Sullivan Park Care Center
SULLIVAN PARK CARE CENTER in SPOKANE, WA — inspection on March 6, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
<Resident 63>
According to the 02/03/2025 quarterly assessment, Resident 63 had severe cognitive impairment with inattention and disorganized thinking. Resident 63 had worsening wandering that significantly intruded on the privacy or activities of others and placed Resident 63 at significant risk of getting into potentially dangerous places.
Review of the 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.
505383
Form Approved OMB
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
Findings included .
<Electrical Appliances>
Review of a 12/16/2024 admission assessment showed Resident 78 admitted to the facility on [DATE] 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.
505383
Form Approved OMB
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
Findings included .
<Resident 44>
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.
505383
Form Approved OMB
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
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.
<Resident 6>
Review of a 02/17/2025 assessment showed Resident 6 admitted to the facility on [DATE] 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.
<Resident 102>
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.
505383
Form Approved OMB
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
Findings included .
<Resident 6>
Review of an admission assessment showed Resident 6 admitted to the facility on [DATE].
The medical record showed the resident was treated with medications for heart failure, high blood pressure, and atrial fibrillation (an irregular and often very rapid heart rhythm).
Additionally, the resident was diagnosed as legally blind.
Review of the resident's baseline care plan showed no goals or interventions to address the provider orders for the management of the cardiovascular diagnoses or the vision impairment.
<Resident 411>
Review of the medical record showed Resident 411 admitted to the facility on [DATE].
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).
505383
Form Approved OMB
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
Findings included .
On [DATE] 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].
2) an unopened, full sealed bottle of liquid Lorazepam (a controlled anti-anxiety medication) that was filled on [DATE].
3) a medication card contained 10 Dronabinol 5 milligram (mg) capsules (used to treat nausea and stimulate appetite) was filled on [DATE] and had expired on [DATE].
Resident 998
4) an unopened, full sealed bottle of liquid Lorazepam that was filled on [DATE].
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] (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] (over seven months ago) and had been on the 100 Hall.
During an interview on [DATE] at 11:29 AM, Staff P, LPN stated there were currently no narcotics on the 100 Hall that were in the refrigerator.
505383
Form Approved OMB
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
Findings included .
<Staff N>
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.
<Staff UU>
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.
<Staff I>
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.
<Staff BB>
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