The resident had just returned from a medical appointment in Idaho and desperately needed to use the bathroom. But at Spokane Health & Rehabilitation, finding help had become a crisis.
Federal inspectors found the facility failed to provide adequate staffing for nine of 17 residents they reviewed, leaving vulnerable people in soiled beds for hours and creating dangerous delays in basic care. The investigation, completed April 24, documented a pattern of neglect affecting residents across the 125-bed facility.
Resident 16 told inspectors they had waited up to an hour for assistance just three weeks earlier. "I wish they could do something to level out this staffing issue," the cognitively intact resident said. "It is not the resident's fault they don't have enough staff, they got to be able to hire some more people."
The desperation led to dangerous self-rescue attempts. Resident 16 fell while trying to transfer themselves to bed rather than wait for help, sustaining a skin tear to their left hand. "I did not want to keep waiting for staff to help me," they explained. "I wanted to get in bed, so I did it myself."
Soaked Beds and Hour-Long Waits
The staffing crisis created a cascade of neglect incidents. On March 26, investigators found Resident 64 "unhappy and yelling" because staff hadn't checked or changed them. The resident's bed and brief were "completely soaked with a wet brown ring of urine."
Resident 61 reported going unchanged from 7:30 AM until 2:15 PM, leaving their bed soaked. "The facility absolutely did not have enough staff," they told inspectors. "Day shift was extremely short staffed, and weekends were worse than other days."
The facility's own incident logs revealed the scope of the problem. Between October 2024 and April 2025, staff documented dozens of neglect allegations, including multiple reports in February alone of residents not being changed during night shifts.
Resident 46's family member told inspectors the facility "needed more staff" and that their loved one "did not get help needed." Investigation records showed Resident 46 hadn't been changed by night shift staff and was found "soiled through brief" the next morning.
Medical Emergencies in Slow Motion
The understaffing created dangerous delays even for urgent medical needs. Resident 22, a diabetic, experienced low blood sugar during the night but had to wait 45 minutes for staff to bring a glass of juice. "I don't want staff to take forever if and when my blood sugar drops again," they told inspectors.
For residents requiring mechanical lifts, the equipment shortage compounded staffing problems. Resident 85 needed a Hoyer lift to get out of bed twice daily per doctor's orders, but records showed they remained bedridden 19 out of 30 times in early April. Only three refusals were documented.
On April 17, staff told Resident 85 that most Hoyer lifts weren't working. "Only one Hoyer was in working order, but other residents needed to get up," according to the incident report. Resident 85 spent the entire day in bed.
"I am stuck in bed for the day. I am not happy," Resident 85 told inspectors. "I do not like to be in bed all day long. My preference is to be up in my chair for a while."
The next day, Resident 85 remained bedridden again. "Staff told them they were shorthanded," the report noted. "I was pissed," the resident said.
Staff Scrambling for Basic Help
Inspectors witnessed the staffing crisis firsthand. On April 22, they observed nursing assistant Staff KK desperately seeking help to change a resident who required two people for safe care.
Staff KK asked multiple nursing assistants but found no one available. When they approached the registered nurse, Staff LL replied: "I am sorry, I can't help you, I am running way behind." Staff KK ultimately told the resident they would attempt the two-person job alone.
"That is what I have been trying to do, I have been trying to get help," Staff KK explained to the nurse.
Confidential Staff A told inspectors the North 100 hall housed "heavy care" residents but was "normally staffed with only four nursing assistants." That wasn't enough, they said. "It was hard to get things done."
Nursing assistant Staff W confirmed they typically cared for about 15 residents each. "The facility was short staffed most of the time," they said.
Management's Response
The facility's staffing coordinator acknowledged serious problems during interviews. Staff N admitted the facility had "a high staff turnover rate and needed more staff." They confirmed using agency workers seven days a week for both nursing assistants and nurses.
Staff N said they used a basic spreadsheet based on census numbers, not resident acuity levels, to determine staffing needs. When asked what would happen if more residents were admitted, Staff N replied they would "have to schedule more agency staffing because the facility did not have enough facility staff."
The coordinator acknowledged receiving complaints about "residents with excessively long call light wait times, and residents not changed timely."
Administrator Staff A initially claimed adequate staffing during the April 24 interview. "I am not short staffed," they insisted, despite the documented evidence of neglect allegations and resident complaints.
A Pattern of Multiple Falls
The understaffing contributed to numerous resident falls. Resident 65, who required maximum assistance from two staff for transfers, fell five times between February and March 2025, including once just 1 hour and 50 minutes after admission.
Resident 46 sustained eight falls between November 2024 and March 2025. Their family member connected the falls to inadequate staffing levels.
During one April observation, inspectors counted 38 out of 60 long-term care residents eating lunch in their beds, suggesting widespread difficulty getting residents up and mobile.
The Resident Council, a group that meets to discuss care concerns, told inspectors the facility "did not have enough staff" and that residents experienced "excessively long call light waiting times, up to an hour." Sometimes staff couldn't find a second person to help with care requiring two people.
Resident 15 waited up to three hours to have their brief changed, "which happened at least once a week." When they complained to staff about the delays, "Resident 15 was told they are shorthanded."
"I am not impressed with resident care because the facility was totally understaffed especially when residents required a lot of care," Resident 15 said. "They can never find staff if we need help."
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
- View all inspection reports for Spokane Health & Rehabilitation
- Browse all WA nursing home inspections
