SPOKANE, WA - A state health inspection revealed that Spokane Health & Rehabilitation failed to maintain a full-time registered nurse in the critical Director of Nursing position, with the interim director splitting time between administrative duties and other responsibilities, potentially compromising oversight of resident care for the facility's entire population.
Absence of Dedicated Nursing Leadership Creates Oversight Gap
The Washington State Department of Health investigation conducted in April 2025 uncovered a significant leadership vacuum at the North Assembly facility. Despite regulatory requirements mandating a full-time Director of Nursing Services (DNS), the facility had been operating with an interim director who primarily focused on Minimum Data Set (MDS) coordination rather than comprehensive nursing oversight.
During the inspection, administrators identified Staff B as the interim Director of Nursing, a position they had assumed in February 2025. However, interviews revealed that this individual continued to function primarily as the MDS Coordinator, dedicating their 40-hour work week to assessment documentation rather than the broader responsibilities of nursing leadership. The facility's Licensed Practical Nurse serving as Assistant Director of Nursing acknowledged to inspectors that they "tried to implement other interventions, but did not always have a chance to complete reviews."
This arrangement meant critical nursing oversight functions were being handled on a part-time or ad-hoc basis. The interim director admitted they were not on-call after hours, leaving emergency situations and allegations of abuse or neglect to be handled by the Assistant Director of Nursing, who held an LPN license rather than the RN credentials required for comprehensive nursing supervision.
Medical Implications of Inadequate Nursing Leadership
The absence of dedicated RN leadership in a skilled nursing facility creates cascading effects throughout the care delivery system. A full-time Director of Nursing serves as the clinical lynchpin for resident care quality, responsible for developing care protocols, ensuring proper medication management, overseeing infection control measures, and maintaining professional standards among nursing staff.
When this position operates at partial capacity or with divided attention, several critical functions become compromised. Incident report reviews may be delayed or incomplete, potentially allowing dangerous patterns to continue undetected. Staff training and competency assessments may lag, leading to inconsistent care delivery across shifts. Most significantly, the lack of consistent RN oversight can result in delayed recognition of changes in resident conditions that require immediate medical intervention.
The regulatory requirement for a full-time DNS exists precisely because nursing homes serve medically complex populations. Residents typically have multiple chronic conditions, take numerous medications, and require skilled nursing assessments to detect subtle changes that could indicate serious health deterioration. Without consistent RN leadership providing systematic oversight, facilities risk missing early warning signs of conditions like sepsis, medication interactions, or cognitive decline.
Administrative Confusion Compounds Leadership Issues
The inspection revealed concerning discrepancies in how facility leadership understood and represented the nursing management structure. The Administrator claimed the interim DNS was "available to work 40 hours a week as a DNS if needed," suggesting a fundamental misunderstanding of regulatory requirements. The position requires actual performance of DNS duties on a full-time basis, not merely availability.
When inspectors requested payroll documentation to verify the hours worked by the interim DNS from February 2025 forward, no documentation was provided. This absence of basic employment records raises questions about the facility's administrative practices and ability to demonstrate compliance with staffing requirements.
The facility's approach to after-hours coverage further illustrated the leadership gap. Emergency situations and allegations of abuse or neglect—precisely the types of situations requiring experienced RN judgment—were being handled by an LPN rather than the designated DNS. While LPNs provide valuable care within their scope of practice, they lack the advanced assessment skills and regulatory authority needed for comprehensive nursing oversight.
Industry Standards Demand Consistent RN Leadership
Washington Administrative Code 388-97-1080 explicitly requires skilled nursing facilities to designate a registered nurse to serve as Director of Nursing on a full-time basis. This standard reflects nationwide recognition that nursing home residents require consistent, professional nursing oversight given their medical complexity and vulnerability.
Standard practice in well-functioning skilled nursing facilities involves a DNS who dedicates their entire professional focus to nursing operations. This includes conducting regular rounds to assess care quality, reviewing clinical indicators for trends requiring intervention, mentoring nursing staff, and serving as the primary clinical resource for physicians and families. The DNS typically participates in daily stand-up meetings, reviews all significant incidents within 24 hours, and maintains 24/7 availability for consultation on complex clinical decisions.
The MDS Coordinator role, while important for regulatory compliance and reimbursement, represents a distinct function that facilities typically staff separately. MDS assessments involve detailed documentation of resident conditions for Medicare and Medicaid reporting purposes. While this work requires clinical knowledge, it differs fundamentally from the active oversight and leadership responsibilities of a DNS. Combining these roles inevitably compromises one or both functions.
Systemic Risks Affect All Facility Residents
The inspection report specifically noted that this failure "placed all residents at risk of lack of RN oversight for care provided, unmet care needs, and a diminished quality of life." This language reflects the pervasive nature of the deficiency—inadequate nursing leadership affects every aspect of facility operations.
Without consistent DNS oversight, facilities often experience gradual degradation in care standards. Documentation becomes inconsistent, making it difficult to track resident conditions over time. Communication between shifts may break down, leading to missed treatments or delayed responses to physician orders. Staff morale typically suffers when clear clinical leadership is absent, potentially increasing turnover and further destabilizing care delivery.
The quality-of-life implications extend beyond medical care. A properly functioning DNS ensures residents receive individualized attention, that their preferences are incorporated into care plans, and that the facility maintains a therapeutic environment. When nursing leadership operates at partial capacity, these person-centered care elements often receive insufficient attention.
Pattern of Non-Compliance Raises Broader Concerns
The facility's inability or unwillingness to provide basic payroll documentation when requested by inspectors suggests potential broader compliance issues. Maintaining accurate employment records represents a fundamental administrative function. The absence of such documentation for a key leadership position raises questions about record-keeping practices throughout the facility.
Furthermore, the Administrator's apparent confusion about regulatory requirements for the DNS position indicates possible gaps in understanding of other critical regulations. If facility leadership misunderstands basic staffing requirements that have been in place for decades, similar misunderstandings may affect other areas of regulatory compliance.
The revelation that the LPN Assistant Director of Nursing handled most DNS duties, despite lacking the required RN license, represents a form of practice beyond scope that could have legal implications beyond regulatory citations. State nursing practice acts clearly delineate the responsibilities that require RN licensure, and facilities that allow LPNs to assume these duties risk both regulatory sanctions and potential liability issues.
Additional Issues Identified
The inspection identified this deficiency at a scope and severity level indicating minimal harm or potential for actual harm affecting many residents. While classified as "minimal harm," the systemic nature of inadequate nursing leadership creates conditions where more serious deficiencies could develop and go undetected. The facility's reliance on an LPN for after-hours clinical decisions and the split focus of the interim DNS between MDS coordination and nursing oversight represented ongoing regulatory violations requiring immediate correction.
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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