SPOKANE, WA - Federal inspectors documented systematic staffing failures at Spokane Health & Rehabilitation during an April 2025 inspection, finding that residents consistently experienced delays of up to three hours for basic care needs. The investigation revealed nine residents who faced documented neglect incidents, with multiple complaints of inadequate assistance for toileting, medication administration, and mobility needs.
The 125-bed facility, which maintains an average daily census of 84 residents, faced citations after inspectors found that staffing levels failed to match the facility's own assessment of resident acuity and care requirements.
Residents Report Extended Wait Times for Basic Care
Multiple residents provided detailed accounts of prolonged delays in receiving assistance. One resident reported waiting three hours to have their incontinence brief changed—an occurrence the resident stated happened at least once weekly. When the resident raised concerns with staff, they were told the facility was "shorthanded."
Another resident described waiting 45 minutes for juice after experiencing low blood sugar during the night. This resident, who has diabetes, expressed concern about potential delays during future hypoglycemic episodes, which can become medical emergencies requiring prompt intervention.
Delayed response times pose particular risks for residents with diabetes. When blood sugar drops below normal levels, the body and brain cannot function properly. Without quick treatment—typically consuming 15-20 grams of fast-acting carbohydrates—blood sugar can continue to fall, potentially leading to confusion, loss of consciousness, or seizures. The standard medical protocol calls for immediate intervention when hypoglycemia occurs.
A February 2025 Resident Council meeting documented facility-wide concerns about "excessively long call light wait times." In an April 2025 council meeting, residents reported wait times reaching one hour, with staff sometimes unable to locate a second caregiver when two-person assistance was required for safe transfers or care procedures.
Incontinence Care Failures Documented
Federal inspectors identified multiple instances where residents remained in soiled briefs for extended periods. On April 1, 2025, two separate residents reported they had not been changed all day. Investigation revealed one resident's bed was "soaked" after going unchanged since 7:30 AM. Another resident was found with their brief "completely soaked through and heavy."
In a separate March 26 incident, a resident was discovered with their bed and brief "completely soaked with a wet brown ring of urine." The resident did not have access to their call light at the time.
Prolonged exposure to urine and feces creates significant health risks. The skin's protective barrier breaks down when exposed to moisture for extended periods, increasing susceptibility to pressure injuries. Urine contains urea and ammonia, which can irritate and damage skin tissue. When combined with feces—which contains bacteria and digestive enzymes—the risk of skin breakdown accelerates substantially. For residents who are immobile or have limited mobility, these conditions create ideal circumstances for pressure ulcer development, which can progress from superficial redness to deep tissue damage involving muscle and bone.
The facility's February 2025 assessment showed it regularly cared for 78 residents with urinary incontinence, 44 residents with bowel incontinence, and 15 residents requiring structured toileting programs. Proper incontinence management requires checking and changing residents at regular intervals—typically every two hours or more frequently based on individual needs.
Mobility Needs Went Unmet
One resident who required a mechanical lift (Hoyer) for transfers reported being "stuck in bed" multiple days because staff told them they were "shorthanded." The resident had a physician's order to be out of bed in their wheelchair twice daily for at least one hour.
Medical records revealed this resident failed to receive their prescribed out-of-bed time on 10 out of 29 documented occasions in late March, with only three refusals documented. In the first half of April, the resident missed out-of-bed time 19 out of 30 times, again with only three documented refusals.
On April 17, the same resident reported being told "most of the Hoyers were not working" and only one lift was functional. Staff indicated other residents needed the equipment, leaving this resident in bed all day. The resident stated: "I am stuck in bed for the day. I am not happy. I do not like to be in bed all day long."
Extended bed rest carries serious medical consequences. Prolonged immobility leads to muscle atrophy, decreased bone density, increased risk of blood clots in the legs (deep vein thrombosis), and potential respiratory complications from decreased lung expansion. For residents taking diuretics—as this resident was—remaining in bed rather than being upright can affect fluid distribution and cardiovascular function. Additionally, pressure points face constant compression when a resident remains in one position, significantly increasing pressure ulcer risk.
An observation on April 16 found 38 out of 60 residents on the long-term care unit eating lunch in bed, suggesting widespread limitations in getting residents up and dressed.
Fall Incidents Linked to Staffing Issues
One resident sustained a fall with a hand laceration on April 7 after attempting to self-transfer into bed. During an interview, the resident explained: "I did not want to keep waiting for [staff] to help me, I wanted to get in bed, so I did it myself." This same resident had previously described wait times of up to one hour for assistance—a delay occurring approximately three weeks before the fall.
Medical records showed this resident required substantial to maximal assistance for toileting and transfers. When residents who need assistance attempt transfers independently due to delayed staff response, the risk of falls and injuries increases substantially.
Another resident who required maximum assistance from two staff members for transfers sustained five documented falls between February 5 and March 14, 2025. A different resident requiring substantial staff assistance experienced eight falls between November 2024 and March 2025.
Respiratory Equipment Failures
Inspectors found that staff failed to ensure one resident's CPAP machine (continuous positive airway pressure device) remained functional for approximately six weeks. The resident had diagnoses including heart failure, chronic obstructive pulmonary disease, and obstructive sleep apnea.
Despite treatment records indicating nursing staff documented CPAP use throughout March and early April 2025, the resident reported the machine had not been working since admission. Provider notes documented the resident had not used their CPAP "for over 6 months."
The resident told inspectors: "Since they were unable to use it, they had difficulty falling asleep and woke up in the night and were unable to fall back asleep." The resident stated they informed staff the device was not working but received no assistance obtaining a replacement.
CPAP therapy is essential for residents with obstructive sleep apnea, particularly those with concurrent heart and lung conditions. During sleep apnea episodes, breathing repeatedly stops and starts, causing blood oxygen levels to drop. This places additional strain on the cardiovascular system. For someone with existing heart failure, untreated sleep apnea can worsen the condition, as the heart must work harder during periods of oxygen deprivation.
Central Supply staff confirmed that obtaining a rental CPAP unit required only a physician's order with settings and correct mask size, typically arriving the same day. Staff indicated no one had requested a CPAP for this resident despite the documented dysfunction.
Prosthesis Care Inadequacies
A resident who received a prosthetic leg in December 2024 was unable to use the device due to lack of staff assistance and training. The resident had expressed wanting to remain at the facility until receiving their prosthesis, then hoped to "walk so they could discharge from the facility."
Records from the prosthesis clinic showed the resident received detailed instructions on applying and removing the device, proper wear time, cleaning requirements, and skin inspection protocols. The clinic recommended gradual wear time—starting at one to two hours daily and building up to eight hours—with the device removed at night.
However, physical therapy staff reported the resident "would not commit to being out of bed beyond trying to stand during their therapy session and would not wear the prosthetic limb except during the therapy treatment time." After therapy discharge in January 2025, multiple staff members reported never seeing the resident use or wear the prosthesis.
The resident's care plan contained no documentation acknowledging the prosthesis, instructions on wear time, proper fitting to prevent skin breakdown, device care, or use of the compression shrinker and limb socks. Medical provider notes from December 2024 through April 2025 made no mention of the prosthesis.
Successful prosthesis use requires consistent practice and gradual acclimation. The residual limb must adapt to bearing weight and pressure in new ways. Without regular use, muscles do not develop the strength needed for walking, balance remains impaired, and the resident's goal of independent mobility and facility discharge becomes unattainable. The clinic representative stated the risk of not wearing the prosthesis daily was "not training your body to use it which can keep you wheelchair bound."
Dialysis Communication Breakdowns
For one resident receiving dialysis three times weekly, inspectors found the facility maintained inaccurate information about the dialysis center location, treatment days, and access site type. Medical orders indicated an arteriovenous fistula in one location, when the resident actually had a central line catheter in the chest—requiring entirely different monitoring protocols.
The resident reported the facility did not communicate with the dialysis center, stating: "I have to make sure I have all my records with me, so they [dialysis] know what's been happening." Medical records contained no dialysis treatment logs documenting the resident's sessions, vital signs, fluid removal, or complications—information essential for monitoring post-dialysis status and ensuring resident safety.
Facility's Staffing Assessment System
The facility's staffing coordinator stated the facility used an "HPD spreadsheet" based on census—not resident acuity—as a guide for determining staff numbers. The coordinator acknowledged that if acuity increased, the facility would "pull staff from other units" rather than adding additional personnel.
The coordinator stated the facility relied on agency staffing seven days a week for both nursing assistants and nurses, had a "high staff turnover rate," and "needed more staff." The coordinator acknowledged staff frequently voiced concerns about inadequate staffing, residents experiencing long call light wait times, and residents not being changed in a timely manner.
Nursing assistants interviewed reported typically caring for approximately 15 residents each. One nursing assistant was observed asking multiple colleagues for assistance changing a resident but was unable to find available help. When the NA requested assistance from a registered nurse, the nurse responded: "I am sorry, I can't help you, I am running way behind." The nursing assistant eventually told the resident they would perform the two-person task alone.
The facility administrator stated staffing was reassessed every shift and the facility attempted to "balance staffing, census, and acuity." However, the administrator acknowledged the facility had experienced an increased number of abuse and neglect allegations. When asked about staffing adequacy, the administrator stated: "I am not short staffed."
Pattern of Neglect Allegations
Facility incident logs revealed 49 separate neglect allegations between October 2024 and April 2025—an average of approximately seven per month. The logs also documented seven abuse allegations, four resident-to-resident altercations, and three misappropriation allegations during this same period.
Inspection Findings
Federal inspectors cited the facility for failing to provide sufficient nursing staff to meet resident needs and care plan requirements. The citations noted that staffing failures placed all residents at risk for "potentially avoidable accidents, unmet care needs, and diminished quality of life."
Additional citations addressed failures in respiratory care, prosthesis assistance, and dialysis service coordination.
The facility's most recent assessment, completed September 2023, stated the facility had "adequate staffing" and that "staffing was reviewed daily to ensure that adequate staff was available to meet the needs of facility residents." The assessment documented an average census of 84 residents, including 55 long-term care residents and 29 short-term skilled residents.
Readers can access the complete inspection report through the Centers for Medicare & Medicaid Services Care Compare website for additional details about cited deficiencies and the facility's correction plans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manor Care Health Services-spo from 2025-04-24 including all violations, facility responses, and corrective action plans.
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