Health Inspection - SULLIVAN PARK CARE CENTER

F-Tag F607

Harm Level: Minimal harm or

Residents Affected: Some Based on interview and record review the facility failed to ensure the facility had enough staff to provide care

F-F607 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 92 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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47328

Residents Affected - Some Based on interview and record review the facility failed to ensure the facility had enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 5 of 10 sampled resident's, (Resident 63, 62, 91, 89, and 42), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life.

Findings included .

Review of the facility assessment reviewed January 2025, documented the facility's average daily census was 120. The facility admitted more acutely ill residents with multiple co-morbidities and provided care for an increased number of residents with drug abuse, cognitive impairment, behaviors and used a wander guard system (system consisting of a bracelet that would alarm when an exit door was approached) on the south side of the building (400, 500, and 600 halls) with secured doors leading onto the unit, for residents that wandered. The assessment further documented the interdisciplinary team met daily Monday through Friday to review resident acuity and staffing needs making staffing levels adjustments as needed. The facility utilized a staffing coordinator and staffed the facility based on [NAME] State's 'Per Patient Day' minimum staffing levels. Agency staff was used as needed to ensure proper staffing patters if in-house staff was not sufficient to meet resident needs.

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 11/01/2024 psychosocial behavioral care plan documented Resident 63 struck out, was combative, wandered, and exhibited verbal, physical and sexually inappropriate behaviors. The care plan instructed staff to administer medications as ordered, anticipate Resident 63's needs, provide supervision, offer distractions/activities as needed, provide simple, direct reminders, and observe whether behaviors endangered the resident and/or others and intervene if necessary. The 11/01/2024 elopement risk care plan documented Resident 63 wandered related to agitation and combative behaviors. The care plan instructed staff to administer medications as ordered, allow wandering in safe areas within the facility, check placement and function of the wandering bracelet/alarm system, address potential pain, encourage attendance and participation in activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 92 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 0725 Review of August 2024 through November 2024 nursing progress notes documented Resident 63 spoke little English and had advanced cognitive impairment with hallucinations at times. Staff noted wandering in Level of Harm - Minimal harm or September 2024, and on 09/18/2024 Resident 63 was found in an opposite sex peer's bed, both sound potential for actual harm asleep. On 10/01/2024 Resident 63 had increased confusion and wandered. On 10/15/2024 Resident 63 moved to the 400 hall. On 10/29/2024 Resident 63 demonstrated increased aggression over the last two Residents Affected - Some days, entered other resident rooms with difficulty in redirection. On 10/30/2024 Resident 63 was involved in a resident-to-resident altercation where they open handedly slapped a peer on the back of their head. On 10/31/2024 Resident 63 refused medications, chased staff attempting to run them over, wandered through

the lobby to the other side of the building, and a wanderguard was placed at that time. On 11/01/2024 Resident 63 wandered onto 400 hall and verbally harassed a peer while they swung a hairbrush. On 11/05/2024 Resident 63 wandered throughout the South side of the building. On 11/06/2024 verbal and physical aggression towards staff and they bit a staff member's arm. On 11/09/2024 at 2:30 AM, Resident 63 was found in a 400-hall peer's room and had rummaged through the bedside dresser, became agitated when redirected and threatened to throw objects at peers. On 11/10/2024 at 5:30 AM, Resident 63 undressed in

the 400-hall, became violent and was combative by kicking, swinging arms and attempting to scratch staff with redirection. At 1:19 PM, Resident 63 yelled and cursed at peers, became aggressive with staff, and pulled a peer's hair on 400-hall. On 11/11/2024 at 6:30 AM, Resident 63 wandered into a peer's room on 500-hall and hit them in the head with a hairbrush. At 10:44 AM, medication changes were made, and staff were currently waiting to see if medication changes were effective.

Review of the October 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 11/10/2024 elopement assessment showed Resident 63 was cognitively impaired, wandered and significantly intruded on the privacy or activities of others and placed the resident at significant risk of getting to an unsafe place. The assessment identified Resident 63 as at risk to wander and/or elopement, a wanderguard was placed on the resident to enable maximal independence with mobility in facility while allowing safety.

During observation on 02/24/2025 at 4:00 PM, Resident 63 was observed dressed, in their wheelchair, self-propelled and wandered down the South unit halls without staff supervision, picked up a peer's tumbler, and wheeled off with it as they drank the unknown contents. Similar unsupervised wandering observations were made on 02/26/2025 at 8:31 AM, 9:34 AM, and 1:04 PM, on 02/27/2025 at 2:38 PM, on 03/03/2025 at 9:29 AM, on 03/05/2025 at 11:21 AM, 11:54 AM, and 12:03 PM.

In an interview on 02/25/2025 at 11:22 AM, Resident 63's family member acknowledged Resident 63 wandered often.

In an interview on 02/26/2025 at 10:01 AM, Staff N, Nursing Assistant (NA), stated sometimes wandering interventions were in a resident's care plan. Staff N acknowledged Resident 63 wandered including entering into other resident's rooms. Staff N was asked what interventions Resident 63 had for wandering besides the use of a wanderguard. Staff N stated Resident 63 had a peer they were to avoid because of a previous resident-to-resident altercation, I guess, we just try to pay attention where [Resident 63] is at and staff on the South units halls attempted to redirect wandering residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 92 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 0725 According to the 01/14/2025 quarterly assessment, Resident 62 had diagnoses including anxiety and depression. Level of Harm - Minimal harm or potential for actual harm Review of the facility 08/23/2024 facility incident investigation documented Resident 62 alleged being hit in

the head by the nurse around midnight when they requested pain medications. Resident 62's care plan was Residents Affected - Some updated to included two staff for all interactions including medication administration and conversations.

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

During an 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 an 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.

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 not require two staff to answer the call light. Staff J reviewed Resident 62's record. Staff J acknowledged Resident 62 required two staff for all interactions and stated that would be hard to do.

According to the 01/30/2025 significant change in status assessment, Resident 89 had severe cognitive impairment. The assessment further documented Resident 89 had exhibited worsening wandering that significantly interfered with participation in activities and disrupted the living environment. Resident 89 was able to ambulate independently with staff supervision and exhibited verbal behaviors directed towards others.

Review of the 08/14/2024 cognitive impairment care plan instructed staff to administer medications as ordered, cue, orient, and supervise as needed. Review of the 08/26/2024 behavior care plan showed Resident 89 wandered the halls, entered peer's rooms, and believed they were an employee. Behavioral interventions instructed staff to remind Resident 89 where they were, ensure their care needs were met, reduce stimulation in the environment, and redirect as needed. The 09/04/2024 elopement care plan showed Resident 89 exhibited exit seeking behaviors and wandered aimlessly with interventions to administer medications as ordered, allow for wandering in safe areas within the facility, approach in a calm manner, provide redirection as needed, check placement and function of the wanderguard system.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 92 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 0725 Review of the August 2024 through January 2025 facility incident log documented Resident 89 eloped from

the facility on 08/29/2024 and sustained falls on 10/15/2024, 10/24/2024, 12/09/2024, 12/28/2024, Level of Harm - Minimal harm or 01/11/2024, 01/26/2024, and 01/28/2024. potential for actual harm

During observation on 03/04/2025 at 4:08 AM, the secured South unit was entered, the double doors leading Residents Affected - Some onto the South unit (400, 500, and 600 halls) were closed. Upon opening the doors, a strong pungent urine odor was smelled, and Resident 89 was observed sitting in the common area, shirtless.

According to the 02/24/2025 quarterly assessment, Resident 91 had severe cognitive impairment. The assessment further documented Resident 91 exhibited wandering that significantly interfered with their care, participation in activities, intruded on the privacy of others, and disrupted the living environment. Resident 91 was able to ambulate independently with staff supervision and exhibited verbal behaviors directed towards others.

Review of the 09/24/2024 mobility care plan showed Resident 91 required distant supervision for transfers and used both a walker and wheelchair for mobility. The 10/08/2024 behavioral care plan showed Resident 91 often ambulated independently without an assistive device, followed staff as they performed their duties, entered peer's rooms, disrobed in public and wandered down other halls on the unit. Behavioral interventions instructed staff to distract Resident 91 with conversation of their favorite movies, remind resident sitting is safer, make family phone calls, offer television, and avoid overstimulation. The 12/16/2024 elopement care plan documented Resident 91 wandered related to cognitive impairment and instructed staff to allow for wandering in safe areas within the facility, approach in a calm manner, provide redirection as needed, check placement and function of the wanderguard system.

Review of September 2024 through January 2025 facility incident log showed Resident 91 sustained falls on 9/25/2024, 9/27/2024, 10/13/2024, 10/29/2024, 12/06/2024, 12/24/2025, 12/25/2024, and 01/02/2025.

Review of October 2024 through February 2025 nursing progress notes documented Resident 91 often ambulated independently on the unit, wandered into peer's rooms, rummaged through peer's belongings, was verbally and physically aggressive towards staff, took and wore peer's items and clothes.

During observation on 03/04/2025 at 4:32 AM, Resident 91 stood in the doorway to their room, wandered down the hall, looked inside the ice chest, and stumbled to the common area on the South unit between 400, 500, and 600 halls. At 4:36 AM, Resident 91 wandered toward the nursing station and placed their hand in a bag with unknown contents.

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.

Review of a 10/15/2024 grievance form documented multiple residents had concerns about excessively long call light wait times and/or not having a call light within reach.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 92 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 0725 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 Level of Harm - Minimal harm or room, turned their call light on at 9:45 PM to be changed after an incontinence episode but staff did not enter potential for actual harm their room until 11:00 PM. Resident 42 further stated this had also occurred four other times.

Residents Affected - Some During observation on 02/27/2025 at 9:25 AM, the bathroom call light for room [ROOM NUMBER] came on. Staff answered the bathroom call light at 9:46 AM, 21 minutes later.

During observation on 02/27/2025 at 9:28 AM, the call light for room [ROOM NUMBER] came on. Staff answered the call light at 9:54 AM, 26 minutes later.

During observation on 02/27/2025 at 2:42 PM, the call light for room [ROOM NUMBER] came on while staff were observed at the nurse's station. At 2:47 PM, the resident in room [ROOM NUMBER] yelled out for assistance to get staff's attention. Staff then approached and the resident stated they needed oxygen.

In an interview on 03/04/2025 at 4:19 AM, Staff KK, Nursing Assistant (NA), stated the facility did not have enough staff on night shift. Staff KK explained the South unit of the facility had a lot of residents that wandered, tried to elope, and exhibited behaviors. Staff KK further stated staff were unable to take lunch breaks most nights and had a hard time completing extra duties such as cleaning wheelchairs because they were too busy trying to manage resident care. Staff KK stated staffing an extra person on night shift would be very beneficial.

In an interview on 03/04/2025 at 4:25 AM, Staff LL, Registered Nurse, stated the facility did not have enough staff. Staff LL explained the South unit had lots of behaviors, residents that wandered, and it was hard for the aides to keep up and get everything done. Staff LL further stated the South unit used to staff two nurses on night shift and it was rough with only one nurse.

In a confidential interview on 03/04/2025 at 4:31 AM, Confidential Staff 1, stated the facility did not staff sufficient staff. Confidential Staff 1 explained the South unit had quite a few behaviors including residents that did not sleep, wandered, were aggressive, and high fall risks. Confidential Staff 1 further stated they were unable to check and change residents timely because of managing residents with behaviors and having

an extra staff member would be helpful.

In an interview on 03/04/2025 at 4:46 AM, Staff NN, Staffing Coordinator, stated they did not work night shift that night but was called in around 4:00 AM (the survey team entered the facility at 4:00 AM) to provide support. Staff NN stated the night shift on the South unit was typically staffed with only one nurse and one nursing assistant per each hall (400, 500, and 600). Staff NN further stated the South unit had gotten into a good routine and did not require more staff.

Review of the 02/25/2025 secured South unit resident census showed the 400-hall had 22 residents, 500-hall had 18 residents, and 600-hall had 21 residents. 61 residents:1 night shift nurse and approximately 20 residents:1 NA. The secured South unit housed majority of the facility's cognitively impaired and behavioral residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 92 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 0725 In an interview on 03/04/2025 at 4:59 AM, Staff K, Nursing Assistant, stated they worked day shift, which started at 6:00 AM, but often came in early at 5:00 AM to help clean, organize the unit, and prepare for the Level of Harm - Minimal harm or day. potential for actual harm

During a follow-up interview and record review on 03/06/2025 at 9:12 AM, Staff NN, stated the North unit Residents Affected - Some was the more acute (intense) unit because that was where most of the new admissions were, and the South unit was more long-term care. Staff NN explained they used a spread sheet to determine staffing levels for day and evening shift. Night shift was always staffed with six nursing assistants, one per hall, two nurses on

the North unit but only one nurse on the South unit. Review of the spread sheet provided documented three columns 1) resident census, 2) total day shift NAs, and 3) total evening shift NAs. Staff NN stated depending

on the number of residents the next column showed how many NAs were needed. Staff NN further stated

they had not heard night shift needed more staff to help manage residents that wandering and/or had behaviors. Staff NN stated Staff L, Maintenance Director, was responsible for staffing the laundry department, Staff NN only staffed laundry with nursing staff if they had a person with light duty restrictions.

LAUNDRY STAFFING

During an interview on 02/24/2025 at 3:03 PM, Resident 50 stated they had not sent their personal clothing to the laundry anymore, because it was not getting done. They further reported some laundry staff had quit and the facility was using maintenance staff now in that department.

During an interview on 03/03/2025 at 12:56 PM, Resident 68 stated they requested to talk to the surveyor because some of their clothing (pants, shirts, underwear and socks) had not been returned from the laundry for about three weeks.

During an interview on 03/03/2025 at 12: 59 PM, Staff W, NA, stated that resident laundry had been an issue for about three weeks and management was in the process of addressing it. Staff W further stated the priority was getting the linens and towels washed. Resident laundry was only delivered on Sunday or Monday and had not arrived yet. Additionally, if a resident was out of clothing, the aides had to go and dig through the bins, which were so high it was time-consuming to sort through them. The interview with Staff W was interrupted when Resident 33 was observed in their doorway, wearing only their footwear. Another staff went to the laundry to get some clothes for Resident 33, as they didn't have any in their room.

During a tour of the laundry area on 03/05/2025 at 12:31 PM with Staff X, Laundry Aide/NA, a large rectangular rolling bin was observed in the soiled laundry area. This bin was approximately four feet wide, three feet deep and waist high. The bin was overflowing with resident clothing. During a concurrent interview, Staff X stated that they usually had 3 staff daily and just got approval to hire a fourth person for the laundry. Washing facility linens was currently prioritized over resident laundry, and nursing assistants brought the dirty linen from the resident care areas to the laundry, rather than having the laundry staff pick it up. Staff X further stated that if they had a sick call or not enough staff, a nursing assistant was pulled from resident care to help. Per Staff X, when fully staffed and resident clothing came into the laundry, it took 24 hours until it was returned to the resident. When asked how long it was currently taking to get resident clothing back to them, Staff X stated, honestly, about a week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 92 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 0725 In an interview on 03/06/2025 at 10:21 AM, Staff B, Director of Nursing, stated Staff A, Administrator, and Staff NN determined staffing levels based on census. Staff B explained night shift was staffed with two Level of Harm - Minimal harm or nurses on the North unit, one nurse on the South unit with one NA per each of the six halls. Staff B stated potential for actual harm they had not heard residents and/or staff voice staffing concerns.

Residents Affected - Some In an interview on 03/06/2025 at 10:34 AM, Staff A, stated they expected sufficient staff to provide care to the facility residents and staffed the facility above the Washington State minimum requirements.

Reference WAC 388-97-1080 (1), 1090 (1)

Refer to

F-Tag F656

Harm Level: Minimal harm or

Residents Affected: Few Based on observation, interview and record review the facility failed to ensure smoking materials were

F-F656 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 92 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 .

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 51 of 92 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

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 52 of 92 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)

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 92 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or 46033 potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident's peripherally Residents Affected - Few inserted central catheter (PICC, also known as a central line, a catheter placed in a large vein in the arm that extended to a large vein in the heart, used if long term antibiotic therapy was required or if antiobiotics were damaging to smaller veins) was maintained according to standards for 1 of 1 sampled residents (Resident 52) reviewed. This failure placed the resident at risk for complications related to their PICC including blood stream infections, blood clots, or inflammation of the vein.

Findings included .

The 2011 Centers for Disease Control and Prevention Guidelines for the Prevention of Intravascular Catheter-Related Infections, updated October 2017, retrieved at https://www.cdc. gov/infection-control/hcp/intravascular-catheter-related-infection/index.html documented the following recommendations: replace transparent dressings used on central venous catheters at least every 7 days or if

it becomes loosened, damp, or visibly soiled, and promptly remove any intravascular (inside a vein) catheter that is no longer essential.

The 2015 Association for Professionals in Infection Control and Epidemiology Guide to Preventing Central Line-Associated Bloodstream Infections recommended the transparent dressing be changed every 7 days, and that a daily assessment of the necessity of the catheter be performed and the catheter be removed promptly if no longer essential.

The 02/04/2025 re-admission assessment documented Resident 52 had diagnoses that included fractured ribs and empyema (pockets of infection between the lung and the chest wall). Resident 52 was cognitively intact, made decisions regarding their care and received antibiotics through a peripherally inserted central venous catheter (PICC line).

A review of the 01/30/2025 care plan revealed there were no goals or interventions developed related to the management of Resident 52's PICC line.

Resident 52 had the following provider orders:

-01/30/2025 flush PICC with 20 milliliters (m)l of saline after each blood draw

-01/30/2025 flush PICC with 10 ml saline prior to and after each dose of antibiotic

-01//30/2025 flush PICC with 10ml saline every 8 hours and prn (as needed)

-01/30/2025 Change PICC transparent dressing every 7 days on Sunday evenings and prn

-01/30/2025 Measure upper arm circumference weekly with dressing change

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 92 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 0694 -01/30/2025 Measure external length of the PICC from the insertion site to the end where the intravenous (IV) tubing connects, document the length in centimeters every Sunday Level of Harm - Minimal harm or potential for actual harm -01/30/2025 Monitor for phlebitis (redness, pain, tenderness, drainage) daily, document + if present, - if not present. Residents Affected - Few -03/02/2025 Cathflo activase (an enzyme that breaks up clots) once for occluded PICC.

A review of the February 2025 and March 2025 medication and treatment administration records (MAR/TAR) documented the resident received the last dose of their antibiotic on 02/20/2025 at 6:00 AM. The PICC dressing changes were omitted on 2/16/2025 and on 03/02/2025. The saline flushes ordered every 8 hours and as needed were omitted from 02/25/2025 until 03/01/2025 at 6:00 AM. The Cathflo Activase ordered on 03/02/2025 was omitted. A corresponding progress note documented the Cathflo Activase was not available.

There were no progress notes that documented attempts to restore the patency of the PICC after it became occluded, notes regarding the continued need for the PICC line or orders for its discontinuation.

On 02/25/2025 at 9:33 AM, Resident 52 was dressed and seated in their wheelchair in the common area of

the unit. A PICC line was observed on the inner upper portion of the resident's right arm. A transparent dressing covered the insertion site and was dated 02/16/2025 (9 days previous). The edges of the dressing were peeling off. Resident 52 stated they were finished with their antibiotics but had not heard what the plan was for the removal of the PICC line.

On 02/26/2025 at 7:50 AM, Resident 52 was seated in the entry area waiting for a ride to an appointment. Their PICC was observed; the dressing was dated as changed on 02/25/2025.

On 03/03/2025 at 9:24 AM, Resident 52 was in the common are of the unit. Their PICC line was still present,

the dressing was still dated 02/25/2025.

On 03/04/2025 at 10:06 AM, Resident 52's PICC line was observed. It was dated 02/25/2025. Resident 52 stated on Sunday, 03/02/2025, the PICC would no longer flush. They stated the nurse on Monday evening tried again to flush it and it still would not so the nurse reported to the resident that they would have Staff D, Infection Prevention, just remove it. Resident 52 had not heard anything further about getting it out since it no longer functioned. On 03/05/2025 at 10:06 AM, Resident 52 stated the PICC line was removed the prior evening by Staff D, and it came out without any difficulty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 92 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 0694 During an interview on 03/05/2025 at 11:20 AM, Staff F, Resident Care Manager, stated a PICC dressing change was considered a procedure that required sterile technique and if Licensed Practical Nurses were Level of Harm - Minimal harm or not comfortable changing them, there were other nurses that were able. Staff F stated PICC lines were potential for actual harm removed when the antibiotics therapy had been completed, or as soon as it was determined that the infection was cured. Staff F stated they expected PICC dressing changes to be completed every 7 days as ordered. Residents Affected - Few This was important because residents that had PICC lines were already being treated for infections so were already at risk for other infections. Staff F stated they assumed there could be a risk to a resident if an occluded PICC line was not removed promptly, but they were unaware what those complications were. Staff F knew there had been Cathflo ordered but had not been aware that it was not given. Staff F stated they were unaware if nurses had completed competencies for the management and care of a resident with a PICC line but they did not think so. Staff F stated, We do not do competencies that I am aware of. That would be a good one.

On 03/06/2025 at 10:32 AM, Staff D, Infection Prevention stated best practice was for PICC dressings to be changed weekly. They had changed the dressing for Resident 52 on 02/25/2025 and had also removed the resident' s PICC. Staff D stated the PICC was not removed sooner as there had been speculation that maybe Resident 52 was going to need more antibiotics. Staff D stated they had been told on Monday, 03/03/2025 that the PICC was occluded, but did not think leaving it in after it became occluded was a risk for

the resident. They expected there would be a progress note regarding the Cathflo, and whether it was effective in re-opening the PICC or not. Staff D stated they were not part of providing competencies for the nursing staff.

Reference: WAC 388-97-1060(3)(j)(ii)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 92 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 46115 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment Residents Affected - Few was maintained in a clean manner for 2 of 4 sampled residents (Residents 35, 74) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection.

Findings included .

Review of the facility policy titled, Respiratory Treatment, dated 06/22/2022, documented the external filter of

an oxygen concentrator provided no protection to the resident from respiratory illness, per manufacturers.

The filter kept debris from the concentrator compressor only and provided no respiratory protection to the resident. Oxygen cannulas/mask and tubing were to be changed as needed if soiled or damaged and the concentrator filters were to be cleaned weekly.

Per the 12/18/2024 quarterly assessment, Resident 74 had diagnoses which included chronic obstructive lung disease (COPD, a group of lung diseases that make it difficult to breathe), respiratory failure and needed oxygen due to those conditions.

Review of the physician orders documented on 08/30/2024, the resident had been prescribed oxygen to be used continuously at 3 liters per minute (lpm), due to COPD.

The 06/21/2024 respiratory care plan showed no direction for cleaning oxygen filters on the oxygen concentrator, a machine that delivers oxygen to the resident.

On 02/24/2025 at 9:53 AM, Resident 74 was observed wearing oxygen at 4 lpm (not 3 lpm as ordered) while sitting in their wheelchair. An inspection of the oxygen concentrator in the resident's room showed the concentrator was unclean with thick dust debris. Subsequent observations of the oxygen concentrator filter being unclean were made on 02/25/2025 at 2:18 PM, 02/26/2025 at 8:38 AM and 12:22 PM.

Subsequent observations were made of Resident 74 wearing their oxygen at 4 lpm on 02/25/2025 at 2:18 PM, 02/26/2025 at 8:38 AM and 12:22 PM, 02/27/2025 at 8:29 AM and 11:46 AM, 02/28/2025 at 8:18 AM.

In an observation and interview on 02/27/2025 at 8:29 AM, Resident 74's oxygen concentrator filter was clean. The resident stated they had cleaned their filter yesterday.

In an observation on 03/03/2025 at 8:41 AM, Res was observed lying in bed wearing oxygen at 2 lpm.

In an interview on 02/28/2025 at 8:50 AM, Staff M, Registered Nurse, stated Resident 74 received oxygen at 3 lpm. Staff M accompanied the surveyor to the resident's room and adjusted the oxygen from 4 lpm to 3 lpm. Staff M had asked the resident if they had adjusted the oxygen, and the resident said no.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 92 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 0695 In an interview on 02/28/2025 at 8:57 PM, Staff C, Assistant Director of Nursing, stated maintenance cleaned

the oxygen concentrators weekly. Staff C stated Resident 74 should have had oxygen administered as Level of Harm - Minimal harm or ordered unless they had an acute change. Staff C stated it was important to follow the provider orders to potential for actual harm avoid carbon dioxide retention and it was important to maintain clean oxygen concentrator filters to ensure

the efficacy of the machine. Residents Affected - Few

In an interview on 03/05/2025 at 1:17 PM, a collateral contact from the oxygen supplier, stated when the oxygen filter was unclean it could clog the airway for the flow of air into the concentrator and would impact

the flow of oxygen.

50027

Per the 12/04/2024 quarterly assessment, Resident 35 had diagnoses which included chronic respiratory failure and needed oxygen.

Review of the physician orders documented on 07/12/2024, the resident had been prescribed oxygen to be used continuously at 1 lpm, and 2 lpm as needed for oxygen levels below 90 percent due to chronic respiratory failure.

The 05/11/2022 care plan documented the resident required oxygen as needed and instructed maintenance staff to clean the concentrator filter weekly. Nursing staff was instructed to change the oxygen tubing as needed when soiled or damaged.

In an interview and observation on 02/24/2025 at 3:07 PM, Resident 35 stated they had asked for a new nasal cannula two days ago because it was dirty with blood on it. The resident stated their tubing was supposed to be changed weekly but had to request that it be done. The resident was observed with dried blood on their oxygen tubing, and it was unclean.

In an observation on 02/24/2025 at 3:20 PM, Resident 35 wore oxygen tubing that was dated 08/02/2024.

The oxygen filter on the concentrator was unclean with dust debris in the vents. The resident's oxygen was set at 2 lpm.

Subsequent observations of the filter being unclean were made on 02/25/2025 at 11:02 AM, 02/26/2025 at 9:29 AM, 02/27/2025 at 1:14 PM, 03/03/2025 at 8:35 AM and 12:28 PM.

In an interview on 03/05/2025 at 3:45 PM, Staff E, Resident Care Manager, verified there was no documentation in the chart that showed the oxygen tubing and cannula had been changed. Staff E added it was important to change the oxygen tubing for infection control.

Reference: WAC 388-97-1060 (3)(j)(vi)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 92 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.

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 59 of 92 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.

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.

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.

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 60 of 92 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

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 61 of 92 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-Tag F686

Harm Level: Minimal harm or

Residents Affected: Few Based on observation, interview and record review, the facility failed to revise the care plans in response to

F-F686 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 92 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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 46033

Residents Affected - Few Based on observation, interview and record review, the facility failed to revise the care plans in response to changing goals, needs of the residents or in response to current interventions for 2 of 33 sampled residents (Residents 44 and 35) reviewed. Specifically, Resident 44 fell and broke their hip, and had continued falls and the care plan was not updated. Additionally, Resident 35 was newly diagnosed with Addison's disease (when the adrenal glands are damaged and do not produce enough hormones to regulate blood pressure, water and salt balance, and respond to stress), and disease related interventions were not added to the residents care plan. These failures put the residents at risk for unmet care needs and unintended health consequences.

Findings included .

A review of the 12/18/2024 significant change assessment documented Resident 44 had diagnoses that included dementia with behavioral disturbances and right femur (upper thigh bone) fracture. Resident 44 was severely cognitively impaired, behaviors had worsened since their last assessment, and they had fallen and sustained a major injury since their admission.

The 08/05/2024 admission Basic Care Plan documented Resident 44 was at risk for falls. Staff were instructed to keep the call light and personal items in the resident's reach, remind to use the call light for assistance, and use non-skid footwear when transferring the resident. The resident was high risk for falls.

A review of nursing progress notes documented on 08/10/2024, Resident 44's roommate came to the door and stated the resident was on the floor. Resident 44 stated they tried to transfer from the wheelchair to their bed. They reported pain, especially in their right hip. After x-ray results were obtained that showed the right femur was broken, the resident was transferred to the hospital.

The 09/19/2024 progress note documented Resident 44 was assisted to the bathroom and was advised to use the call light when done. The resident yelled out that they were done and by the time the nurse entered

the bathroom, the resident was walking out of the bathroom with their walker and stated they had fallen. The nurse wrote that they had never left the resident's room, the resident's story kept changing but the nurse assessed the resident and there were no injuries.

The 11/17/2024 progress note documented Resident 44 was in the common area and slid out of the recliner.

The resident had been exhibiting more aggressive behaviors and required frequent bathroom trips every 10 minutes. The resident had been started on an antibiotic for urinary tract infection symptoms.

A review of the facility incident logs showed the resident had the following additional falls:

-11/21/2024 at 6:00 PM, the resident fell in their room with no injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 92 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 0657 -12/04/2024 at 9:01 PM, the resident fell in their room, sustained skin tears.

Level of Harm - Minimal harm or -12/27/2024 at 9:21 PM, the resident fell in their room with no injury. potential for actual harm -01/13/2025 at 1:30 AM, the resident fell in their room with no injury. Residents Affected - Few

After Resident 44 fell and fractured their femur on 08/10/2024, their care plan related to their fall risk was not updated until 11/18/2024.

A review of the comprehensive care plan showed on 11/18/2024, a fall care plan was initiated for Resident 44, that documented the resident had an unwitnessed fall and was at risk for injury, pain and recurring falls. Staff were instructed to anticipate the resident's need, keep the call light in reach, explain procedures and provide reassurance during mobility tasks to alleviate fear of falling, keep personal items within reach, provide proper footwear, remind/cue the resident to ask for assistance, monitor for complications from falls and notify the provider if observed. On 01/09/2025, the care plan was updated to include remind the resident to use the call light and wait for assistance prior to attempting to transfer. On 02/04/2025, the care plan was updated to include remind the resident to call for assistance.

On 02/24/2025 at 11:05 AM, Resident 44 was observed resting in their bed. The bed was in low position and there was a fall mat on the floor. Resident 44 stated they did not feel well. When asked if they had ever fallen, they stated they had fallen but was unable to remember when. Resident 44 stated nothing got broken when they fell , but it never felt good.

During an interview on 03/04/25 at 8:56 AM, Staff B, Director of Nursing, stated if a resident fell and broke their leg, they would expect to see changes to the resident's plan of care. Staff B stated the incident occurred

during a time of transition of facility ownership and there was a period that documentation was completed on paper. Staff B stated they would attempt to see if they could locate additional documentation regarding Resident 44's care plan.

During an interview on 03/04/2025 at 9:30 AM, Staff Y, Nursing Assistant, stated they remembered when Resident 44 fell and broke their leg. Staff Y stated the resident used to be and was still impulsive and tried to sit on the edge of the bed and holler. Staff Y stated they tell Resident 44 to wait until they get there, and if

they do not get there timely the resident tried to get up. Staff Y stated Resident 44 probably did not know what their call bell was for most of the time.

During an interview with Staff F, Resident Care Manager (RCM), and Staff G, RCM, on 03/05/2025 at 10:14 AM, Staff G stated a fall with major injury was reviewed in the morning meetings with the interdisciplinary team. Staff G stated the MDS (Minimum Data Set) coordinators initiated the resident care plans. The RCMs might add a few interventions, or they emailed the MDS coordinator when an incident occurred so the MDS coordinator could update the care plan.

50027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 92 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 0657 Per the 02/26/2025 comprehensive assessment, Resident 35 had diagnoses which included chronic respiratory failure (a condition in which the lungs were unable to adequately exchange oxygen and carbon Level of Harm - Minimal harm or dioxide over an extended period), dry eye syndrome (a condition where both upper eyelid glands failed to potential for actual harm produce enough tears) and diabetes. The resident was cognitively intact to make decisions regarding their care. Residents Affected - Few

In an observation and interview on 02/24/2025 at 03:34 PM, Resident 35 was lying in their bed. They stated

they were concerned about their medical care related to their diagnosis, Addison's disease (when the adrenal glands are damaged and do not produce enough hormones to regulate blood pressure, water and salt balance, and respond to stress) during an adrenal crisis (a flare-up). They stated they were administered

an injection when they had an adrenal crisis. They stated they had an adrenal crisis at the facility which did not subside until 48 hours later after two injections. The resident stated they felt the nursing staff were not educated on how to address it.

Review of the December 2024 through February 2025 MARS documented Resident 35 had two physician orders for primary adrenocortical insufficiency (Addison's Disease): Hydrocortisone oral tablet, 20 mg, three times daily ordered on 07/12/2024 and Hydrocortisone injection, 100 mg as needed every 24 hours for an adrenal crisis ordered on 10/02/2024.

Review of the December 2024 MARS and nursing progress notes documented Resident 35 was administered the injection on 12/03/2024 at 9:58 PM, 12/28/2024 at 8:04 AM, and 12/31/2024 at 10:19 AM. Further review documented the only words the resident was able to state was that they needed their injection

on 12/31/2024. The progress note documented the resident had spastic movements and their eyes tracked to the right. There was no further documentation found related to interventions.

Review of the January 2025 MARS and nursing progress notes documented Resident 35 was administered

the injection on 01/05/2025 at 6:00 PM and 1/10/2025 at 12:21 AM. There was no further documentation found related to interventions.

Review of the February 2025 MARS and nursing progress notes documented Resident 35 had muscle spasms and was administered the injection on 02/02/2025 at 3:21 PM. The resident initially had no response to the injection. The nurse called the provider at 4:10 PM. While on the phone, the resident showed improvement in their condition at 4:30 PM and was placed on alert charting. There was no further documentation found related to interventions.

Review of the 12/05/2024 care plan showed no documentation related to Resident 41's Addison's Disease diagnosis.

In an observation and interview on 03/03/2025 at 08:44 AM, Resident 41 was lying in their bed. They stated

they received an injection after convincing the new nurse on duty that they needed one. They stated they were in pain and I know my body. They stated their symptoms began at 4:00 AM. They stated they delayed informing the new nurse of their symptoms because it was too difficult to explain their disease since it is a rare condition.

Review of the March 2025 nursing progress notes documented Resident 35 was administered the injection

on 03/03/2025 at 8:01 AM. There was no further documentation found related to interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 92 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 0657 In an interview on 03/05/2025 at 1:38 PM, Staff Y, Registered Nurse, reviewed the resident's physician orders for their disease and stated if the resident continued to show symptoms after an injection then the Level of Harm - Minimal harm or nurse should know to contact the provider. They stated when a resident has a change in their health, the potential for actual harm nurse should put them in the alert charting system, but they primarily were verbally informed during a staff shift change. Residents Affected - Few

In an interview on 03/05/2025 at 03:22 PM, Staff E, Resident Care Manager, stated they had previously met with Resident 35 regarding their concerns about making sure that staff was aware of the interventions for their disease. They stated the disease should have been added to the resident's care plan with special instructions/interventions. Staff E further stated this was important because it would ensure staff provided the appropriate care for Resident 35 and management of their condition.

Reference: WAC 388-97-1020(5)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 92 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 .

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 37 of 92 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.

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 38 of 92 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 39 of 92 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 46115 potential for actual harm Based on observation, interview and record review the facility failed to implement the bowel management Residents Affected - Few protocol when indicated for 2 of 3 sampled residents (Resident 18 and 71), reviewed for constipation. In addition, the facility failed to identify changes in a resident's skin condition timely for 1 of 2 sampled residents, (Resident 15), reviewed for skin conditions. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life.

Findings included .

Review of the facility policy titled, Bowel Protocol, revised Febuary 2019, documented nursing staff was to

review a resident's bowel monitor every shift. The policy instructed nursing staff to implement the bowel program if a resident did not have a bowel movement (BM) for three days. The policy documented nursing staff was to administer Milk of Magnesia (MOM) on day three and a laxative suppository was to be administered the next shift if there were no results from MOM. If the resident exceeded four days without a BM, the Licensed Nurse performed an abdominal assessment and notified the provider.

CONSTIPATION

The 12/26/2024 quarterly assessment documented Resident 18 was able to make decisions regarding cares and needed substantial to maximal assistance from staff for activities of daily living, such as toileting.

Review of the 05/09/2022 constipation care plan documented interventions for Resident 18 to have the bowel protocol placed upon admission and the licensed nurse was to initiate the protocol as ordered. The care plan instructed staff to monitor bowel movements and for signs and/or symptoms of constipation.

Review of the Order Summary Report documented on 05/09/2022, the physician ordered Resident 18 to be administered a laxative (Milk of Magnesia) to be given on day three of no BM as needed, and a suppository to be given the next shift if no results from the MOM.

Review of the bowel records from 01/31/2025 through 02/28/2025, documented Resident 18 had no BMs for

the following dates:

01/31/2025 through 02/04/2025 (five days)

02/06/2025 through 02/09/2025 (four days)

02/11/2025 through 02/13/2025 (three days)

02/15/2025 through 02/18/2025 (four days)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 92 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 0684 02/21/2025 through 02/23/2025 (three days)

Level of Harm - Minimal harm or 02/25/2025 through 02/28/2025 (four days) potential for actual harm Additional review of the Medication Administration Records (MARs) for January 2025 and February 2025, Residents Affected - Few documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 18's record that stated the reason for the omissions.

The 01/10/2025 quarterly assessment documented Resident 71 was able to make decisions regarding cares and needed substantial to maximal assistance from staff for activities of daily living, such as toileting.

Review of the 07/19/2023 constipation care plan documented interventions for Resident 71 to have the bowel protocol placed upon admission and the licensed nurse was to initiate the protocol as ordered. The care plan instructed staff to monitor bowel movements and for signs and/or symptoms of constipation.

Review of the Order Summary Report documented on 07/19/2023, the physician had ordered a laxative (Milk of Magnesia) to be given on day three of no BM as needed, and a suppository was to be given the next shift if no results from the MOM.

Review of the bowel records from 01/28/2025 through 02/28/2025, documented Resident 71 had no BMs for

the following dates:

01/28/2025 through 01/30/2025 (three days)

02/05/2025 through 02/07/2025 (three days)

Additional review of the MARs for January and February 2025, documented Resident 71 had not received

the bowel medication as ordered during the above time frames, and no documentation was found in Resident 71's record that stated the reason for the omissions.

In an interview on 03/04/2025 at 9:37 AM, Staff M, Registered Nurse, stated MOM was administered on day three of no BM, if that was not effective a suppository was given on the next shift, if that was not effective an enema (liquid laxative inserted rectally) was given, and the provider was notified.

During an interview on 03/04/2025 at 9:48 AM, Staff E, Resident Care Manager, stated the bowel medications should have been administered for the above dates.

In an interview on 03/05/2025 at 2:05 PM, Staff B, Director of Nursing, stated the bowel medications should have been given as ordered, an abdominal assessment completed and documented, and the provider notified. Staff B stated it was important for the bowel protocol to be followed to prevent bowel obstruction.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 92 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 0684 50027

Level of Harm - Minimal harm or SKIN potential for actual harm <Resident 15> Residents Affected - Few Per the 02/25/2025 quarterly assessment, Resident 15 had diagnoses which included Alzheimer's Disease, heart failure, and depression. Resident 15 did not have any skin conditions and was not cognitively intact to make decisions regarding their care. Resident 15 required substantial to maximal assistance to complete personal hygiene and bathing tasks.

During an observation on 02/24/2025 at 11:35 AM, Resident 15 was in their room, sitting in their wheelchair watching TV. Their head was shaved in a low buzz cut. The right side of their head showed a visible patch of red, irritated scalp the size of an average avocado, with striations of blood and hard flakes scattered throughout their scalp, transcending down towards their right ear. Resident 15 had heavy flakes of skin in and around their right ear, in which they were significantly rubbing, picking, and flicking flakes onto the floor. Resident 15 had a noticeable amount of dry skin flakes on their shirt and pants.

In an observation on 02/26/2025 at 8:52 AM, Resident 15 was sitting in their room watching television. Their scalp had reddish indentations on the right side with hard crud flakes. Their ears, face and neck were dry, showing flakes of skin that had fallen on their upper and lower shirt. Their skin was pinkish red within the goatee area on their face. Resident 15 was digging in and scratching their right ear and rubbing their eyes lids.

In an observation on 02/27/2025 at 8:47 AM, Resident 15 was asleep sitting in their wheelchair in the dining area. They were wearing a baseball cap and had noticeable flakes of skin on their black shirt.

In an interview on 02/25/2025 at 02:04 PM, a family member stated Resident 15 had a medical history of psoriasis (a condition in which the skin cells build up and formed scales and itchy dry patches). They stated Resident 15's ears were not cleaned during showers. They stated Resident 15's head was bleeding and itching during their visit on the previous day. The family member stated they cleaned Resident 15's ears and applied their personal psoriasis moisturizing cream to their scalp, face, and neck while they were visiting.

Per record review of the 11/20/2024 nursing care plan, staff were instructed to use lotion on Resident 15's dry skin skin as needed and inform the nurse of any new skin issues. No documentation was found to show Resident 15 required interventions specifically for their scalp.

Review of the September 2024 through February 2025 nursing and provider progress notes showed no changes in Resident 15's skin condition.

Review of the provider orders as of 02/26/2025 showed Resident 15 had no orders to treat their skin conditions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 92 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 0684 Per review of the shower record from 01/29/2025 to 02/27/2025, Resident 15 received showers on Saturdays and Wednesdays. Per review of the personal hygiene record from 01/29/2025 to 02/27/2025, Resident 15 Level of Harm - Minimal harm or received personal hygiene cares two to three times daily. There was no documentation found for new skin potential for actual harm changes.

Residents Affected - Few In an observation on 02/28/2025 at 8:28 AM, Resident 15 was sitting in their wheelchair in the dining area.

They had speckles of reddish scabs on the right side of their scalp.

In an observation on 03/04/2025 at 11:16 AM, the right side of Resident 15's scalp had residual reddish indentations with a few hard scabbed flakes, in and around their right ear, with noticeable flakes that had fallen onto their upper shirt.

In an observation and interview on 03/05/2025 at 10:56 AM, Resident 15 was in their room with a family member. Their scalp was slightly reddish with flakes in the same area and in and around both of their ears.

The family member stated that Resident 15 did not have a prescription at the facility for their skin and/or scalp. They stated staff was aware they needed to apply their personal psoriasis moisturizing cream.

In an interview on 03/06/2025 at 9:51 AM, Staff FF, Registered Nurse, stated they assessed residents' skin every shower day and as needed when there were skin issues. Staff FF stated staff had informed nurse of residents' skin issues. Staff FF stated they were not aware Resident 15 had new skin issues and/or concerns nor that they used a personal psoriasis moisturizing cream.

In an interview on 03/06/2025 at 12:54 PM, Staff E, RCM, acknowledged staff should have informed the nurse regarding Resident 15's skin issues. Staff E stated this was important to ensure a resident's skin was healthy and interventions were in place to prevent infection.

Reference WAC 388-97-1060 (1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 92 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 44 of 92 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.

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 45 of 92 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.

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 46 of 92 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

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 47 of 92 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.

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 48 of 92 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 49 of 92 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-Tag F689

Harm Level: Minimal harm or

Residents Affected: Few Based on interview and record review, the facility failed to ensure the completion of a required

F-F689 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 92 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 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. 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 ensure the completion of a required Pre-Admission Screening and Resident Review (PASRR) Level 2 evaluation (a person-centered evaluation that is completed for anyone identified as having or suspected of having a serious mental illness, intellectual disability, developmental disability, or related condition) prior to admission for 2 of 5 sampled residents (Resident 6 and 102), reviewed for PASRR. Additionally, the facility failed to ensure Resident 52's PASRR Level 2 recommendations were implemented. These failures placed the residents at risk for unmet mental health care needs.

Findings included .

Review of the facility policy titled PASRR Process dated March 2019, showed that if a Level 2 PASRR was indicated the facility Social Worker would ensure the resident was evaluated within a timely period.

Review of a 02/17/2025 assessment showed Resident 6 admitted to the facility on [DATE REDACTED] with medically complex conditions and assessed as cognitively intact. The assessment showed diagnoses of depression, anxiety disorder, and post-traumatic stress disorder.

Review of a 12/06/2024 PASRR Level 1 completed by the hospital showed, Resident 6 was identified with indicators of Serious Mental Illness (SMI). This evaluation showed a PASRR Level 2 was required for the SMI and a referral was sent to PASRR coordinator on 12/06/24. Review of Resident 6's medical record showed no documentation the facility ensured completion of the PASRR Level 2 prior to the resident's admission to the facility.

The above information was shared with Staff Q, Social Services Director, on 03/04/2025 at 8:40 AM. Staff Q acknowledged the lack of the required PASRR Level 2 prior to admission and afterwards and stated, PASRRs from the hospitals are a mixed bag. No further information was provided.

A review of the 01/20/2025 admission assessment documented Resident 102 had diagnoses that included delusional disorder (unshakeable false beliefs) and major depressive disorder. The resident took antipsychotic and antidepressant medications (also referred to psychotropic medications that affect the mind, emotions and behavior) daily.

A PASRR-level I screen dated 01/02/2025 documented Resident 102 required a level II evaluation related to their history of delusions and psychotic disorder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 92 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 0644 The 01/14/2025 hospital discharge summary documented Resident 102 exhibited paranoid delusions while hospitalized , particularly with regards to his neighbors, and had some hallucinations. The summary stated Level of Harm - Minimal harm or Resident 102 was started on citalopram and risperidone, both psychotropic medications, and required potential for actual harm outpatient mental health follow-up when discharged .

Residents Affected - Few A copy of the PASRR level II evaluation was requested. In an email dated 03/04/2025 at 7:48 AM, Staff A, Administrator, wrote that the facility did not have a level II evaluation for Resident 102 yet, the evaluator was behind.

The 12/26/2024 admission assessment documented Resident 52 had diagnoses that included borderline personality disorder and depression. Resident 52 was cognitively intact and took antipsychotic and antidepressant medications daily.

The 12/18/2024 PASRR level II notice of determination documented Resident 52 had an existing behavioral health diagnosis and required specialized behavioral health services, met the requirement for nursing home level of care and required specialized behavioral health services.

The 02/04/2025 Physician Assistant progress note documented Resident 52 was seen for suicidal ideation, had always reached out for help in the past and had never harmed themselves. Resident 52 was agreeable to a behavioral health consultation while at the facility. An order was entered for the behavioral health referral.

On 03/03/2025 12:22 PM, any behavioral health provider progress notes for Resident 52 were requested and none were provided.

During an interview on 03/03/2025 at 2:23 PM, Resident 52 stated someone had recently asked them about seeing a behavioral health provider about it.

During an interview on 03/05/2025 at 1:14 PM, Staff Q, Social Work Director, stated Resident 52 had a level II evaluation completed prior to their admission to the facility. Staff Q stated they were not aware the resident had not been seen by a behavioral health provider yet and acknowledged this was not timely. Staff Q stated

they were not aware that if a level II evaluation was recommended that it was required to be completed prior to admission to the facility. Staff Q further stated the admission nurses reviewed documentation prior to admission to ensure everything was complete. Staff Q stated they were not involved with the PASRR process until after residents had already arrived at the facility.

In an interview on 03/05/2025 at 1:01 PM, Staff A, Administrator, stated they expected staff to follow the appropriate PASRR process.

46033

50027

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 92 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 0644 Per the 02/24/2025 comprehensive quarterly assessment, Resident 91 had diagnoses which included stroke, aphasia and dementia. The resident was severely cognitively impaired. Level of Harm - Minimal harm or potential for actual harm A review of Resident 91's record documented a Level I PASARR was completed on 02/27/2025, 155 days

after the resident admitted to the facility. On 11/01/2024, the resident had a physician's order to start an Residents Affected - Few antidepressant medication following a new diagnosis of depression. No new Level I PASARR or a Level II PASARR was found.

In an interview on 03/05/2025 at 12:18 PM, Staff Q, Social Services Director, stated they did not have an earlier Level 1 PASARR for Resident 91. They stated there was a different process in place last year to ensure PASARRs were completed. They stated that social services should have been notified regarding Resident 91's new diagnosis to implement a new Level I PASARR with a Level II referral. Staff Q stated this important so that residents were appropriately evaluated for state programs.

Reference: WAC 388-97-1915(4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 92 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities

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 Preadmission Screening and Resident Residents Affected - Few Review Level I (PASRR, determines if an individual had or was suspected of having a serious mental illness [SMI], intellectual or developmental disability or related condition) were accurately completed for 3 of 5 sampled residents (Residents 6, 411, and 63 ) reviewed for PASRR. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Findings included .

Review of the facility policy titled, PASRR Process dated March 2019, showed the facility ensured that upon

a resident's admission to the facility, a PASRR Level I was included in the admission paperwork. If there was no PASRR Level I, the Medical Records Director or designee contacted the hospital to obtain it.

Review of the Washington State Department of Social and Health Services Level I PASRR form showed the facility was responsible for ensuring the form was complete and accurate before a resident's admission to

the facility. In the event the resident experienced a significant change in condition, or if an inaccuracy in the current Level I was discovered, the facility was instructed to complete a new PASRR Level I and make referrals to the appropriate entities if a SMI and/or intellectual disability or related condition was identified or suspected.

Review of a 02/17/2025 admission assessment showed Resident 6 admitted to the facility on [DATE REDACTED] with medically complex conditions. This assessment showed the diagnoses of anxiety disorder, depression, and post-traumatic stress disorder (PTSD).

Review of a 12/06/2024 PASRR Level I showed the diagnosis of PTSD but no identification of the anxiety disorder or depression.

Review of the medical record showed Resident 411 admitted to the facility on [DATE REDACTED]. The diagnoses list included depression, anxiety, borderline personality disorder, and PTSD.

Review of a 02/11/2025 PASRR Level 1 showed no mention of the PTSD, and that Resident 411 showed indicators within the last two years of Schizophrenia, for which there was no diagnosis for in the medical record.

The above information was shared with Staff Q, Social Services Director, on 03/04/2025 at 8:53 AM. Staff Q acknowledged the inaccurate PASRR Level I's for Residents 6 and 411. Staff Q stated, That would be good to double check on these on admission. We would do a new PASRR that is more accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 92 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 0645 According to the 02/03/2025 quarterly assessment, Resident 63 admitted to the facility on [DATE REDACTED] with diagnoses including depression. The assessment further showed Resident 63 took antipsychotic (a drug or Level of Harm - Minimal harm or other substance that affected how the brain worked and caused changes in mood, awareness, thoughts, potential for actual harm feelings, or behavior and were typically used to treat mental health conditions) and antidepressant medications. Residents Affected - Few

Review of the 08/15/2024 PASRR showed Resident 63 had no mood or psychotic disorders and identified a level II evaluation was not indicated.

Review of Resident 63's diagnoses showed a 08/20/2024 depression diagnosis.

In an interview on 03/05/2025 at 1:03 PM, Staff Q, explained PASRRs were completed by hospitals prior to admission, reviewed by the facility's central admission intake nurse prior to admission and social services reviewed them once the resident admitted to the facility. Staff Q reviewed Resident 63's medical record. Staff Q stated Resident 63 had a diagnoses of depression upon admission and went through several psychotropic medication changes since admission. Staff Q acknowledged Resident 63's PASRR was inaccurate, should have been reviewed for accuracy and corrected as needed. Staff Q further stated social services should

review PASRRs prior to admission for accuracy.

In an interview on 03/05/2025 at 1:01 PM, Staff A, Administrator, stated they expected social services to

review PASRRs for accuracy, make corrections as needed, and follow the appropriate PASRR process.

Refer to WAC 388-97-1915 (1)(2)(a-c)

Refer to

F-Tag F699

Harm Level: Minimal harm or

Residents Affected: Few Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of

F-F699 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 92 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 .

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.

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 28 of 92 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.

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 29 of 92 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

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 30 of 92 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

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 31 of 92 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-Tag F726

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46115

Residents Affected: Some including identification of potential allegations, timely reporting allegations to the State Survey Agency as

F-F726 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 92 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42802

Residents Affected - Few Based on observations, interview and record review, the facility failed to ensure that controlled medications were tracked, and controlled medications for discharged residents were discarded, in 1 of 2 medication rooms (North Hall) inspected. This failure placed the facility at risk for drug diversion.

Findings included .

On [DATE REDACTED] at 8:40 AM, the North Hall medication room was inspected with Staff F, Licensed Practical Nurse/ Resident Care Manager (LPN/RCM.) In the locked narcotic box in the refrigerator, the following medications were found for two residents:

Resident 999

1) an unopened, full sealed bottle of liquid Morphine (a narcotic pain medication) that was filled on [DATE REDACTED].

2) an unopened, full sealed bottle of liquid Lorazepam (a controlled anti-anxiety medication) that was filled on [DATE REDACTED].

3) a medication card contained 10 Dronabinol 5 milligram (mg) capsules (used to treat nausea and stimulate appetite) was filled on [DATE REDACTED] and had expired on [DATE REDACTED].

Resident 998

4) an unopened, full sealed bottle of liquid Lorazepam that was filled on [DATE REDACTED].

During a concurrent interview, Staff F stated that all medications that were locked in the narcotic box, had a page number (written on the medication) that corresponded to the page number in the narcotic book and was counted every shift. The bottles of Lorazepam and Morphine did not have a page numbers on them, and the Dronabinol had page number 140 on the card. Additionally, Staff F stated all 4 of the medications definitely should have been counted every shift. Per Staff F, the bottles of Morphine and Lorazepam likely were not entered into the narcotic book, and they thought that Resident 999 and 998 were discharged a while back.

A review of Resident 999's medical record showed that the resident had discharged on [DATE REDACTED] (almost five months ago) and had been on the 300 Hall.

A review of Resident 998's medical record showed the resident had discharged on [DATE REDACTED] (over seven months ago) and had been on the 100 Hall.

During an interview on [DATE REDACTED] at 11:29 AM, Staff P, LPN stated there were currently no narcotics on the 100 Hall that were in the refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 92 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 0755 A review of the 100 Hall Narcotic books (#3 and #4,) dated back to [DATE REDACTED], showed no entry for the liquid Lorazepam bottle for Resident 998. Level of Harm - Minimal harm or potential for actual harm A review of the 300 Hall Narcotic book #29, dated back to [DATE REDACTED], showed no entries for the liquid Lorazepam bottle, liquid Morphine bottle or the Dronabinol 5mg capsules for Resident 999. Page 140 was Residents Affected - Few blank (page number on the Dronabinol capsules) The prior 300 Hall Narcotic books were not found on the 300 Hall.

During an interview on [DATE REDACTED] at 9:41 AM, Staff H, Registered Nurse (RN) stated that the facility nurse that received the medication from the pharmacy was responsible for putting it in the refrigerator and entering the medication into the appropriate hall narcotic book.

During an interview on [DATE REDACTED] at 10:15 AM, Staff QQ, LPN stated that the facility nurse was supposed to put

the narcotics in the log book when delivered, and if for some reason a refrigerated narcotic was not in the log book, the mistake probably wouldn't be caught.

During an interview on [DATE REDACTED] at 2:46 PM, Staff B, Director of Nursing verified that the facility staff who received the medication from the pharmacy would put the medication in the locked box in the refrigerator, with the page number of the narcotic book written on the medication. Staff B was informed of the medications found in the North Hall narcotic box for Resident 999 and 998. When asked what was done with medications once a resident was discharged , Staff B stated that they would go through the resident's medications and waste or send them back to the pharmacy. Staff B admitted that they had not been checking the narcotic box

in the medication refrigerator for discharged resident medications, especially if they weren't in the medication book. Staff B acknowledged that if they were not tracked in the narcotic books, there was a risk of drug diversion and the facility staff would not even know it.

Reference: WAC [DATE REDACTED](1)(b)(ii), (2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 92 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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 46033 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure medications were Residents Affected - Few administered according to the provider's order for 2 of 7 sampled residents (Residents 95 and 102) reviewed for medication administration. Specifically, multiple doses of a medication that treated Resident 95's lupus (the body's immune system attacks it's own healthy tissues causing pain and swelling) were omitted. Additionally, medication to control Resident 102's heart rate was not held when hold parameters were met.

This failure placed the residents at risk for unintended health consequences from omitted doses, and medication side effects when medications were not held as ordered.

Findings included .

A review of the 02/14/2025 quarterly assessment documented Resident 95 had diagnoses that included lupus and drug-induced suppression of the immune system. Resident 95 was cognitively intact and frequently had pain that interfered with therapy and day-to-day activities.

The 11/19/2024 care plan documented Resident 95 was at risk for pain and discomfort. Staff were instructed to administer medications as ordered, monitor for medication side effect and notify the provider if observed, position for comfort, and assess for the presence of pain every shift.

A review of the January 2025 and February 2025 medication administration records (MARs) documented Resident 95 was to receive Cellcept, (a medication to treat lupus that reduced overactive immune system activity) daily at bedtime.

Further review of the MARs documented Resident 95 did not receive Cellcept on 01/31/2025, 02/01/2025, 02/02/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/16/2025, 02/17/2025, and 02/18/2025 . A code 9 was entered on the MAR on those dates. The key on the MAR defined the code 9 as Other/see Nurses Notes. Corresponding progress notes documented the medication was not available, was ordered from the pharmacy, had not been delivered and was unavailable in the Cubex (a medication storage unit that held extra doses of commonly ordered medications).

On 02/25/2025 at 2:06 PM, Resident 95 was seated in their wheelchair at the dining table in the common area of the nursing unit. Resident 95 stated they had pain and took medication for lupus. Resident 95 stated that several times during their stay, the facility had run out of the medication and it caused them to have more pain. They stated the longest they went without it was four days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 92 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 0760 During an interview on 03/05/2025 at 11:33 AM, Staff F, Resident Care Manager, stated for specialty medications like Resident 95's Cellcept, they received an order from the provider and the order is sent to the Level of Harm - Minimal harm or pharmacy. Staff F stated after review, the medication might need a prior authorization before the pharmacy potential for actual harm will dispense it. A form is filled and sent back to the pharmacy and, if all is complete, the medication is sent to

the facility. Staff F reviewed the February 2025 MARs and progress notes and agreed there had been Residents Affected - Few omissions of the medication. They stated they expected to see more documentation that the nurses contacted the pharmacy or notified the provider if the medication was unavailable so adjustments to the medication could be made, or other arrangements to obtain the medication could be made. Staff F stated if Resident 95 missed doses of Cellcept, it could cause a flare-up of their lupus and that could cause the resident increased pain, inflammation, fatigue, or many other concerns.

A review of the 01/20/2025 admission assessment documented Resident 102 had diagnoses that included rapid atrial fibrillation (AFIB, a rapid irregular heartbeat) and stroke. Resident 102 was able to make decisions regarding their care and required substantial assistance of staff for activities of daily living.

A review of the 01/14/2025 hospital discharge summary documented Resident 102 was found down at their home for an undetermined amount of time and was taken to the hospital. The resident was diagnosed with a stroke and AFIB. The AFIB was initially treated with medication named Cardizem to control the fast heartbeat and was eventually switched to amiodarone. The amiodarone provided good rate control. Eventually the resident was discharged to the facility.

On 01/15/2025, an order was received to give Resident 102 amiodarone once a day. The order instructed staff to take the resident's pulse and blood pressure before administration. The medication was to be held if

the heart rate was less than 60 beats per minute, or if the systolic blood pressure (SBP, the top number of a blood pressure reading) was less than 110, and the provider was to be notified.

A review of the February 2025 MAR showed Resident 102's SBP reading was below 110 but the amiodarone was still given on 02/17/2025, 02/18/2025, 02/20/2025, 02/21/2025, 02/24/2025 and 02/25/2025.

During an interview on 03/05/2025 at 9:25 AM, Staff P, Licensed Practical Nurse, reviewed the MAR and stated they had just begun their employment at the facility on the dates mentioned and did not realize the amiodarone was to be held if the SBP was below 110. Staff P stated they had not discussed the low readings with the provider and if a resident had low blood pressure, they would want to make sure the resident was not having any symptoms. Staff P stated they should have held the amiodarone. They stated there were frequent interruptions that prevented them from concentrating when giving medications.

During an interview on 03/05/2025 at 10:41 AM, Staff F stated when there are parameters ordered for a medication, the medication needed to be held, and the provider was to be notified. This allowed the provider to change the dose if necessary. If the medication was given, staff needed to monitor the resident to make sure their blood pressure or heart rate did not get even lower.

Reference: WAC 388-97-1060(3)(k)(iii).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 92 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 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 50027

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure dietary staff had the required qualifications (current Washington State Food Worker Cards) for 1 of 14 dietary staff (Staff Z), whose records were reviewed. This failed practice had the potential risk for unsafe food handling practices and placed residents at risk for developing foodborne illness.

Findings included .

On 02/28/2025, a copy of dietary staff's current Washington State Food Worker cards were requested.

Review of dietary cards on 02/28/2025 at 3:25 PM showed no documentation Staff Z, Dietary Manager/Registered Dietician, had a Food Workers Card, as required. Staff Z acknowledged they did not have a Washington State Food Worker card.

In a follow-up interview on 03/06/2025 at 10:53 AM, Staff Z confirmed they were required to obtain the Washington State Food Worker card. Staff Z further stated it was important because it showed proof of competency and knowledge of dietary operations.

Reference WAC 388-97-1160.

.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 92 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50027 potential for actual harm Based on observation, interview, and record review, the facility failed to provide appetizing and palatable Residents Affected - Some food for 5 of 14 sampled residents (Residents 35, 46, 211, 20, and 17) reviewed for food. This failure placed

the residents at risk for decreased nutritional intake, potential weight loss, and a diminished quality of life.

Findings included .

In a Resident Council (group of facility residents that regularly met to discuss care at the facility) Meeting on [DATE REDACTED] at 10:37 AM, the Council stated the food was only good maybe two days a week. The Council explained the vegetables were overcooked, the menu lacked variety, and the weekend food was the worst.

The [DATE REDACTED] comprehensive assessment documented Resident 35 had diagnoses which included diabetes and depression. Resident 35 was cognitively intact to make decisions regarding their care.

In an observation and interview on [DATE REDACTED] at 3:16 PM, Resident 35 was lying in bed and watching television. Resident 35 stated the quality and taste of the food had diminished over the past year. Resident 35 explained the meat (i.e., chicken, hamburger patties) was extremely overcooked and so tough they could not chew it, the vegetables were mushy, and desserts were even worse because there was often cake without icing.

In an observation on [DATE REDACTED] at 1:02 PM, Resident 35 was sitting up in their bed with their lunch tray on the table in front of them. The meal served was beef stroganoff with noodles, peas, a roll, cake and 1 cup of milk.

The beef stroganoff looked like chunky gravy with barely any meat, all the peas were welted like raisins, and

the cake looked dry with a thin layer of icing. Resident 35 only ate the noodles, half of the roll, cake, and drank half of their milk.

In an observation and interview on [DATE REDACTED] at 10:15 AM, Resident 35 was lying in bed making jewelry. Resident 35 stated last night's dinner was the worst meal they had been served. Resident 35 explained the chicken was so dry they could not swallow it, the vegetables were cooked to oblivion, the rice was undercooked, and the dessert was a version of a smashed flat chocolate peanut butter candy bar. Resident 35 stated that the meal was inedible and instead ate their left-over vegetable tray ordered from the local grocery store.

46033

The [DATE REDACTED] significant change assessment documented Resident 211 had diagnoses that included protein calorie malnutrition. Resident 211 was cognitively intact and required set-up assistance from staff to eat.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 92 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 0804 During an interview on [DATE REDACTED] at 4:10 PM, Resident 211 stated food was tough, overcooked and the hot food was not hot. On [DATE REDACTED] at 2:56 PM, Resident 211 stated their lunch that day was not good. They stated Level of Harm - Minimal harm or the cheese ravioli had been cooked for so long that the sauce soaked completely into the pasta. They stated potential for actual harm they picked off the pasta and were going to eat only the cheese insides, but that was rubbery and had no taste. They stated the pumpkin pie had a dark layer on top, beneath that was mushy and the pie had an Residents Affected - Some off-putting smell.

46115

The [DATE REDACTED] quarterly assessment documented Resident 20 had diagnoses which included heart failure and diabetes. Resident 20 was cognitively intact and was independent with eating.

During an interview on [DATE REDACTED] at 10:31 AM, Resident 20 stated the food was terrible, overcooked and was served cold. On [DATE REDACTED] at 12:27 PM, Resident 20 stated the chicken that was served was not good and they did not like it.

In an interview on [DATE REDACTED] at 12:27 PM, Resident 20 stated they did not like the beef stroganoff that was served so they requested an egg salad sandwich and said it was better than nothing.

The [DATE REDACTED] quarterly assessment documented Resident 71 had diagnoses which included heart failure and diabetes. Resident 71 was cognitively intact and needed set up assistance for eating.

In an interview on [DATE REDACTED] at 2:43 PM, Resident 71 stated the food was not good, was not always served hot,

the biscuits were hard, the food was flavorless, and the meat was tough and dry.

During an interview on [DATE REDACTED] at 12:30 PM, Resident 71 stated they were served tamales for dinner last night and it looked awful, and the beans were terrible. Resident 71 stated they had ordered food and ate that for dinner.

47328

According to the [DATE REDACTED] quarterly assessment, Resident 46 had diagnoses including malnutrition. The assessment further showed Resident 46 received a therapeutic diet, was cognitively intact and able to clearly verbalize their needs.

In an interview on [DATE REDACTED] at 2:19 PM, Resident 46 stated the food was terrible. Resident 46 explained there was an alternate menu, but they did not like that food either.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 92 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 0804 On [DATE REDACTED] at 1:23 PM, a test tray of the lunch meal directly from the kitchen steam table was sampled by the survey team. The entree meal consisted of a lemon fish (cod) almondine, red bliss potatoes, candied carrots, Level of Harm - Minimal harm or and fruit parfait. The temperature of the food was lukewarm, and the appearance of the main entree was potential for actual harm unappetizing with dull colors. The fish and potatoes tasted bland; the fish had no lemon or almond flavoring and the potatoes taste like plain salt free boiled potatoes, the textures were firm. The carrots were watery, Residents Affected - Some mushy with minimal carrot flavor and not candied . An egg salad and bacon, lettuce, and tomato (BLT) sandwiches were also ordered from the alternate menu. The egg salad sandwich tasted like hard boiled eggs with no seasoning. The fruit parfait was diced soft peaches with cinnamon and tasted mediocre. The BLT sandwich was the only food item that was appetizing and tasted flavorful.

In an interview on [DATE REDACTED] at 3:31 PM, Staff Z, Dietary Manager, stated the cooks tasted the food during the cooking process. Staff Z further stated they themselves also tasted the food to check for proper seasonings to ensure the meal was palatable and tasty. Staff Z adjusted ingredients as needed and consumed each meal served while they were present. Staff Z stated sampling the food was important for resident satisfaction.

In a follow-up interview on [DATE REDACTED] at 10:52 AM, Staff Z stated they had also eaten the entree meal served for lunch on [DATE REDACTED]. Staff Z acknowledged the lemon fish almondine had no lemon flavor and had to add seasoning to their meal.

Reference WAC [DATE REDACTED] (1), (2).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 92 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50027

Residents Affected - Some Based on observation, interview, and record review the facility failed to store, discard and distribute food, monitored temperatures of foods being served, ensure accuracy of preparation of thickened liquids, and maintain a cleaning schedule in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life.

Findings included .

Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised [DATE REDACTED], showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be discarded as directed by the food manufacturer's use-by-date.

During a kitchen observation and interview on [DATE REDACTED] at 09:02 AM, the reach-in refrigerator contained an unlabeled tossed salad covered with plastic wrap. Staff Z, Dietary Manager, acknowledged the salad should have been labeled with a date and quickly disposed of it. Staff Z stated that it was important for food to be discarded at the appropriate time to reduce potential for bacterial growth.

During a kitchen observation and interview on [DATE REDACTED] at 09:15 AM in the dry storage room, there were four opened bags of cereal with expired dates: Cornflakes expired on [DATE REDACTED], Cheerios expired on [DATE REDACTED], Raisin Bran expired on [DATE REDACTED], and [NAME] Krispies expired on [DATE REDACTED]. Further observation showed there was a 22-quart container of rice measured at 5 liters labeled with a use-by-date of [DATE REDACTED].

During a kitchen observation on [DATE REDACTED] at 09:22 AM, the walk-in refrigerator contained the following items opened and unlabeled with a date: precooked sausage patties (120 count), packages of sliced turkey meat, half a jar of dill pickles (,d+[DATE REDACTED] count) size, 1 gallon of lemon juice with heavy sediment, 1 gallon of mayonnaise, 1 gallon of creamy Cesar salad dressing, 1 gallon of salsa.

During a kitchen observation on [DATE REDACTED] at 10:22 AM, the walk-in freezer contained the following items unlabeled with a date: frozen bunch of bananas blackened in a carboard box, 1 cup of bacon bits wrapped in plastic, 14 lemon cookies in a plastic bag, and a medium sized box of scones wrapped in an opened plastic bag.

In an observation and interview on [DATE REDACTED] at 09:45 AM, the north nourishment refrigerator was greatly overcrowded with resident commercial food and drink items. The refrigerator had the following resident food items opened and unlabeled with a date: overripen cut-up fruit in container, 3-inch block of cheese and a beef summer sausage in a plastic baggie, half of an egg salad sandwich in a baggie, two seafood salads in a bowl, dried up sliced raw vegetables in a container, medium sized bottle of V8 juice. Staff Z stated items in

the refrigerator are rarely managed and the kitchen staff often inquired about unlabeled food. Staff Z stated

the perishable food items should have been labeled with a date when opened and should have been discarded within 7 days due to bacterial contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 92 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 0812 Further inspection of the north nourishment refrigerator found 20 facility assembled cups of applesauce with lids unlabeled. Staff Z stated the facility used the FIFO method (first in and first out) to track when the Level of Harm - Minimal harm or applesauce was used. potential for actual harm <Food Preparation and Service> Residents Affected - Some

Review of the facility policy titled, Food Temperatures, dated [DATE REDACTED] (reviewed February 2019), showed the dietary department would check food temperatures on all items prepared by the dietary department, hot foods should be held at 135 degrees Fahrenheit (F), and potentially hazardous cold food kept at or below 41 degrees F. The policy instructed staff to measure and record food temperatures on a temperature log every meal. The Serving temperatures will be recorded by the cook or other designated personnel for all items served prior to serving on a temperature log.

Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised [DATE REDACTED], showed that there is an increased risk of contamination when food is held, cooled and reheated at improper temperatures. Thus, temperatures of food must be taken and monitored. Records must be maintained to verify food temperatures are within the parameters required for food safety.

During an observation of a tray line service held in the kitchen on [DATE REDACTED] at 11:25 AM, the fruit cups being served for lunch were setting on resident trays stacked on the meal cart. At 11:48 AM, Staff ZZ, Dietary Cook, began to prep food items, such as chopped hamburger, fixings and place them in the steam table pans where the other entree items were already placed.

At 11:53 AM, the dietary staff began coordinate and serve the lunch meal (lemon almondine fish, red bliss potatoes, steamed carrots, butter roll, fruit parfait, hamburger with fixings, BLT sandwich). Staff ZZ began to serve from the steam table. Staff ZZ placed the hamburger and fixings on a plate and began to add other food items to it. No staff checked the food temperatures of the food resting in the steam table. This surveyor prompted Staff ZZ to check the temperatures of all food items at the steam table. Staff ZZ stated they took

the temperatures right before this surveyor entered the kitchen approximately 30 minutes ago. They replied with an undetermined explanation of their policy on checking food temperatures during tray line.

At 11:56 AM, this surveyor informed Staff ZZ they needed to check the temperatures during the inspection visit and proceeded to check the temperatures. At 12:00 PM, the fruit parfait had a temperature of 46 F. Staff Z instructed the dietary staff to remove the fruit parfait from the meal cart and they placed them in the refrigerator. Staff Z stated the cold food temperature needed to be below 40 F due to prevention of bacterial growth.

In an observation at 12:06 PM, staff ZZ still had not checked the temperature of the regular and chopped hamburger, and fixings (lettuce, tomato, cheese).

In an observation and interview on [DATE REDACTED] at 12:22 PM, Staff Z instructed the dietary staff to obtain the fruit parfait from the refridgerator. The staff began to add the fruit parfait to the meal trays. Staff ZZ stated the fruit parfait was below 70 F, but safe for consumption.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 92 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 0812 In an interview on [DATE REDACTED] at 12:39 PM, Staff Z stated the kitchen staff documented temperatures on a log daily. They stated holding temperatures were referenced to food items being held on the steam table. They Level of Harm - Minimal harm or stated that it was important to check food temperatures for prevention of bacteria, foodborne illness and potential for actual harm ensure food palatability.

Residents Affected - Some Review of the kitchen temperature logs from [DATE REDACTED] through [DATE REDACTED] had missing final cooking and holding temperatures for the following dates: [DATE REDACTED] to [DATE REDACTED] and [DATE REDACTED]-[DATE REDACTED]. The log did not include temperature checks before tray line or mid service.

Review of the facility policy titled, Thickened Liquids, dated [DATE REDACTED], showed thickened liquids that not pre-thickened are prepared by the dietary department and thickened according to the mixing chart and provided for the requested meal or to nursing for hydration or medication pass, including oral liquids supplements.

In an observation and interview during kitchen tray line on [DATE REDACTED] at 12:10 PM, Staff AAA , Dietary Aide, pumped 3 full strokes of liquid thickener from a dispenser (Simply Thick Thickener) into an 8 ounce (oz) cup of lemonade, swished the cup around, placed a lid on the cup and set it on a tray in the resident meal cart.

They stated the correct consistency for thickened liquids were 3 pumps for honey thick and 2 pumps for nectar thick liquids. They stated that if the liquid is too thin, then they added more thickener to thicken the drink. Staff Z stated the kitchen used the International Dysphagia Diet Standardization Initiative (IDDSI) Flow Test to measure the thickness of liquids with a syringe.

In an interview on [DATE REDACTED] at 12:15 PM, Staff Z stated that an 8 oz. cup of liquid required 4 pumped full strokes for honey thick and 3 pumped full strokes for nectar thick. Staff Z was informed of this surveyor's

observations of Staff AAA. Staff Z acknowledged the dietary staff needed more education/training. Staff Z stated that this was important to ensure the accuracy of thickened liquids to decrease the risk of aspiration.

In an interview on [DATE REDACTED] at 3:31 PM, Staff Z stated the kitchen did not complete an IDDSI Flow Test every time thickened liquids were prepared. Staff Z stated they did not conduct training for all dietary staff but intended to do so.

In a kitchen observation and interview on [DATE REDACTED] at 10:30 AM, there was no sanitizer bucket in the kitchen. Staff Z stated that the kitchen had a red sanitizer bucket that should have been in the designated area. Staff Z instructed Staff AAA to locate the sanitizer bucket. At 10:39 AM, Staff AAA found the bucket, filled it with cleaning solution and performed an Ecolab strip test (tool used to measure the concentration of various sanitizing and disinfecting solutions) which showed the correct strength.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 92 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 0812 In an interview on [DATE REDACTED] at 10:43 AM, Staff Z stated that they did not have a documented cleaning schedule for staff to follow. They stated they verbally instructed staff to complete cleaning tasks and they Level of Harm - Minimal harm or themselves inspected the results afterwards. They acknowledged there should have been a cleaning potential for actual harm schedule log. They stated this was important to ensure proper sanitization, decrease bacteria and eliminate cross contamination within the kitchen was documented. Residents Affected - Some

Review of the latest cleaning schedule, Food Service Task Sheet, showed 3 weeks in the month of [DATE REDACTED] (, d+[DATE REDACTED]-,d+[DATE REDACTED], ,d+[DATE REDACTED]-,d+[DATE REDACTED], & ,d+[DATE REDACTED]-,d+[DATE REDACTED]). The schedules had tasks that were not completed for the majority of the days.

Reference: WAC [DATE REDACTED](3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 92 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 46033

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 5 sampled residents (Resident 104) whose discharge records reviewed. Specifically, Resident 104 was sent to the local hospital for urgent treatment and the medical

record did not include events leading to the resident's decline and need for transfer. This failure created a risk for incomplete sharing of vital information with care givers across levels of care and lack of evidence of care provided.

Findings included .

A review of the 01/30/2025 five-day assessment documented Resident 104 had diagnoses that included stroke and difficult swallowing. Resident 104 required substantial staff assistance for their activities of daily living and was able to make decisions regarding their care.

On 03/03/2025 at 9:07 AM, it was observed that Resident 104 was not present in their room and the nursing unit. When asked, Staff Y, Nursing Assistant, stated they heard Resident 104 had been vomiting blood and was sent to the hospital, but they were unsure.

During an interview on 03/03/2025 at 9:10 AM, Staff P, Licensed Practical Nurse, stated the report they received was that Resident 104 had vomited and there was blood in it, so they were sent to the hospital at around 4:30 AM that morning.

A review of progress notes documented the resident was last seen by the facility Physician Assistant on 02/28/2025. A 02/28/2025 nursing progress note documented the resident's care plan was updated to show female care givers only. A 03/03/2025 at 11:29 AM progress note documented the hospital had called and notified that Resident 104 was being admitted .

The 03/02/2025 eINTERACT facility to hospital transfer form documented Resident 104 was sent to the hospital at 4:50 PM that day. The Reason for Transfer area was blank.

There were no entries in the record from 02/28/2025 to 03/03/2025 that described events of the resident's decline, who was notified, any interventions that had been attempted, any provider notification, any orders given to intercede on the resident's behalf and what information had been provided to the hospital regarding

the resident's clinical situation.

During an interview on 03/05/2025 at 10:54 AM, Staff F, Resident Care Manager, stated they believed Resident 104 left the facility early on 03/03/2025 before 6:00 AM. Staff F stated the resident had nausea and vomiting and there was some blood in it. Staff F reviewed the resident's record and stated they did not see any documentation regarding that. Staff F stated they expected staff to document the events that lead up to

the resident's transfer to the hospital, any notifications to the providers, and any other relevant information. Staff F stated, It was important because people would come in and want to know what happened to the resident.

Reference: WAC 388-97-1720(2)(a-m).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 92 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 0880 Provide and implement an infection prevention and control program.

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 infection control practices Residents Affected - Some were followed during wound care to include removal of gloves and performing hand hygiene (HH) when indicated for 2 of 5 sampled residents (Residents 101 and 105), reviewed for pressure ulcers. Specifically, staff did not implement or follow Enhanced Barrier and Contact Precautions when indicated. Additionally, staff failed to notify the Infection Preventionist (IP) of a potential gastrointestinal (GI) outbreak in 1 of 4 units

in the facility. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences.

Findings included .

The Centers for disease Control (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of infectious Agents in Healthcare Settings updated September 2004 retrieved from https://www.cdc. gov/infection-control/hcp/isolation-precautions/index.html documented Standard Precautions were recommended the use of gloves, disposable gowns, masks, or protective eyewear in any setting where there would be exposure to any body fluid. Contact precautions were recommended when the presence of excessive wound drainage, incontinence of stool or other discharges from the body created an increased potential for extensive environmental contamination. Implementation of Contact Precautions included donning a gown and gloves for all patient interactions upon room entry and discarding before exiting the room to help contain pathogens (viruses or bacteria that are highly contagious and cause illness) especially those transmitted through environmental spread including noroviruses and other intestinal pathogens.

The CDC Implementation of Personal Protective Equipment (PPE, gloves, disposable gowns, eye protection or masks, for example) Use in Nursing Homes to prevent Spread of Multidrug-resistant Organisms updated July 12, 2002, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended use of Enhanced Barrier Precautions (EBP) as an infection control intervention that employed targeted gown and glove use during high contact resident care activities when Contact Precautions do not apply for residents with wounds or indwelling medical devices such as feeding tubes or catheters. EBP directs staff to don gowns and gloves when dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 92 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 0880 During an observation of wound care on 02/27/2025 at 9:34 AM, Staff T, Licensed Practical Nurse (LPN), began a dressing change on Resident 101. Staff T donned gown and gloves before entering the resident's Level of Harm - Minimal harm or room. Resident 101 was assisted to their right side while in bed. Staff T removed two soiled dressings, one potential for actual harm from each buttock. Staff T then removed their gloves, did not complete HH, donned new gloves, and cleansed the wounds to the buttocks. After cleansing the wounds, Staff T did not remove gloves and Residents Affected - Some complete HH, proceeded to apply dressings to the wounds, and dated the dressings with a writing instrument taken out of their uniform pocket. Resident 101 then rolled to their back. With the same gloves on, Staff T reapplied the resident's incontinence brief. Staff T then proceeded to physically check Resident 101's gastrostomy tube (G-tube, a tube inserted through the belly that delivered nutrition directly to the stomach) site with the same gloves on, touched the dressing to the G-tube site, tossed the used wound supplies and wrappers, rubbed the resident's left shoulder, then removed the gloves and washed their hands. Staff T then donned a new pair of gloves, cleaned the G-tube site, then removed their gloves. Staff T completed no HH, then donned another pair of gloves, and applied a new dressing to the G-tube site. Staff T removed the glove to the right hand, obtained a piece of tape, put a glove back on the right hand, secured the G-tube site dressing with the piece of tape, and dated the dressing. Staff T completed HH.

On 02/27/2025 at 9:58 AM, Staff T stated that HH during a dressing change should occur, before and upon glove switching. Staff T acknowledged the missed opportunities where hand hygiene should have occurred but did not.

The 12/18/2024 quarterly assessment documented Resident 74 had diagnoses that included heart failure, high blood pressure, and anxiety. The resident was cognitively intact and made their needs known.

During an interview on 03/03/2025 at 8:41 AM, Resident 74 stated they had the flu, in reference to having nausea, vomiting and diarrhea.

On 03/03/2025 at 12:55 PM, there was no contact precaution sign on Resident 74's door. At 1:02 PM, Resident 74 was observed in bed and stated they did not feel good.

The 01/10/2025 quarterly assessment documented Resident 20 had diagnoses that included heart failure, high blood pressure and diabetes. The resident was cognitively intact and made their needs known.

During an interview on 03/03/2025 at 8:42 AM, Resident 20 stated they were nauseated and had vomited.

On 03/03/2025 at 12:56 PM, there was no contact precaution sign on Resident 20's door.

In an interview on 03/03/2025 at 1:13 PM, Staff M, Registered Nurse, stated Resident 20 had vomiting and diarrhea on 03/02/2025 and Resident 74 had nausea and diarrhea that morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 92 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 0880 During an interview on 03/03/2025 at 1:37 PM, Staff M, stated the residents probably needed contact precautions for nausea, vomiting and diarrhea. Staff M stated this was important to prevent the spread of Level of Harm - Minimal harm or germs to the other residents and themselves. Staff M added they needed to inform the infection preventionist potential for actual harm when nausea, vomiting and diarrhea occurred but had not done so.

Residents Affected - Some <Enhanced Barrier Precautions Not Followed>

A review of the 01/20/2025 five-day assessment documented Resident 102 had diagnoses that included stroke and paralysis on one side of their body. Resident 102 had a stage 3 (involved all layers of skin loss that extended into the fat layer of tissue) and required substantial assistance from staff for their activities of daily living.

On 03/03/2025 at 8:47 AM, the doorway to Resident 102's room was observed to have signage hanging that indicated EBP was to be used when care was provided for Resident 102. Upon entry, staff W, Nursing Assistant (NA), and Staff VV, NA, were observed standing next to resident 102's bed. They were moving a mechanical lift away from the bedside. Resident 102 was observed in bed. When asked if the resident required EBP, Staff W stated if they came in contact whit the resident's legs where there were wounds, they used EBP. Staff W stated they did not use EBP when they transferred the resident to bed or when they toileted the resident because they did not get near the legs.

On 03/03/2025 at 11:48 AM, Resident 102's skin condition in their periarea (the groin, buttocks and lower back region) was observed. Staff W and Staff VV donned disposable gowns and gloves prior to entering the resident's room. When asked about the use of gown and gloves during this resident interaction, Staff W stated they planned on dressing Resident 102 in their pants after their skin was observed, so because they would be touching the resident's legs, they had to use EBP.

According to the 02/02/2025 admission assessment, Resident 105 had diagnoses that included malnutrition and muscle weakness. The assessment further showed Resident 105 had an indwelling urinary catheter (flexible tube inserted into the bladder to help drain urine) and required substantial staff assistance for most of their ADLs.

Review of the 02/03/2025 bladder care plan showed Resident 105 used an indwelling urinary catheter and instructed staff to provide catheter care routinely and monitor for potential signs and/or symptoms of a bladder infection. The skin care plan implemented on 02/05/2025 showed Resident 105 had a deep tissue injury (DTI, intact or nonintact skin with localized area of persistent unchanging deep red, maroon, purple discoloration) to their buttock and bilateral heels blisters. The care plan did not include instructions for staff to use EBP.

During an observation on 02/24/2025 at 10:21 AM, Resident 105's wound care was observed with Staff D, Infection Preventionist and a wound specialist staff. There was no enhanced barrier precaution signage posted outside of Resident 105's room and staff performing wound care did not don a disposable gown prior to providing the wound care. Resident 105 had an indwelling catheter present and a moist wound to their coccyx (tailbone) that was covered with dead tissue and required a dressing to contain drainage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 92 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 0880 In an interview on 03/04/2025 at 9:12 AM, Staff J, Nursing Assistant, explained enhanced barrier precautions was the use of gown and gloves during high contact care activities and were required when a resident had a Level of Harm - Minimal harm or catheter and/or a wound. Staff J stated staff should follow enhanced barrier precautions. potential for actual harm

In an interview on 03/05/2025 at 9:26 AM, Staff E, Resident Care Manager, explained enhanced barrier Residents Affected - Some precautions included use of gloves and a gown during high contact care activities. Staff E further stated EBP should be implemented when a resident had a chronic wound such as a pressure injury to protect the resident.

In an interview on 03/05/2025 at 11:48 AM, Staff D, Infection Preventionist, acknowledged they did not wear

a gown on 02/24/2025 at 10:21 AM when completing Resident 105's wound care, and they should have.

During an observation on 03/03/2025 at 1:23 PM, Staff GG, Nursing Assistant and Staff HH, Nursing Assistant, were in room [ROOM NUMBER] providing cares for a resident on EBP. Signage on the resident's doorway indicated EBP was to be used. Staff GG and HH were not wearing gowns as instructed. When interviewed at 1:31 PM, Staff HH stated they were not aware the resident was on EBP precautions because

they did not see the sign. Staff HH stated they should have worn a gown, and this was important to protect

the residents from the spread of germs.

On 03/04/2025 at 10:01 AM, Staff II, housekeeper, was observed in Resident 74's room without a gown. At 10:02 AM, Staff II walked out of the room and was asked about contact precautions. Staff II looked at the contact precaution sign and stated they should have worn a gown. Staff II stated it was important to wear a gown to protect the residents and themselves from spreading germs.

On 03/04/2025 at 7:51 AM, room [ROOM NUMBER] had a contact precaution sign posted outside the door that instructed staff to perform hand hygiene then put gloves and a gown on prior to entering. Staff JJ, Nursing Assistant (NA), entered room [ROOM NUMBER] without performing hand hygiene or putting gloves or a gown on. Staff JJ exited the room with a meal tray, placed it on the meal cart, then reentered the same room, again without performing hand hygiene, or putting on gloves and/or a gown.

During observation and interview on 03/04/2025 at 9:27 AM, room [ROOM NUMBER] had a contact precaution sign posted outside the door that instructed staff to perform hand hygiene then put gloves and a gown on prior to entering. Staff H, Registered Nurse, entered room [ROOM NUMBER] without performing hand hygiene or putting gloves or a gown on. The sign was pointed out to Staff H. Staff H stated staff only had to put PPE on when they provided care, not when entering the room.

On 03/04/2025 at 10:51 AM, Staff M was observed in room [ROOM NUMBER] applying a treatment to Resident 20's chest and did not wear a gown. At 10:53 AM, Staff M stated they should have worn a gown, and it was important to do so to prevent the spread of infections.

On 03/04/2025 at 11:02 AM, Staff JJ, NA, brought a mechanical lift out of resident 71's room and wheeled it down the hall and parked it. Staff JJ did not clean the machine after using it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 92 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 0880 In an interview on 03/03/2025 at 1:51 PM, Staff D, Infection Prevention, stated they were unaware there were residents on the 400 hall with gastrointestinal issues. Staff D stated it was important to have contact Level of Harm - Minimal harm or precautions in place to ensure an infectious disease was not spread between residents. potential for actual harm

During an interview on 03/04/2025 at 11:46 AM, Staff B, Director of Nursing, stated mechanical lifts needed Residents Affected - Some to be cleaned after each use for infection prevention.

In an observation on 03/05/2025 at 9:21 AM, Staff M had assisted a resident on EBP and removed their PPE

in the doorway. Staff M brought the soiled PPE down the hall and disposed of it in the soiled utility room.

During an interview on 03/05/2025 at 9:28 AM, Staff D stated the PPE should have been placed in a bag and then disposed of to prevent exposure of germs.

During an interview on 03/05/2025 at 3:42 PM, Staff B, Director of Nursing, stated they expected staff to implement and follow EBP when indicated. Staff B acknowledged Staff D should have worn a gown when providing wound care.

During an interview on 03/06/25 at 10:47 AM, Staff D, Infection Prevention, stated staff education regarding

the use of EBP occurred when they hung signage on a resident's doorway. It consisted of letting the staff on

the unit at the time know the resident required EBP. Staff D stated the signage indicated what PPE was needed to be worn and when. Staff D stated there was no formal monitoring of staff compliance with EBP use. They expected the nurse on the unit to monitor the staff. Staff D stated they were comfortable having

the nurses on the units determine when to implement EBP or contact precautions and then notifying them. Staff D stated they had not been notified of any residents on the 400's unit having diarrhea or vomiting and Staff D stated they should have been notified. Staff D stated most of the time, staff asked them when it was ok to take a resident off of isolation precautions.

During an interview on 03/06/2025 at 10:52 AM, Staff A, Administrator, stated they expected staff to implement and follow EBP, as required.

Reference: WAC 388-97-1320(1)(c)(2)(b)

46033

46115

47328

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 92 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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46033

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure staff were educated regarding the risks and benefits of and provided the COVID (a highly contagious viral illness that caused fever, breathing difficulty and potential hospitalization ) vaccine if desired, and failed to ensure minimum documentation was maintained regarding staff COVID vaccination status for 1 of 1 sampled staff (Staff P) reviewed. This failure placed staff and residents at risk of exposure to and illness from COVID-19.

Findings included .

The Centers for Disease Control and Prevention (CDC) Recommended Adult Immunization Schedule 2025 for ages [AGE] years or older retrieved from www.cdc.gov/acip-recs/hcp/vaccine-specific/ documented adults age 19-[AGE] years, or adults age 65 or older who were unvaccinated for COVID-19, were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of COVID-19 vaccine unless contraindicated. Those previously vaccinated before 2024-2025 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of 2024-2025 COVID-19 vaccine unless contraindicated.

During an interview on 03/04/2025 at 5:45 AM, Staff P, Licensed Practical Nurse, stated they had been employed by the facility for about two weeks. They stated they had been offered a COVID vaccine during orientation, but had not received any education and had not signed any type of consent or declination to receive the vaccine.

During an interview on 03/06/2025 at 11:14 AM, Staff D, Infection Prevention Registered Nurse, stated they had started to look back and create a log of the staffs previous COVID vaccinations, but it was not yet completed and they were not the one that offered COVID vaccination to new hires. Staff D stated Human Resources kept vaccination records in employee files.

During an interview and observation on 03/06/2025 at 11:37 AM, Staff P's employment file was reviewed with Staff AA, Human Resources. The file contained only a record of Staff P's tuberculosis screening and the results of their respirator mask fit test. Staff AA stated they kept a separate health folder for each employee for any health related documents given to them by Staff D. Staff AA stated they kept a spreadsheet of any documents they were given, but it was not a comprehensive list of what was required to be kept for each staff member.

Reference: WAC 388-97-1320(1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 92 505383

F-Tag F880

Harm Level: Minimal harm or 47328

Residents Affected: Some as required and provide education based on the outcome of these reviews for 4 of 6 sampled staff (Staff I,

F-F880 for additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 92 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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 47328 potential for actual harm Based on interview and record review, the facility failed to complete annual staff performance reviews yearly Residents Affected - Some as required and provide education based on the outcome of these reviews for 4 of 6 sampled staff (Staff I, BB, N, and UU), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life.

Findings included .

Review of Staff N's, Nursing Assistant (NA), personnel file showed they were originally hired on 09/06/2016. No documentation of a performance evaluation was found.

Review of Staff UU's, NA, personnel file showed they were originally hired on 02/21/2018. No documentation of a performance evaluation was found.

Review of Staff I's, NA, personnel file showed they were originally hired on 01/14/2022. No documentation of

a performance evaluation was found.

Review of Staff BB's, NA, personnel file showed they were originally hired on 03/14/2022. No documentation of a performance evaluation was found.

In an interview on 03/05/2025 at 2:42 PM, Staff AA, Human Resources, acknowledged Staff I, N, BB, and UU did not have a yearly performance evaluation on file, as required.

In an interview on 03/06/2025 at 10:21 AM, Staff B, Director of Nursing, stated evaluations were completed yearly but when the recent facility change of ownership occurred, there was a gap in paperwork. Staff B acknowledged some staff did not have yearly performance evaluations on file, as required.

In an interview on 03/06/2025 at 10:34 AM, Staff A, Administrator, stated they expected performance evaluations to be completed yearly, as required.

Reference WAC 388-97-1680 (1), (2)(a-c)

Refer to

Sullivan Park Care Center

Inspection Findings

F-Tag F607

F-Tag F656

F-Tag F686

F-Tag F689

F-Tag F699

F-Tag F726

F-Tag F880

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