/28/2025. There were no showers documented after 02/28/2025.

During an interview on 02/24/2025 at 10:18 AM, Resident 52 stated that ever since their admission they had not received their showers twice weekly as scheduled and preferred. They stated many times, the shower aide was removed from shower duties and given assignments on a different unit. Resident 52 stated their showers were scheduled on the evening shift when there was less staff and they were often told there was no one to give them their shower.

On 02/26/2025 at 1:25 PM, Resident 52 stated they had not been given their shower the previous evening.

They stated they asked for one and was told there was not enough staff. At this time, Resident 52 notified

the nurse and was told they would work it in for the resident.

On 02/27/2025 at 8:31 AM, Staff P, Licensed Practical Nurse stated Resident 52 was provided their shower

on 02/26/2025 as they had requested.

During an interview on 03/04/2025 at 9:40 AM, Staff Y, Nursing Assistant, stated there were two shower aides for the 100, 200 and 300 units that worked on the day shift. Staff Y stated the shower aides were frequently pulled from shower duties to cover staff that had called in. Staff Y stated the shower aides were also pulled to accompany residents on appointments if an escort was needed. Staff Y stated residents that had showers scheduled on evening shifts usually did not get them. Staff Y stated if there was no shower aide scheduled, they worked with the other aide on their unit to try to get them done but that took them away from other care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 During an interview on 03/05/2025 at 11:07 AM, Staff F, Resident Care Manager, stated if Resident 52 did not receive a shower on their scheduled day, the shower aides worked to make it up the next day. Staff F Level of Harm - Minimal harm or stated they wondered if it was a matter of the showers not being documented. Staff F stated if the shower potential for actual harm aide was pulled to work on the unit, the Nursing Assistant on the unit was expected to provide the shower. Staff F thought the shower aide was pulled to the unit maybe once a week but was unsure. Staff F reviewed Residents Affected - Few the shower documentation and agreed Resident 52 had not gotten a shower since 02/28/2025.

<Resident 41>

Per the 02/21/2025 quarterly assessment, Resident 41 had diagnoses which included stroke and heart failure. The assessment further documented the resident had moderate cognitive impairment, required partial to moderate assistance with personal hygiene and substantial to maximal assistance with showering.

Review of the 11/20/2024 nursing care plan, revised on 02/24/2025, documented staff were instructed to provide Resident 41 partial assistance with personal hygiene and substantial assistance with showering.

In an observation and interview on 02/25/2025 at 9:15 AM, Resident 41 was unshaved and had a stubbled, scruffy, wispy beard. They stated they could not recall the last time they were shaved. Resident 41 stated

they felt refreshed when they were shaved.

Per review of the personal hygiene record from 01/31/2025 to 02/25/2025, Resident 41 received personal hygiene tasks daily and required mostly partial to dependent assistance.

Per review of the shower record from 01/31/2025 to 02/25/2025, Resident 41 received showers two days a week, on Tuesdays and Fridays. One refusal was documented on 01/31/2025.

In an observation on 02/26/2025 at 9:07 AM, Resident 41 had a clean-shaven face.

In an observation and interview on 02/27/2025 at 08:34 AM, Resident 41 had noticeable stubbled facial hair.

The resident stated they had a shower 2-3 days ago.

In an observation on 03/03/2025 at 8:49 AM, Resident 41 had a 5 o'clock shadow beard.

In an observation and interview on 03/06/2025 at 11:10 AM, Staff XX, Nursing Assistant, stated residents were groomed daily. They stated residents were shaved on their shower days and during the week as needed. They stated Resident 41 required assistance with shaving, and it was the staff's responsibility to initiate it.

In an observation and interview on 03/06/2025 at 11:25 AM, Resident 41 wheeled through the dining area in their wheelchair. They had a scruffy beard with wispy whiskers. Staff XX viewed the resident as they passed by and acknowledged they should have been shaved.

In an interview on 03/06/25 at 12:13 PM, Staff FF, Registered Nurse, confirmed Resident 41 had a shower

on 03/04/2025 and acknowledged Resident 41 should have been shaved. They stated this was important because they needed to be treated with dignity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Reference: WAC 388-97-1060(2)(a)(ii).

Level of Harm - Minimal harm or 50027 potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297 potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents who admitted Residents Affected - Few without pressure injuries did not develop pressure injuries and residents with pressure injuries did not worsen. Specifically, the facility failed to communicate interventions to the staff including settings of specialty mattresses, the correct use of positioning devices, and to address the identification of refusals of care for 3 of 5 residents (Residents 101, 1, and 105), reviewed for pressure injury. These failures placed residents at risk for pressure injury development, wound infections and/or complications, and diminished quality of life.

Findings included .

Review of the facility policy titled, Skin at Risk/Skin Breakdown revised September 2020, showed residents who entered the facility without pressure injuries would not develop pressure injuries unless the clinical condition demonstrated it was unavoidable and a resident with pressure injuries would receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Residents would be evaluated for risk for pressure injury development upon admission, weekly for the initial three weeks following admission, significant changes of condition, and annually. The licensed nurse was to complete full body skin evaluations weekly, indicating if new skin impairment was observed or not. If new skin impairment was noted after admission staff was to initiate alert charting, review current skin risk and interventions for effectiveness, and implement new interventions as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 The national institute of health website nih.gov with regard to the revised National Pressure Ulcer Advisory Panel pressure injury staging system showed a pressure injury is localized damage to the skin and Level of Harm - Minimal harm or underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can potential for actual harm present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and Residents Affected - Few shear may also be affected by microclimate, nutrition, perfusion [flow of fluid or blood to cells and tissues], comorbid condition [medical conditions that coexist and affect health and treatment], and condition of the soft tissue. Stage 1 pressure injury: intact skin with a localized area of non-blanching erythema [redness that does not disappear when pressure is applied to the area]. Stage 2 pressure injury: partial thickness [involving epidermis and/or dermis] loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage 3 pressure injury: full thickness [wound that extends below the epidermis and dermis into the subcutaneous tissue or deeper] skin loss, in which adipose (fat) or granulation [new connective tissue] tissue is visible in the ulcer. Stage 4 pressure injury: full thickness skin and tissue loss with exposed or directly palpable fascia [connective tissue], muscle, tendon [strong cords of tissue that connect muscle to bones], ligament [bands that connect bones and joints], cartilage [tough, flexible connective tissue that protects bones and joints, and provides structure to the nose and ears], or bone in the ulcer. Unstageable pressure injury: full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead skin or tissue that can appear in a wound] or eschar [dead tissue that forms over healthy skin and eventually falls off]. Deep Tissue Pressure Injury [DTPI]: intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation reveling a dark wound bed or blood-filled blister. It is essential that the intended staging or classification system be used for each type of injury to ensure appropriate treatment.

<Use of Positioning Devices>

<Resident 101>

Review of an admission assessment showed Resident 101 admitted to the facility on [DATE REDACTED] with medically complex conditions. This assessment showed the staff assessed the resident had severe cognitive impairment, was dependent on the staff for bed mobility and transfers, and did not reject care. The assessment showed Resident 101 admitted to the facility with no pressure ulcers but was at risk of developing pressure ulcers. Review of a 01/17/2025 worksheet associated with the assessment showed the staff assessed Resident 101, Needs special mattress or seat cushion to reduce or relieve pressure.

An observation on 02/25/2025 at 9:38 AM showed Resident 101 in bed. Observed at the foot of the bed was

a pump connected to the mattress, set at a 230 pound setting, a 10 minute cycle time, and on alternate mode. Observed under the mattress were two blue colored foam wedges placed under the resident's mid torso and legs areas.

In an interview on 02/25/2025 at 9:38 AM, Staff T, Licensed Practical Nurse (LPN), stated that the staff placed the wedges under the mattress, I believe to get pressure off the bottom like turning the resident to the side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 In an interview on 03/04/25 at 6:21 AM, Staff U, Bath Aide, stated that the wedges in Resident 101's room go under the sheet to keep the resident turned. Staff U stated that the wedges were used like every two hours in Level of Harm - Minimal harm or when [the resident was] in bed. Staff U stated Resident 101 rarely refused cares provided by the staff, to potential for actual harm include turning and repositioning.

Residents Affected - Few Review of the February 2025 physician orders and the care plan showed no instruction to the staff on the use of the wedges or the pump settings for the specialty mattress.

The above findings were shared with Staff G, LPN Supervisor, on 03/04/2025 at 10:14 AM. Staff G stated that the wedges should be placed under the bed sheet and not under the mattress. Staff G acknowledged Resident 101's care plan and orders showed no instructions for the pump settings associated with the specialty mattress and that, it should be care planned and have an order with the settings. Staff G stated the use and purpose of the wedge, should be in the care plan.

<Management of Refusals>

Review of Resident 101's 01/10/2025 Admission Evaluation showed, No other skin concerns are noted. Resident refused and resisted turning in bed to check [their] buttocks, coccyx [tailbone], sacrum, and back.

The evaluation showed that an aide stated the resident, is also resisting/refusing turning and pericare [hygiene] for them.

Review of a Skin at Risk care plan, initiated and revised on 01/13/2025 showed, Pressure reduction cushion to chair and Pressure reduction mattress as ordered if indicated, Staff to reposition resident frequently during every shift to offload high pressure areas, and Use lift pads to minimize friction and shear.

Review of a 01/20/2025 progress note showed the staff, Noted new pressure ulcer spanning the sacrum [the lower back, above the tail bone] and Resident doesn't tolerate much time up in w/c [wheel chair] and spends most of [their] day in bed. The note showed the staff revised the care plan, for an air mattress to reduce pressure. Air mattress placed. Review of the medical record showed no documentation what the staff did differently to prevent pressure ulcer development prior to 01/20/2025, even though they had knowledge Resident 101 was intolerant to much time up in w/c, or spent most of [their] day in bed.

Review of a 01/20/2025 Wound Consultant note showed, Consultation was requested for sacral wound. The note showed the staff identified Resident 101, refused, turning and repositioning upon arrival to facility and for several days after admission. The note showed the staff identified an open wound to sacrum when up for their shower and a LAL [low air loss, a specialty mattress] was obtained today after discovery of the wound.

The wound consultant assessed the wound as a DT or deep tissue injury (DTI). Review of progress notes from 01/10/2025 to 01/17/2025 showed no documentation what the staff did to address the refusals mentioned by the Wound Consultant in the 01/17/2025 notes, to include identifying the reason why Resident 101 refused to turn or reposition.

Review of a Skin care plan initiated on 01/21/2025 and revised on 02/25/2025 showed no documentation the staff considered refusals as a contributor to the development of Resident 101's pressure ulcer or put interventions in place to address rejection of turning and repositioning, as stated by the Wound Consultant's note of 01/17/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 In an interview on 03/04/25 at 10:23 AM, Staff G, Resident Care Manager, stated they expected, the aide to alert their nurse, who then could have alerted me to get an order to track the refusals, and alerted the wound Level of Harm - Minimal harm or nurse so they could assess and order something different. Find out why the resident is refusing. Interview the potential for actual harm resident. Look at the care plan and see what needs to be changed. Staff G acknowledged the medical record did not show the staff acted upon their identification of Resident 101's refusals to turn or reposition prior to Residents Affected - Few the development of a DTI.

47328

<Resident 1>

According to the 02/14/2025 quarterly assessment, Resident 1 had diagnoses including malnutrition and multiple sclerosis (disorder where nerve cells deteriorate). The assessment further showed Resident 1 required substantial up to dependent staff assistance for bed mobility, lower body dressing, and transfers. Resident 1 did not refuse cares, was at risk for pressure injury development and had one Stage 4 pressure injury, not present on admission. Resident 1 was cognitively intact and able to clearly verbalize their needs.

Review of the skin care plan revised 08/14/2024 showed Resident 1 had chronic moisture associated skin damage (MASD) that deteriorated into a Stage 3 pressure injury. The care plan showed Resident 1 refused to adhere to skin integrity interventions and instructed staff to review risk versus benefits of refusals to adhere to skin integrity interventions with Resident 1, quarterly. The care plan showed Resident 1 used an air mattres but no documentation of resident specific settings for the use of the air mattress was found.

Review of January 2024 through August 2024 nursing progress notes showed no documentation Resident 1 refused to adhere to skin integrity interventions or risk versus benefits of refusals were discussed with Resident 1 quarterly, as care planned. On 07/01/2025 Resident 1 was seen by the wound specialist for deteriorating bilateral buttock skin breakdown with use of an air mattress and compliance with turning. On 07/08/2024 Resident 1's MASD deteriorated and presented as a Stage 3 pressure injury.

Review of provider orders as of 02/25/2025 showed a 12/04/2023 order for staff to monitor Resident 1's Roho (a cushion with individual flexible air-filled cells) cushion for proper inflation twice daily. No documentation was found to show Resident 1 to have or use an air mattress or what the settings were to be set to.

In an interview on 03/03/2025 at 1:28 PM, Staff J, Nursing Assistant, stated resident skin was monitored

during routine cares and new skin issues identified would be reported to the nurse for follow-up. Staff J further stated skin interventions were in a resident's care plan and staff were to implement them because skin and/or wounds could worsen if not implemented. Staff J stated Resident 1 did not refuse cares but had a wound on their buttock for awhile because they used to like to stay up in their WC.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During observation and interview on 03/05/2025 at 9:27 AM, Staff H, RN, stated residents' skin was monitored via weekly skin assessments. Staff H stated skin interventions implemented would be in a Level of Harm - Minimal harm or resident's care plan and staff were expected to implement interventions. Staff H further stated if a resident potential for actual harm used an air mattress for skin integrity, then a provider order was required as well as care planning. Staff H demonstrated two different air mattresses/pumps on the unit and explained air mattresses were set up based Residents Affected - Few on the resident's weight. One of the air mattress/pump observed did not show a weight range for the settings and had a comfort zone instead. Staff H was asked how the appropriate comfort zone setting was determined. Staff H explained if the comfort zone setting was determined based on the resident's comfort level and was adjusted as needed. Staff H acknowledged Resident 1 developed a pressure injury from resisting to lay down and staying up in their WC all day.

In an interview on 03/05/2025 at 9:11 AM, Staff E, Resident Care Manager (RCM), stated NAs monitored skin during routine care and nurses completed weekly skin assessments. Staff E further stated if a skin issue was identified current interventions were reviewed and new interventions added as needed. Staff were expected to implement care planned interventions and notify the RCM if/when a resident refused so appropriate education could be done. Staff E explained when an air mattress was used for skin integrity it was typically just care planned, and no provider order or consent was obtained. Staff H stated air mattresses were set up by restorative nursing staff or maintenance staff and settings determined based on the resident's comfort level. Staff H reviewed Resident 1's medical record. Staff H stated Resident 1 had MASD to their buttock that deteriorated into a pressure injury last year because of refusal to reposition. Documentation of quarterly risk versus benefit education was requested at that time.

In an interview on 03/05/2025 at 9:42 AM, Staff CC, Restorative Nursing Assistant, stated restorative nursing had nothing to do with setting up air mattresses. Staff CC stated maintenance set up air mattresses.

In an interview on 03/05/2025 at 9:46 AM, Staff L, Maintenance Director, stated maintenance only assisted nursing by setting up new air mattresses, by unpackaging them when purchased, all other times air mattresses were set up by nursing staff. Staff E explained the facility used two different brands of air mattresses and the setting could be very easily adjusted by nursing staff.

<Resident 105>

According to the 02/02/2025 admission assessment, Resident 105 admitted to the facility on [DATE REDACTED] with diagnoses including malnutrition, muscle weakness, difficulty walking, and repeat falls. The assessment further showed Resident 105 required substantial up to dependent staff assistance for bed mobility, lower body dressing, and transfers. Resident 105 was assessed and identified to be at risk for pressure injury development and admitted to the facility without any pressure injuries. Resident 105 was cognitively intact and able to clearly verbalize their needs.

Review of the 01/27/2025 hospital discharge summary showed Resident 105 had worsening progressive generalized weakness and was referred to a neurologist (doctor that specializes in disorders of the nervous system) for evaluation of a possible neurodegenerative (condition where nerve cells deteriorate and lead to progressive loss of function) condition.

Review of the 01/27/2025 BRADEN (simple tool used to check how likely someone was to a develop pressure injury) showed Resident 105 was at risk for pressure injury development.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of the 01/27/2025 admission assessment showed Resident 105 admitted to the facility with a Stage 1 pressure injury to their right buttock. Level of Harm - Minimal harm or potential for actual harm Review of the 01/28/2025 baseline care plan showed Resident 105 required maximal assistance from staff for bed mobility, had a current pressure injury and required wound care. No description or documentation of Residents Affected - Few interventions implemented was found.

Review of the 02/04/2025 skin evaluation showed Resident 105 now had a DTI to their coccyx. The evaluation included notes that showed the wound began as a Stage 1 that developed into a DTI, an air mattress was requested at that time.

Review of the skin care plan implemented on 02/05/2025 showed Resident 105 had a DTI to their buttock and DTI to bilateral heels were identified on 02/20/2025. The care plan instructed staff to administer medications as ordered, use a pressure reduction cushion in the wheelchair (WC), educate the resident on pressure injury risk factors, use an air mattress and use of padded boots when in bed/WC. The care plan showed no resident specific settings for the use of the air mattress and the padded boots were implemented

on 02/22/2025, after the bilateral heel DTIs developed.

Review of the 02/10/2025 wound assessment report showed Resident 105's coccyx DTI developed in the facility on 02/04/2025.

Review of provider orders as of 02/24/2025 showed no provider order for Resident 105 to have or use an air mattress.

Review of the 02/24/2025 wound assessment report showed Resident 105's acquired the bilateral heel blisters in the facility on 02/21/2025.

In an interview on 02/24/2025 at 9:19 AM, Resident 105's spouse stated Resident 105 had a wound to their buttock that worsened at the facility.

During observation on 02/24/2025 at 10:21 AM, Resident 105's wounds were observed. Resident 105 had

an unstageable wound to their coccyx covered with black eschar in the center surrounded by thick attached yellow slough, left heel had a large fluid filled blister, and the right heel had a smaller intact blister.

During interview and record review on 03/04/2025 at 5:18 AM, Staff K, Nursing Assistant, stated Resident 105 did not refuse cares, had a wound on their buttocks and blisters on both heels. Staff K further stated skin interventions were in a resident's care plan and pulled up Resident 105's medical record to show they were care planned to use bilateral heel boots, an air mattress, and a Roho WC cushion. Staff K explained it was very important to ensure the Roho cushion was filled up properly or else it would not be effective.

During observation on 03/04/2025 at 9:34 AM, Staff H, RN, Resident 105's air mattress pump was observed to be set at 5/8 firmness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During observation and interview on 03/04/2025 at 10:47 AM, Resident 105 stated their bed was too hard and uncomfortable. Resident 105 further stated they were unable to assist with bed mobility and typically just Level of Harm - Minimal harm or laid in bed once in bed. The air mattress pump hanging off the footboard showed the air mattress was set at potential for actual harm 5/8 on firmness.

Residents Affected - Few In an interview on 03/05/2025 at 9:26 AM, Staff E, RCM, reviewed Resident 105's medical record. Staff E acknowledged Resident 105 admitted with a Stage 1 pressure injury to their coccyx that developed into a DTI and also acquired bilateral heel blisters since admission. Staff E was unsure how air mattress setting were determined when the pump had a comfort zone versus a weight range.

In an interview on 03/05/2025 at 3:27 PM, Staff C, Assistant Director of Nursing, stated air mattresses were placed by maintenance and setting based on resident comfort. Staff C was asked how staff were to monitor air mattresses for proper settings when no provider order was implemented with resident specific settings. Staff C stated air mattresses were adjusted based on resident comfort. Staff C was informed different individuals could have different comfort levels, some individuals could prefer the firmest setting. Staff C acknowledged adjusting air mattress settings based on resident comfort was not the best practice.

In an interview on 03/06/2025 at 10:47 AM, Staff A, Administrator, acknowledged Resident 105 had a coccyx wound that worsened and developed bilateral heel blisters, since their admission. Staff A stated they expected staff to follow care planned interventions.

Reference WAC 388-97-1060 (3)(b)

Refer to

F-F689 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297

Residents Affected - Few Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that documented resident specific goals and treatment plans for 2 of 3 residents (Resident 6 and 411), reviewed for new admissions. This failure placed residents at risk for unmet care needs, possible medical complications, and diminished quality of life.

Findings included .

<Resident 6>

Review of an admission assessment showed Resident 6 admitted to the facility on [DATE REDACTED]. The medical

record showed the resident was treated with medications for heart failure, high blood pressure, and atrial fibrillation (an irregular and often very rapid heart rhythm). Additionally, the resident was diagnosed as legally blind. Review of the resident's baseline care plan showed no goals or interventions to address the provider orders for the management of the cardiovascular diagnoses or the vision impairment.

<Resident 411>

Review of the medical record showed Resident 411 admitted to the facility on [DATE REDACTED]. The medical record showed the resident was treated with medications for chronic obstructive pulmonary disease (lung diseases that lead to breathing difficulties) and asthma.

Review of the resident's baseline care plan showed no goals or interventions to address the provider orders for the management of the lung diseases.

The above information was shared with Staff G, Resident Care Manager, on 03/04/2025 at 10:43 AM. Staff G acknowledged Resident 6's and 411's baseline care plans did not identify the residents' nursing needs, interventions, or goals related to the active or treated diagnoses, and should have been included.

Reference WAC 388-97-1020 (3).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40297

Residents Affected - Few Based on observation, interview and record review the facility failed to develop the care plans and implement interventions for 3 of 24 sampled residents (Resident 78, 62, and 41), reviewed for care planning. This failure placed the residents at risk for inadequate care, unmet care needs, and a diminished quality of life.

Findings included .

Review of the facility policy titled Quarterly MDS [Minimum Data Set, an assessment]/Care Plan Review dated June 2017 showed, the facility reviewed a resident's care plan, no less frequently than quarterly to ensure the care plan reflected the resident's current needs.

<Resident 78>

Review of a 12/16/2024 admission assessment showed Resident 78 admitted to the facility on [DATE REDACTED] with medically complex conditions. The assessment further showed Resident 78 had difficulty hearing and used a hearing aid or other hearing appliance.

During an observation on 02/24/2025 at 9:50 AM, Resident 78 was in bed with a hearing aid (HA) to the right ear.

An observation on 02/25/2025 at 10:19 AM showed Resident 78 in bed. The HA was observed on the over

the bed table to the left side of the resident's bed. Resident 78 took the HA, and this time placed it in the left ear, upside down. Resident 78 gestured they could not hear from it. Communication with Resident 78 occurred in a handwritten interview. Resident 78 stated their family took care of the HA when they came in

the evening hours and that they communicated with the staff through feeling. Resident 78 stated that HA was old and chose to wear it and keep their brand-new HAs at home for safe keeping. Resident 78 stated that the staff use a little bit of both writing or use of pictures to communicate with them.

On 02/27/2025 at 10:08 AM, Resident 78 was observed in bed, the HA was on the over-the-bed table. Resident 78 placed the HA in the left ear. Staff T, Licensed Practical Nurse (LPN), stepped by the doorway and stated to the Surveyor, Just so you know, [Resident 78] is very hard or hearing, even with a hearing aid.

In a written interview, Resident 78 stated they only had one hearing in use at the facility.

An interview with a Resident Representative (RR) on 02/27/2025 at 5:02 PM showed Resident 78 was, very hard of hearing, almost 100% deaf, and used HAs, reads lips, and if anybody knows how to sign [language], [Resident 78] signs. The RR stated, It's difficult to have conversations with Resident 78. The RR explained Resident 78 managed the care of their HAs and the one HA went in their left ear.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 03/04/2025 at 8:02 AM, Staff BB, Nursing Assistant stated they communicated with Resident 78, Most of

the time [Resident 78] read my lips, then I will put [their] hearing aid in, and just watching your face. Staff BB Level of Harm - Minimal harm or stated that when reading lips was not effective for Resident 78, they would then use written communication. potential for actual harm

Review of a 12/19/2024 Communication care plan showed Resident 78 had mild hearing loss with HA and Residents Affected - Few moderate loss without. A 12/19/2024 intervention showed Resident 78 had hearing aids to both ears, contrary to observations and interviews. All other interventions were dated 12/19/2024 and did not include other ways the resident and staff could communicate with each other, like sign language, reading lips, or written form.

The above information was shared with Staff F, Resident Care Manager, on 03/04/2025 at 6:47 AM. Staff F stated that they communicated with Resident 78 verbally by using a louder tone and, Not to my knowledge does [Resident 78] wear any hearing aids. Staff F acknowledged Resident 78's care plan was not developed to showed resident-centered alternative communication techniques, like sign language, lip reading, or written communication, nor show the use of only one HA.

47328

<Resident 62>

According to the 01/14/2025 quarterly assessment, Resident 62 had diagnoses including anxiety and depression.

In an interview on 02/24/2025 at 2:56 PM, Resident 62 stated approximately three months ago, a night shift staff knocked me on the head with a bottle of roll-on pain relief lotion that was on the bedside table.

Review of the facility 08/23/2024 facility incident investigation showed Resident 62 alleged being hit in the head by the nurse around midnight when they requested pain medications. Resident 62's care plan was updated to included two staff for all interactions including medication administration and conversations.

Review of general information care plan showed Resident 62's care plan was updated on 09/04/2024 requiring two staff for all interactions.

During observation on 03/03/2025 at 1:14 PM, Staff J, Nursing Assistant, entered Resident 62's room alone to answer their call light. At 1:15 PM, Staff J informed the surveyor Resident 62 wanted to speak with them and the surveyor entered the room. Resident 62 stated they do not send two staff in here all the time.

During observation on 03/04/2025 at 10:59 AM, Staff J, again entered Resident 62's room alone to answer their call light. Staff J exited Resident 62's room at 11:01 AM. At 11:03 AM, Staff J returned to Resident 62's room with crackers as requested. At 11:06 AM, Staff J exited the room and informed Staff H, Registered Nurse (RN), Resident 62 was ready to take their pills. At 11:07 AM, Staff H entered Resident 62's room, alone, to administer medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 In an interview on 03/04/2025 at 11:16 AM, Staff J, stated Resident 62 had behaviors, yelled, cursed and was mean to staff. Staff J further stated Resident 62 was two person assist when care was provided but did Level of Harm - Minimal harm or not require two staff to answer the call light. Staff J reviewed Resident 62's record. Staff J acknowledged potential for actual harm Resident 62 required two staff for all interactions and stated that would be hard to do.

Residents Affected - Few In an interview on 03/04/2025 at 11:21 AM, Staff H, RN, stated Resident 62 was verbally abusive to staff. Staff H reviewed Resident 62's medical record. Staff H acknowledged Resident 62 required two staff for all interactions. Staff H explained that having a conversation with a person was an interaction so technically Resident 62 required two staff to talk with them.

In an interview on 03/05/2025 at 12:17 PM, Staff E, RCM, reviewed Resident 62's medical record. Staff E acknowledged Resident 62 required two staff for all interactions and expected staff to follow the care plan.

In an interview on 03/06/2025 at 11:11 AM, Staff A, Administrator, stated they expected staff to follow care planned interventions.

50027

<Resident 41>

Per the 02/21/2025 quarterly assessment, Resident 41 had diagnoses which included stroke and heart failure. The resident was moderately cognitively impaired, had adequate vision with glasses and reading books, newspapers and magazines was important to them.

Per review of the 11/20/2024 care plan, there was no documentation related to Resident 41's vision.

Review of the November 2024 to February 2025 nursing and provider progress notes documented no changes or interventions regarding Resident's 41's eyes or vision. A nursing note on 02/25/2025 documented the resident was scheduled for an eye appointment for cataracts (clouding of the eye lens which was typically clear) in March 2025.

In an observation and interview on 02/25/25 at 09:07 AM, Resident 41 was in their room near their computer desk holding a typed letter. They stated they were in the process of improving their eyesight and should be wearing their glasses. The resident began to read the letter out loud. They struggled to read the first sentence and then placed the letter down on their desk. No glasses were found in their room.

Subsequent observations of Resident 41 not wearing their glasses were made on: 02/26/2025 at 11:40 AM and 1:38 PM.

In an observation on 02/27/25 at 08:34 AM, Resident 41 was in their room sitting at the desk with their computer on. They were not wearing their glasses. There were various pieces of unopened mail scattered across their desk.

In an observation on 02/28/2025 at 08:26 AM, Resident 41 not wearing their glasses. At 09:04 they had letters, unopened mail and snacks spread across their desk in their room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 03/03/2025 at 08:49 AM, Resident 41 was in the unit quad area and was observed for the first time wearing their glasses. Level of Harm - Minimal harm or potential for actual harm In an observation on 03/04/2025 at 11:14 AM, Resident 41 was sitting at the table in the unit quad area.

They had an insurance letter on the table in front of them and was not wearing their glasses. They stated Residents Affected - Few they needed their glasses to read the letter and reminders to wear them daily.

In an observation on 03/05/2025 at 11:09 AM, Resident 41 was wearing their glasses and the right lens was missing.

In an interview on 03/06/25 at 12:25 PM, Staff FF, Registered Nurse, stated Resident 41 wore glasses daily.

They stated the resident occasionally misplaced their glasses, in which staff would have to find them.

In an interview on 03/06/2025 at 1:00 PM, Staff E, Resident Care Manager, acknowledged Resident 41 required glasses for their activities of daily living (ADLs) and should have been documented in their care plan. They stated this was important for the resident's safety during ADLs and performance for activities of interests.

Reference WAC 388-97-1020 (1), (2)(a)(b)

Refer to

F-F726 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46115 potential for actual harm Based on interview and record review the facility failed to implement the facility's abuse prevention policy Residents Affected - Some including identification of potential allegations, timely reporting allegations to the State Survey Agency as required, thoroughly investigating allegations, and monitoring residents for potential psychosocial harm after allegations were made for 6 of 10 sampled residents (Resident 42, 62, 63, 35, 311, and 20), reviewed for abuse. This failure placed residents at risk of potential abuse, neglect and/or misappropriation or their property and diminished quality of life.

Findings included .

Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, documented the facility would develop and implement policies to prevent and identify abuse or mistreatment of residents; neglect of residents; and/or theft, exploitation or misappropriation of resident property. Staff would be provided orientation and training on abuse prevention, incident identification and reporting. The policy further showed all potential allegations of abuse, neglect, mistreatment, or misappropriation of resident property would be identified, reported within the required timeframes, investigated, and residents protected from potential harm during the investigation process.

<Resident 20>

The 01/10/2025 quarterly assessment documented Resident 20 was cognitively intact and made their needs known.

In an interview on 02/24/2025 at 10:46 AM, Resident 20 stated there was a resident on the same hall that entered their room and yelled at them and wandered into their room often. Resident 20 stated three staff members removed the resident from their room.

The incident for 02/05/2025 was written on a single piece of paper that stated Staff A, Administrator, spoke to Resident 20 regarding their interaction with Resident 89 on 02/05/2025 at 5:00 PM. Resident 20 stated Resident 89 was trying to enter their room, and Resident 20 blocked them from coming in with their wheelchair. Resident 20 stated Resident 89 placed their hand on their left arm to support themselves when

they turned around. Staff A stated they had asked Resident 20 if Resident 89 had squeezed their arm, and Resident 20 said no. Resident 20 stated they told Resident 89 to leave their room, staff came and redirected

the resident. Staff A stated Resident 20 reassured them several times that nothing happened, Resident 89 did not hit them, and they were not afraid of them.

Review of the February 2025 incident log had no documentation that Resident 20 was involved in a resident-to-resident altercation and the State Survey Agency was not notified as required.

In a follow-up interview on 02/28/2025 at 8:19 AM, Resident 20 stated Resident 89 had wheeled themselves into my room, they were angry and held my arm. Resident 20 stated they yelled at me, and this was the worst experience I had with them. Resident 20 stated you never knew how Resident 89 was going to act.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 The facility investigation did not include staff or other resident interviews. There was no progress note written

on 02/05/2025 regarding the resident-to-resident altercation. A progress note on 02/06/2025 stated there Level of Harm - Minimal harm or was no evidence of latent injury to Resident 20's right arm and no psychosocial issues were noted. potential for actual harm

The investigation was reopened after concerns were shared with Staff A, Administrator. The investigation Residents Affected - Some documented a stop sign was placed across Resident 20's door to their room, a behavioral health visit was requested for Resident 89, an activity referral was made, the interdisciplinary team discussed a memory care unit for the resident, and resident and staff interviews were completed. Staff A was provided re-education by

the Regional Director of Clinical Services on Washington State reporting guidelines to prevent future similar incidents from going unreported.

In an interview on 03/06/2025 at 11:18 AM, Staff B, Director of Nursing, stated it was important to do thorough investigations to prevent harm or re-occurrence and to identify triggers to prevent future occurrences. Staff B stated staff, and resident interviews should have been completed.

47328

<Resident 42>

According to the 12/12/2024 annual assessment, Resident 42 had diagnoses including muscle weakness and pain. Resident 42 was cognitively intact and able to clearly verbalize their needs.

In an interview on 02/24/2025 at 10:26 AM, Resident 42 stated the night prior (02/23/2025), they waited for

an hour and 15 minutes for their call light to be answered. Resident 42 explained they had a clock in their room, turned their call light on at 9:45 PM to be changed after an incontinence episode but staff did not enter their room until 11:00 PM. Resident 42 further stated this had also occurred 4 other times.

In an interview on 02/24/2025 at 2:02 PM, Staff A, Administrator, was notified of the allegation Resident 42 made earlier that morning. Staff A stated they were not aware of the allegation.

Review of the 02/24/2025 facility incident investigation documented residents and staff were interviewed related to the allegation of delay in response to call lights the weekend on February 22 and 23, 2025. A 02/27/2025 statement by Staff I, Nursing Assistant (NA), documented Resident 42 was glad Staff I answered their call light because Resident 42 had waited for an hour to be changed. Staff I reported Resident 42's allegation of delayed call light response time to the nurse. The investigation further documented the allegation of abuse and/or neglect was not reported to the State Survey Agency until 02/24/2025 at 3:40 PM,

after the allegation was brought up to administration by the surveyor.

<Resident 62>

According to the 01/14/2025 quarterly assessment, Resident 62 had diagnoses including anxiety and depression.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 In an interview on 02/24/2025 at 2:56 PM, Resident 62 stated approximately three months ago, a night shift staff knocked me on the head with a bottle of roll-on pain relief lotion that was on the bedside table. Resident Level of Harm - Minimal harm or 62 explained they had concerns with being hit in the head. potential for actual harm

Review of the facility 08/23/2024 facility incident investigation documented Resident 62 alleged they were hit Residents Affected - Some in the head by the nurse around midnight when they had requested pain medications. The investigation further documented the allegation of abuse was not reported to the State Survey Agency until 08/23/2024 at 5:44 PM, over 24 hours after the allegation was made.

Review of August 2024 nursing progress notes showed a 08/23/2024 note no behaviors noted. No further documentation was found until 08/27/2024, 4 days later, to monitor Resident 62 for potential psychosocial harm related to the allegation of abuse.

<Resident 35>

According to the 02/26/2025 annual assessment, Resident 35 was cognitively intact and able to clearly verbalize their needs.

Review of the 10/31/2024 grievance form documented Resident 35 was missing $50 that was replaced by

the facility when they were unable to locate the money.

Review of the October 2024 through November 2024 incident log showed no entries for Resident 35's missing $50.

<Resident 311>

According to the 10/03/2024 discharge assessment, Resident 311 admitted to the facility on [DATE REDACTED] and discharged on [DATE REDACTED]. Resident 311 was cognitively intact.

Review of the 10/02/2024 grievance form showed Resident 311 was missing $40 that was replaced by the facility when they were unable to locate the money.

Review of the October 2024 incident log showed no entries for Resident 311's missing $40.

<Resident 63>

According to the 02/03/2025 quarterly assessment, Resident 63 had severe cognitive impairment with inattention and disorganized thinking. Resident 63 had worsening wandering that significantly intruded on the privacy or activities of others and placed Resident 63 at significant risk of getting into potentially dangerous places.

Review of the September 2024 through November 2024 incident log showed Resident 63 was involved in resident-to-resident altercations on 10/30/2024, 11/10/2024 and 11/11/2024.

Review of the facility incident investigations showed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 -10/30/2024 at 1:45 PM: Staff witnessed Resident 63 open handedly slapped a peer on the back of their head. The incident was not reported to the State Survey Agency until 10/31/2024 at 1:00 PM, 23 hours after Level of Harm - Minimal harm or the physical aggression incident was witnessed by staff. potential for actual harm -11/10/2024 at 11:45 AM: Resident 63 wandered onto 400 hall and had exhibited aggressive behaviors. Staff Residents Affected - Some witnessed when Resident 63 pulled a peer's hair. The incident was not reported to the State Survey Agency until 11/11/2024 at 11:55 AM, 24 hours after the physical aggression incident was witnessed by staff and another resident-to-resident altercation occurred the following day.

-11/11/2024 at 6:35 AM: Resident 63 wandered onto 500 hall and had exhibited aggressive behaviors. Staff found Resident 63 in a peer's room and they had hit them on the back of the head with a hairbrush. The incident was not reported to the State Survey Agency until 11/11/2024 at 11:40 AM.

In an interview on 03/04/2025 at 5:15 AM, Staff K, NA, stated allegations of abuse needed to be reported to

the State Survey Agency within two hours, the nurse should have been notified so the resident could have been monitored for potential psychosocial harm, and management notified so an investigation was completed. Staff K explained everyone was a mandated reporter and acknowledged allegations of waiting over an hour to have a call light answered, missing money, and resident-to resident verbal/physical aggression were all potential allegations of abuse and/or neglect that needed to be reported and thoroughly investigated.

In an interview on 03/04/2025 at 9:42 AM, Staff H, Registered Nurse, stated when an allegation of abuse/neglect was made against a staff member, they needed to be immediately removed from providing direct resident care pending the results of the investigation. Staff H stated residents were placed on alert charting to monitor for potential psychosocial harm after an allegation was made. Staff H was unsure how abuse and/or neglect was ruled out. Staff H acknowledged allegations of waiting over an hour to have a call light answered, missing money, and resident-to resident verbal/physical aggression were all potential allegations of abuse and/or neglect that needed to be reported and thoroughly investigated.

In an interview on 03/05/2025 at 12:03 PM, Staff E, Resident Care Manager, stated when an allegation of abuse was made resident safety was the first priority. Staff E explained if an allegation identified an individual staff, the staff needed to be immediately removed from direct resident care pending the results of the investigation. Staff E further stated all allegations needed to be reported to the State Survey Agency per the required timelines and thoroughly investigated by conducting resident and staff interviews. Staff E acknowledged allegations of waiting over an hour to have a call light answered, missing money, and resident-to resident verbal/physical aggression were all potential allegations of abuse and/or neglect that needed to be reported and thoroughly investigated. Staff E explained the facility 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 40 505383 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 505383 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sullivan Park Care Center 14820 East Fourth Spokane, WA 99216

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 In an interview on 03/05/2025 at 3:44 PM, Staff B, Director of Nursing, stated allegations of abuse needed to be reported to the State Survey Agency within two hours, residents placed on alert to monitor for potential Level of Harm - Minimal harm or psychosocial harm after an allegation was made, abuse and/or neglect was ruled out through resident and potential for actual harm staff interviews. Staff B was informed Staff I was informed of Resident 42's allegation of delayed call light response times when the incident occurred but it was not identified as a potential allegation or reported until Residents Affected - Some the allegation was brought to administration by the surveyor. Staff B explained if an allegation identified an individual staff, ideally the staff was immediately removed from direct resident care pending the results of the investigation. Staff B was informed Resident 62's allegation of abuse occurred on night shift when only one nurse was working the South unit, but the identified nurse was not removed from direct resident care at that time and Resident 62 was not monitored for potential psychosocial harm following the allegation. Staff B further stated allegations of missing money was individualized depending on the amount of money missing and if it was found within 24 hours or not. Staff B was informed Resident 35 and 311's grievances of missing money were not identified as potential allegations, reported or investigated as such.

In an interview on 03/06/2025 at 10:55 AM, Staff A, Administrator, stated allegations of abuse and/or neglect were reported to the State Survey Agency within two hours, thoroughly investigated, and residents monitored

after allegations were made. Staff A explained if an allegation identified a staff, they would be removed from direct resident care as soon as the facility became aware of the allegation. Staff A stated they expected staff to report allegations within two hours. Staff A further stated instances of missing money were reported to the State Survey Agency on a case-by-case basis, if it was over $100 or if theft was suspected.

Reference WAC 388-97-0640 (2)

Refer to