The visitor described watching staff nearly cause head injuries during improper transfers at Spokane Valley Health and Rehabilitation of Cascad. "I have never seen two people in there with [the resident] and I come down there quite often," the family member told state inspectors on November 3.
The violations put the resident at serious risk. During one transfer, the visitor saw the resident "almost hit their head on the headboard and, I just cringed." In another incident, they watched staff "just lift [their] legs from under the bed and [the resident] falls over onto [their] right side."
When the visitor raised concerns with the resident, they were told staff "sometimes" used two people for transfers. The family member's response was direct: "Sometimes isn't enough."
Multiple staff members admitted to inspectors they routinely violated the resident's care plan. Staff member H, interviewed October 31, said they "usually transferred Resident 3 by themself, Always one person since taking care of [the resident]."
The nursing assistant knew proper protocol required two people for mechanical lifts but rationalized solo transfers with sit-to-stand equipment. "It just happens that way," they told inspectors, admitting they never asked other staff for assistance with transfers or positioning the resident in bed.
Staff member J revealed the extent of unsafe practices during their anonymous interview. When unable to find help, they would "physically pick them up and put them in bed but only if they were semi-mobile." The worker acknowledged transferring residents alone with sit-to-stand lifts "every once in a while."
Another anonymous staff member explained why safety protocols were ignored. Some workers "did not use the mechanical lifts because they were physically big enough to lift and transfer the residents on their own."
Even registered nurse Staff K admitted to solo transfers, telling inspectors they assisted the resident "by myself numerous times." The nurse described the physical challenges: "Turning [the resident] in bed you can do with one person. You have to go slow and easy and [the resident's] legs are heavy, so you have to be a strong person."
The resident required heightened assistance due to deteriorating condition. Staff K explained that initially, workers used a Hoyer mechanical lift before transitioning to a sit-to-stand lift "and had been using a sit-to-stand for a couple of months." Staff J noted the resident "had become more dependent on the staff and required more physical assistance."
When confronted with inspection findings on November 4, facility administrator Staff A confirmed the violations. The resident "required two-person assistance for bed mobility and transfers because of weakness to the legs and decreased mobility," the administrator acknowledged.
Asked directly whether Staff H had followed the care plan requiring two people for transfers and bed mobility, the administrator's answer was unequivocal: "No."
The pattern extended beyond a single worker. Staff members described a facility culture where safety protocols were treated as suggestions rather than requirements. Workers made individual decisions about when to follow care plans based on their own physical capabilities or convenience.
The inspection revealed a fundamental breakdown in resident safety oversight. Despite clear care plan requirements and staff awareness of proper procedures, multiple workers consistently chose to work alone rather than seek required assistance.
The resident's family member, present multiple times daily, never witnessed proper two-person transfers despite months of observation. Their testimony painted a picture of systemic neglect of basic safety protocols designed to prevent injuries during vulnerable moments of care.
Federal regulations require nursing homes to provide services according to each resident's comprehensive care plan. The facility's own administrator confirmed this resident's plan specifically required two-person assistance for all transfers and bed mobility due to leg weakness and decreased mobility.
The violations occurred despite staff training on proper transfer techniques and mechanical lift usage. Workers understood the rules but chose to ignore them, creating unnecessary risk for a resident whose condition made them particularly vulnerable to falls and injuries during transfers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spokane Valley Health and Rehabilitation of Cascad from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Spokane Valley Health and Rehabilitation of Cascad
- Browse all WA nursing home inspections