Spokane Health & Rehabilitation: Prosthesis Care Failures - WA
The resident, identified in inspection records only as Resident 31, had an amputation of the left lower extremity. A prosthetics clinic fitted them with a new leg on December 6, 2024, and sent the facility detailed instructions: how to clean the liner, how to manage the limb sock thickness, how to inspect the skin, when to call the clinic if something felt wrong. The clinic expected the facility to wear the prosthesis daily, as long as there were no sores or pain, and to use a shrinker sock when the prosthesis was off to control swelling and reduce phantom pain.
None of that made it into the care plan. None of it made it into a provider order.
Inspectors reviewed eleven separate physician notes written between December 31, 2024 and April 9, 2025. Not one of them mentioned the prosthesis existed.
The care plan on file dated back to June 2024, before the prosthesis was ever issued. It noted the amputation and said the wound would heal without complications. It said nothing about wear time, nothing about fit checks, nothing about what staff should do with the shrinker or the limb sock, and nothing about how to recognize problems before they became serious.
The prosthetics clinic had told the facility directly: if you see issues with fit, pain, or skin breakdown, call us. The risk of not wearing the prosthesis daily, a clinic contact told inspectors, was "not training your body to use it which can keep you wheelchair bound."
Staff interviewed by inspectors in April 2025 described a resident who was essentially never seen using the leg. A nursing assistant said they transferred Resident 31 out of bed with a mechanical lift once a day and never saw the resident walk. "I don't think [they] really use it during the day," the aide said. They applied the shrinker in the morning. Night staff took it off. The prosthesis itself stayed off.
A licensed practical nurse on the unit said the same thing, more plainly: "Never really seen [the resident] walk." The nurse said occasionally the resident would ask for the prosthetic to be put on, and aides could do that. No one described any system for making it happen.
The physical therapist who had worked with Resident 31, identified in the report as Staff FF, told inspectors the resident had resisted wearing the prosthesis outside of therapy sessions. "It's kind of a behavior thing," the therapist said. "It was a lot of work to get out of bed. It was painful for [the resident], too, to a certain degree." The therapist described the resident as "not receptive to being out of bed for a longer period of time." After therapy was discharged at the end of January 2025, the therapist said: "I have not seen [the resident] with the prosthetic on."
That discharge came with its own complications. A physical therapy summary from January 30, 2025 noted that Resident 31 could apply and remove the prosthesis with minimal help, but would not commit to being out of bed beyond trying to stand during therapy, and would not wear the leg outside of treatment time. The prosthetics clinic learned through that same period that all therapy had been stopped, and noted in a January 29 visit that the resident was wearing the prosthesis for thirty minutes, three times a week while sitting.
The therapy notes from December through April showed a different picture than the nursing staff described. A December 12 note said the resident had stood with the prosthesis in therapy. December 19 showed continued work. December 23 noted improvements. January 28 showed the resident was upset when told therapy was ending, saying they wanted to use the prosthetic leg more. The resident agreed to try getting out of bed more to build stamina.
Inspectors found no documented refusals of care in the progress notes from December 12, 2024 through April 20, 2025.
When the unit manager, identified as Staff F, was told what inspectors found on April 21, 2025, she said she was not aware of any refusals. "The resident was very eager to have it," she said. She believed the resident put the shrinker on themselves, and that nursing staff had helped at first. She acknowledged the care plan did not reflect the current status of the residual limb, and when pressed, acknowledged the medical record contained no directions on prosthesis care, no instructions from the clinic, no guidance on wear time, no skin inspection protocol, nothing.
"I believe that area is healed," she said of the stump.
The clinic that built the prosthesis had a different concern. Their job was to build the leg and teach the resident how to use it. The facility's job was to carry that forward every day, to make sure the limb sock was the right thickness, to watch the skin, to call if something shifted or rubbed or hurt. That handoff never happened in any documented form.
Resident 31 had been eager enough to get the prosthesis that they were upset in January when therapy ended before they felt ready. Four months later, a nursing assistant was lifting them in and out of bed with a mechanical lift, had never seen them walk, and didn't think they used the leg at all during the day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spokane Health & Rehabilitation from 2025-04-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 31, 2026 · Our methodology
SPOKANE HEALTH & REHABILITATION in SPOKANE, WA was cited for violations during a health inspection on April 24, 2025.
The resident, identified in inspection records only as Resident 31, had an amputation of the left lower extremity.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.