Spokane Health & Rehabilitation
SPOKANE HEALTH & REHABILITATION in SPOKANE, WA — inspection on April 24, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed with them timely.
Staff T stated admission related paperwork should be reviewed and filled
In an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, explained
was informed the survey team requested admission packets for all admits in the past 30 days but only received two packets.
Staff U acknowledged that was correct, they were only able to locate two admission packets for admits in the past 30 days.
Staff U explained the facility had been struggling since January 2025 to complete admission packets timely because of the admissions director/coordinator position vacancy.
Staff U acknowledged residents and/or their representatives would not be fully informed of facility rules, rights, resident conduct and responsibilities, if admission paperwork was not reviewed with them timely.
In an interview on 04/22/2025 at 10:22 AM, Staff A, Administrator, stated the admissions director/coordinator and/or Staff U reviewed and completed the admission agreement packets and the associated paperwork with residents and/or their representatives.
Staff A acknowledged the facility had identified admission packets were not being completed timely but were unable to implement corrective action due to staffing.
Staff A stated they expected admission agreements to be reviewed and signed within 72 hours of an admission.
Reference WAC 388-97-0300 (1)(a), (7)(b) Refer to F-F552, F-F578, F-F579, F-F582, F-F620, and F-F625 for additional information.
505322 04/24/2025
Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205
Review of the September 2024 through March 2025 facility incident log showed Resident 69 sustained a fall on 09/19/2025.
A 09/19/2024 progress note documented Resident 69 reported they fell in their room and had gotten themselves up off the floor.
The resident stated they landed on their right side.
The nurse stated they initiated neuros.
The neuro monitoring sheet revealed 10 omissions and documented the resident was asleep.
Review of Resident 69's record revealed there were no further progress notes regarding the fall. <b[TRUNCATED]
505322 04/24/2025
Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205
According to the 03/31/2025 quarterly assessment, Resident 86 admitted to the facility on [DATE] with diagnoses including weakness. Resident 86 had severe cognitive impairment and was able to verbalize their needs.
Review of the 11/06/2024 hospital history and physical that was provided to the facility during the admission process showed Resident 86 smoked cigarettes every day.
Review of the 11/12/2024 safety assessment showed Resident 86 did not use tobacco products and the facility did not allow resident smoking.
Review of the 11/19/2024 tobacco use care plan showed Resident 86 preferred to smoke cigarettes daily.
Interventions instructed staff to educate the resident about smoking risks and hazards, smoking cessation aids available, remind the resident the facility was non-smoking, there was no smoking on the facility property, and to complete a smoking assessment as needed.
In an interview on 04/16/2025 at 9:24 AM, Resident 86 stated they used to smoke but had not smoked in a while. Resident 86 further stated staff had not spoken to them about smoking and they were unaware the facility was a non-smoking building.
In a follow-up interview on 04/24/2025 at 9:55 AM, Staff A stated they expected staff to accurately assess residents for tobacco use and safe smoking abilities when a resident chose to smoke.
Staff A further stated they also expected staff to implement smoking safety interventions as needed for resident safety.
Reference: WAC 388-97-1060 (3)(g) Refer to F-F572, F-F620, and F-F657 and F-F867 for additional information
505322 04/24/2025
Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205
Review of the 04/19/2025 facility census showed Residents 15, 16, 22, 46, 61, 63, 64, 65, and 85 all
In an interview on 04/22/2025 at 9:30 AM, Staff W, Nursing Assistant (NA), stated the facility was short staffed most of the time and they typically cared for about 15 residents.
During observation on 04/22/2025 at 9:32 AM, Staff KK, NA, was observed asking several NAs for assistance to change the resident in room [ROOM NUMBER] but was unable to get help.
Staff W told Staff KK to ask a manager for help because they needed to help a resident who asked for help. At 9:47 AM Staff KK was observed asking Staff LL, Registered Nurse, for help but Staff LL stated, I am sorry, I can't help you, I am running way behind and asked Staff KK to let them know when they changed the resident in room [ROOM NUMBER] because they needed to apply cream to them.
Staff KK replied, that is what I have been trying to do, I have been trying to get help. At 9:49 AM Staff KK told the resident they would change them alone, since they were unable to find staff to help.
In an interview on 04/23/2025 at 12:07 PM, Staff N, Staffing Coordinator, stated they used a HPD (hours per resident day, minimum staffing requirements) spreadsheet that was based on census, not based on acuity as a guide to see how many staff were needed. A copy of the spreadsheet was requested at that time.
Staff N explained if the facility needed to provide 1:1 monitoring for a resident they would make an exception to the budget and cover the 1:1 needs.
Staff N stated if the facility acuity increased they would have to pull staff from the other units and adjust section assignments to better staff the more acute unit.
Staff N explained the North 100 hall was the easier unit, it was more consistent because the residents were long-term care and the South hall was the more acute unit because that was where residents admitted to and were typically more ill.
Staff N was asked what would happen with staffing if the census increased.
Staff N stated if the census increased they would have to schedule more agency staffing because the facility did not have enough facility staff.
Staff N further stated the facility used agency staffing seven days a week, for both NAs and nurses.
Staff N further stated the facility had a high staff turnover rate and needed more staff.
Staff N acknowledged staff voiced staffing concerns related to the need for more staff, residents with excessively long call light wait times, and residents not changed timely.
In an interview on 04/23/2025 at 12:43 PM, Staff A, Administrator, had a copy of the HPD spreadsheet used by Staff N as a guide for staffing.
Staff A stated the form was just a quick and fast tool used to see if the facility had enough staff, based on census.
Staff A did not provide a copy of the spreadsheet as requested.
In a follow-up interview on 04/24/2025 at 8:34 AM, Staff A, explained the facility reassessed staffing every shift and attempted to balance staffing, census, and acuity.
Staff A stated they used agency staffing daily and staff would bring staffing concerns to them, if there were any.
Staff A stated if/when residents reported excessively long call light wait times, it was reported as an allegation of neglect.
Staff A acknowledged the facility had an increased number of allegations of abuse and/or neglect.
Staff A stated, I am not short staffed.
Reference WAC 388-97-1080 (1), 1090 (1) Refer to F-F658 and F-F919 for additional information.
Findings included .
The American Nurses Association (ANA) is a national professional organization that represents the interests of registered nurses in the United States and sets and promotes high standards of nursing practice to ensure quality and ethical care for patients.
The ANA developed the document, Nursing: Scope and Standards of Practice, with its fourth edition released in 2021.
The resource informs and guides nurses in providing safe, quality, and competent patient care.
The resource outlined and described 18 standards of practice for nursing professionals to follow.
Review of the Nursing: Scope and Standards of Practice resource showed the first six standards included:
1.
Assessment: effectively collect data and resident information that is relative to their condition or situation.
2.
Diagnosis: analyze the data gathered during the assessment phrase, to determine potential or actual diagnoses.
3.
Outcomes Identification: effectively predict outcomes for the resident.
4.
Planning: After identifying a diagnosis and outcomes, develop a plan or strategy to attain the best possible outcome for the resident in need.
5.
Implementation: Implement the identified plan.
This may be done by coordinating care for the residents, such as administering treatment, or implementing/following provider orders.
6.
Evaluation: After implementation, a nurse must monitor and evaluate the patient's progress towards the expected outcome or health goals.
FAILURE TO ASSESS AND IMPLEMENT TREATMENT FOR NON-PRESSURE SKIN CONDITIONS
Review of an undated facility policy titled, Skin Tears, Abrasions, and Bruises Management showed, the nurses completed weekly skin observations and documented their findings in the medical record.
The documentation included the location of the skin condition and its description, to include the size, along with treatment orders and interventions to promote healing.
The policy instructed the nurses to evaluate the effectiveness of the treatment weekly.
505322
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505322 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205
Findings included .
Review of a facility admission agreement showed smoking or vaping was prohibited within and on the grounds of the facility.
The agreement informed the residents that possessing smoking related items, like cigarettes and lighters, was strictly prohibited.
Residents were informed that the facility would provide information and assistance with exploring smoking cessation interventions and products if they had a history of smoking or tobacco use prior to admission to the facility and if so desired.
Violation of the Smoke-Free Facility policy endangered the health and safety of the residents in the facility and was ground for discharge.
Review of the facility policy titled, Smoking Prohibited for Residents But Allowed For Staff dated October 2021, showed if staff found a resident with smoking materials, they were to be given to the nurse who secured them.
The policy further showed staff would notify the provider for each incident of policy violation, document incident in the medical record, and investigated by the facility leadership team to evaluate the scope and potential endangerment to other residents and staff.
The results of the investigation determined the course of action to protect other residents and staff from endangerment, to include re-education of the resident, removal of smoking materials, discussion about smoking cessation support, evaluation of the resident's ability to smoke safely without staff assistance or supervision in a location out of the facility and off the facility grounds, and/or discharge from the facility.
During the entrance conference on 04/14/2025 at 8:42 AM, Staff A, Administrator, stated the facility was a non-smoking facility and there were no residents that smoked.
505322
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505322 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205
Findings included .
Review of the facility assessment reviewed 09/01/2023 showed the assessment was conducted annually to determine and update the capacity to meet the needs of and competently care for the residents during day-to-day operations.
The assessment further showed the facility was licensed for 125 beds, had an average daily census of 84 which included 55 long-term care residents and 29 short term skilled (received higher level of medical care and/or rehabilitation services) residents.
The facility had between two to five admissions during the week and two to three admissions on weekends.
The facility provided care to residents who required specialized care, had mobility impairments, required assistance completing activities of daily living (ADLS) such as toileting, and were incontinent (unintentional leakage of urine or stool).
The assessment showed on average the facility cared for 78 residents with urinary incontinence, 44 residents with bowel incontinence, and 15 residents that required a toileting program.
The assessment further showed the facility had adequate staffing, staffing was reviewed daily to ensure that adequate staff was available to meet the needs of facility residents, the facility employed a full-time staffing coordinator (during weekdays) and used contracted/agency staff when facility staff was unable to meet the needs of [facility] residents.
<Resident 65>
According to the 02/11/2025 significant change assessment, Resident 65 admitted to the facility on [DATE] with diagnoses including syncope (to faint) and collapse.
The assessment further showed Resident 65 required substantial staff assistance for toileting hygiene, was frequently incontinent of urine and always incontinent of bowel. Resident 65 had severe cognitive impairment.
Review of the 02/06/2025 rehabilitation care plan showed Resident 65 required maximum assistance from two staff for transfers and was dependent for toileting.
The 02/06/2025 risk for falls care plan instructed staff to anticipate Resident 65's needs, ensure appropriate footwear, place common items within reach, keep the bed against the wall, and ensure Resident 65 was in areas of high visibility when up in their wheelchair.
Review of the 02/15/2025 allegation of neglect incident investigation showed at 6:54 PM it was reported Resident 65 was not changed.
Review of the February 2025 through March 2025 facility incident log showed Resident 65 sustained falls on 02/05/2025 (1 hours and 50 minutes after admission), 02/13/2025, 02/28/2025, 03/12/2025, and 03/14/2025.
505322
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505322 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Spokane Health & Rehabilitation North 6025 Assembly Spokane, WA 99205
F-F919 for additional information.
505322
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.