Spokane Health & Rehabilitation
SPOKANE HEALTH & REHABILITATION in SPOKANE, WA — inspection on April 24, 2025.
Found 9 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
Findings included .
ENHANCED BARRIER PRECAUTIONS
According to a 06/28/2024 Centers for Disease Control article, EBP involved gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). EBP expanded the use of gown and gloves beyond anticipated blood and body fluid exposures. EBP directed staff to don (put on) gowns and gloves when dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting.
<Resident 6>
Review of the 02/23/2025 significant change assessment showed Resident 6 admitted to the facility on [DATE] with medically complex conditions.
The assessment showed Resident 6 had moderately impaired cognition and an indwelling urinary catheter.
Review of the medical record showed the staff treated Resident 6 for wounds to the right foot.
An observation on 04/14/2025 at 11:31 AM showed Resident 6 in their wheelchair, and the urinary catheter bag was covered. No EBP signage was observed near Resident 6's room to show the staff needed to don PPE prior to entering the room when providing high contact activities.
<Resident 88>
Review of a 03/22/2025 admission assessment showed Resident 88 admitted to the facility on [DATE] with medically complex conditions, including an MDRO.
The assessment showed the resident was cognitively intact and received dialysis (a procedure that removed waste products and excess fluid from the blood when the kidneys failed to do so).
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 .
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
F-F657 for additional information.
In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were unaware there were issues with care conferences not being offered or held.
Staff A asked how they were out of compliance, and it was explained that 12 residents were reviewed and only one resident had a care conference for those that were scheduled in February 2025.
Staff A stated the PIP included looking at the scheduled care conferences daily and asking if they had been completed and the staff said they were.
Staff A did not check to see that the care conferences had been completed.
-Admission Processes
See
F-F658 for additional information.
Similar deficiencies were cited during the annual recertification survey dated 01/19/2024 and during a complaint investigation on 05/29/2024.
In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were not aware there were concerns with monitoring after falls occurred.
Staff A stated the previous Director of Nursing (DNS) completed a PIP in December 2024 in which they performed audits and educated the staff.
Staff A stated the DNS felt the PIP was successful as they reduced their number of falls from 28 to 23 and they no longer needed to do a full QAPI on falls.
-Care Conferences
See
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 .
<Resident 15>
The 01/01/2025 quarterly assessment documented Resident 15 was cognitively intact and was able to make their needs known.
On 04/16/2025 at 12:05 AM, Resident 15's meal was observed.
They were served barbequed ribs and mashed potatoes. Resident 15 stated they were upset.
They had ordered the shrimp scampi and filled out their menu twice. Resident 15 attempted to eat the ribs and stated they were going return their meal.
On 04/17/2025 at 12:13 AM, Resident 15's meal included a chicken patty, green beans and mashed potatoes. Resident 15 stated they had ordered the alternate menu choice but their menu must have been lost.
They stated they had filled out their menu twice and had given it to an aide.
They were going to request a sandwich.
On 04/18/2025 at 8:47 AM, Resident 15 stated they were frustrated because they were supposed to get boiled eggs but was served scrambled eggs.
On 04/18/2025 at 12:34 PM, Resident 15 had pudding and fluids on their meal tray.
They stated they had been given fish and that was not what they ordered. Resident 15's visitor stated Resident 15 did not eat rice, but it was served to them. Resident 15 stated they were tired of getting sent the wrong things despite filling out the menus.
<Resident 89>
The 01/23/2025 significant change in condition assessment documented Resident 89 was cognitively intact and was able to make their needs known.
On 04/18/2025 at 8:49 AM, Resident 89 stated they did not get their yogurt and milk and got orange juice instead of apple juice.
On 04/18/2025 at 12:32 PM, Resident 89 stated they were upset because they did not get yogurt again. Resident 89's tray card instructed staff to send yogurt on the meal trays.
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 .
According to the 03/26/2025 admission assessment, Resident 17 had diagnoses which included heart failure (where the heart cannot pump enough blood for the body's needs), Chronic Obstructive Pulmonary Disease (COPD, a lung disease that causes chronic respiratory symptoms and airflow limitations) and obstructive sleep apnea (OSA, a condition where the airway becomes blocked during sleep, causing pauses in breathing).
The resident was alert and able to make their needs known.
A review of the medical record showed the following provider orders for use of their CPAP machine:
1) CPAP home setting, to be worn at bedtime every evening and night shift, started on 03/20/2025.
2) CPAP on at bedtime, started on 03/20/205.
3) CPAP mask cleaning every morning on day shift, started on 03/21/2025.
4) Change CPAP tubing on night shift, every month on the 19th, started on 04/19/2025.
Resident 17's Respiratory care plan, initiated on 04/02/2025, documented they were at risk for respiratory complications due to OSA.
One of the interventions was to assist the resident as needed to administer/setup their CPAP machine.
Review of the March 2025 Treatment Administration Record (TAR) documented the following:
1) CPAP home setting every evening and night, initialed by nurse as done on evening and night shift from 3/20/25 through 03/31/2025.
2) CPAP on at bedtime, initialed by the nurse as done on night shift from 3/20/25 through 03/31/2025.
3) CPAP mask cleaning every morning on day shift, initialed by the nurse as done on from 3/21/25 through 03/31/2025.
Review of the April 2025 TAR documented the following:
1) CPAP home setting every evening and night, initialed by nurse as done on evening and night shift from 04/01/2025 through 04/14/2025.
The only exception was the 04/09/2025 evening shift slot was blank.
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 .
<Staff K >
Review of Staff K's, Nursing Assistant, personnel file showed they were hired on 04/01/2023. No documentation of a performance evaluation was found.
<Staff L>
Review of Staff L's, Nursing Assistant, personnel file showed they were hired on 11/29/2023. No documentation of a performance evaluation was found.
<Staff M>
Review of Staff M'S, Nursing Assistant, personnel file showed they were hired on 12/06/2023. No documentation of a performance evaluation was found.
In an interview on 04/23/2025 at 3:18 PM, Staff A, Administrator, acknowledged Staff K, L, and M did not have performance evaluations on file.
Staff A stated they expected staff to complete performance evaluations yearly, as required.
Reference WAC 388-97-1680 (1), (2)(2-c)
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 .
In an interview on 04/14/2025 at 8:34 AM, Staff A, Administrator, identified Staff B as the interim Director of Nursing.
Staff A stated the facility had no nurse staffing waivers in place.
Review of the facility staff list provided on 04/15/2025 showed Staff B was the MDS (Minimum Data Set, standardized resident assessment tool) RN/DNS.
Staff C was identified as Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON).
In an interview on 04/18/2025 at 11:29 AM, Staff C, explained they reviewed the facility incident reports after they were completed by floor staff, they tried to implement other interventions, but did not always have a chance to complete reviews.
In an interview on 04/23/2025 at 11:16 AM, Staff B, Interim Director of Nursing, stated they were the MDS Coordinator.
Staff B explained they became the interim DNS in February 2025 but Staff C, LPN/ADON, handled most of the DNS duties.
Staff B further stated they worked a 40-hour work week and focused on MDS duties.
Staff B stated they were not on-call after hours, staff contacted Staff C in case of emergencies and/or if there were allegations of abuse/neglect made but they were kept in the loop.
In a follow-up interview on 04/23/2025 at 12:01 PM, Staff A, again stated Staff B was the interim DNS since 02/22/2025 and worked 40-ish hours a week.
Staff A was asked if they expected Staff B to perform DNS duties 40 hours a week.
Staff A stated Staff B was available to work 40 hours a week as a DNS if needed.
Staff A further stated Staff B reviewed incident reports and was notified if/when allegations of abuse were made.
Payroll data was requested at that time for Staff B from February 2025 until current. No documentation was provided.
Reference WAC 388-97-1080 (2)(b)
Refer to