Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Central Care Center during CMS and state inspections, most recent first.
The DNS and other nurse managers regularly worked as charge nurses when staffing coverage could not be found, even though the facility's average daily census was consistently above 60. Facility records and staff interviews confirmed this practice, which was not in compliance with regulatory requirements for facilities of this size.
The facility failed to ensure proper food labeling and dating, served cold food items above recommended temperatures, and did not maintain required dishwashing temperatures. Staff did not consistently follow hand hygiene and glove-changing protocols during meal service, including touching potentially contaminated surfaces and personal items while handling food.
The facility did not ensure that required interventions to prevent waterborne bacteria, including Legionella, were consistently monitored and documented. Logs for water temperature checks and flushing of high-risk areas were missing for a period, and the Maintenance Director could not confirm completion of these tasks after delegating them to Central Supply staff.
Residents did not receive mail on weekends due to the facility's practice of locking the front doors and not staffing the front desk, resulting in mail carriers treating the facility as closed and returning mail to the postal station. Staff interviews revealed a lack of awareness about the mail delivery process on weekends, and observations confirmed the absence of clear instructions or a mail receptacle for carriers.
A resident with weakness, diabetes, and heart conditions had 5 hospital transfers, but the record often did not show what information was sent to the hospital, including SBAR details, POLST, meds, or the reason for transfer. In 4 of 5 transfers, there was no documentation that a bed-hold notice was offered or provided, and there was no documentation that the Ombudsman was notified of any of the transfers.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
Annual performance evaluations were not completed as required for three nursing assistants, with personnel files lacking documentation and leadership confirming the oversight. One evaluation was only completed after the survey exit.
A resident who was cognitively intact and receiving antidepressant medication was administered Duloxetine multiple times without documented informed consent. Staff interviews and record reviews confirmed that required consent for the psychotropic medication was not obtained prior to administration, contrary to facility policy and state regulations.
A resident who was frequently incontinent and often refused hygiene care was not provided with adequate interventions to address strong urine odors in their room. Despite staff awareness of the persistent odor, including a saturated mattress and urine found under the bed, there was no documentation or care planning to minimize or address the odors resulting from care refusals.
The facility did not complete timely PASRR screenings for two residents with mental health diagnoses after their exempted hospital stays expired. One resident with depression and end stage renal disease did not have the required PASRR section completed and did not receive a new PASRR upon readmission. Another resident with depression and dementia remained in the facility beyond the exemption period, but an updated PASRR was not completed until two months later.
Two residents who required assistance with ADLs did not consistently receive shaving and nail care. One resident with severe cognitive impairment was repeatedly observed with facial stubble, and their care plan lacked grooming instructions. Another resident with left-sided paralysis had long, unclean fingernails on the right hand, with documentation and staff interviews confirming that nail care was not consistently provided.
Two residents with lower extremity edema did not have individualized care plans or monitoring in place for their condition. One resident with lymphedema and a surgical wound refused ordered compression garments, but no alternative interventions or monitoring were documented. Another resident with a history of Lasix use and ongoing edema had no care plan addressing edema, and no evidence of monitoring was found. Staff confirmed that appropriate interventions and monitoring were not implemented.
A resident with respiratory and heart failure received oxygen at higher flow rates than ordered and had oxygen saturations above the recommended range for COPD. Staff did not consistently document or follow cleaning protocols for the resident's CPAP mask, which was observed to be unclean. These failures were confirmed through observation, interviews, and record review.
A large area of torn and missing linoleum in the kitchen dishwashing area left exposed wood that was not a cleanable surface, creating a tripping hazard and infection control issue. The Dietary Manager acknowledged the problem, and the DON was unaware of the condition due to limited access to the area.
DNS Served as Charge Nurse Despite High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing Services (DNS) did not serve as a charge nurse when the average daily occupancy exceeded 60 residents. Record review showed the facility's average daily census ranged from 75 to 85 residents, and the staffing plan required a full-time DNS to meet resident care needs. Despite this, interviews with the administrator, resident care manager, staffing coordinator, and DNS confirmed that the DNS and other nurse managers rotated on-call duties during weekends and were required to work as charge nurses if staffing coverage could not be found. The DNS acknowledged working the floor as a charge nurse under these circumstances, even though the facility census was consistently above the threshold where this practice is not permitted. The facility's contingency staffing plan allowed for interdepartmental staff support to address staffing shortages, provided licensure and certification requirements were not violated. However, the DNS and other nurse managers regularly filled in as charge nurses during staffing shortages, contrary to regulatory requirements for facilities with an average daily census over 60. This practice was confirmed through multiple staff interviews and review of facility records, which documented the ongoing use of the DNS in a charge nurse role despite the facility's census and established staffing policies.
Food Safety, Hygiene, and Equipment Failures During Meal Service
Penalty
Summary
The facility failed to adhere to food safety and hygiene standards during meal service and food storage. Observations revealed that food items in the resident refrigerator were not consistently labeled or dated, with some frozen drinks lacking both identifiers. Staff interviews confirmed that all items should have been labeled and dated to ensure proper identification and timely disposal. During lunch meal service, cold food items such as pudding, cottage cheese, fruit cup, salad, and watermelon were served at temperatures above the recommended 41 degrees Fahrenheit. Staff acknowledged that cold items were not maintaining appropriate temperatures once removed from refrigeration, and some items were served despite being above the required temperature. Additionally, staff did not follow proper hand hygiene and glove-changing protocols during meal plating. One staff member was observed touching potentially contaminated surfaces, adjusting their glasses, and wiping their mouth while wearing the same gloves used to handle food. The facility also failed to maintain the required final rinse temperature of 180 degrees Fahrenheit in the high-temperature dishwasher, with temperature logs showing repeated failures over several months. Staff interviews confirmed awareness of the importance of these practices but indicated lapses in execution and monitoring.
Failure to Monitor and Document Water Management Interventions
Penalty
Summary
The facility failed to ensure that interventions outlined in its Water Management Plan to prevent the growth of waterborne bacteria, including Legionella, were consistently monitored and completed. The plan required weekly flushing of unused toilets and sinks, cleaning of shower heads with sanitizing agents, weekly flushing of basement floor drains, and quarterly Legionella testing. During a review, it was found that documentation logs for water temperature checks and flushing of high-risk areas were only available up to early May 2025, with no records available from that date to the present. The Maintenance Director was unable to confirm whether the required water flushes and documentation had been completed after delegating the task to Central Supply staff.
Failure to Ensure Timely Resident Mail Delivery Due to Locked Entry and Lack of Weekend Staffing
Penalty
Summary
The facility failed to ensure residents received their mail on days when mail was delivered, specifically on Saturdays. During a resident group meeting, all six residents present reported not receiving mail on Saturdays, with some stating that the absence of front desk staff prevented mail delivery. Staff interviews revealed a longstanding practice of locking the front doors on weekends for security reasons, with no front desk receptionist available to accept mail. Staff members were generally unaware of the specific process for mail delivery on weekends, and some believed mail was not delivered on Saturdays, despite evidence to the contrary. Interviews with postal service representatives confirmed that mail is delivered to the facility on Saturdays unless the business is closed. However, due to the locked doors and lack of staff to accept deliveries, mail carriers treated the facility as closed and returned the mail to the postal station. Observations during the survey period showed that while there was a sign instructing visitors to ring the bell for admittance, there were no specific instructions for mail carriers and no visible mail receptacle. The Director of Nursing confirmed the doors had been locked on weekends for years and was unaware of any concerns or alternative arrangements for mail delivery to residents on those days.
Missing transfer documentation, bed-hold notices, and ombudsman notification
Penalty
Summary
The facility failed to document the information conveyed to the hospital during 4 of 5 hospital transfers for a resident whose closed record was reviewed. The resident was admitted with weakness, diabetes, and several heart conditions, and the admission assessment showed intact cognition and a need for physical assistance with activities of daily living. During the transfers, the record often did not show what information was sent with the resident, such as SBAR documentation, provider contact information, family or representative contact information, POLST, advanced directives, plan of care and treatment, current medications, or the reason for transfer. For the first transfer, the resident was sent to the hospital for abnormal blood work, and the progress note stated staff called the hospital to give report, but the record did not show what information was communicated. For the second transfer, the resident insisted on going to the ER for excruciating pain and left after calling 911, but there was no documentation of what information was conveyed or that a bed hold notice was offered or provided. For the third transfer, staff could not flush the urinary catheter and noted blood in the urine; an SBAR form was used to communicate with the hospital, but there was no documentation that a bed hold notice was provided or offered. For the fourth transfer, the provider assessed the resident as pale and ordered transfer to the ER for evaluation and blood transfusion, and the notes stated that paperwork, the transfer order, and recent labs were sent, but the record did not identify what information was conveyed or show that a bed hold notice was offered or provided. For the fifth transfer, the resident became unresponsive after a critically low blood sugar reading and was transferred to the hospital, and the record later showed a call to the representative to offer a bed hold, but there was no documentation of what information was conveyed to the hospital at the time of transfer. The report also states there was no documentation that the Office of the State Long-Term Care Ombudsman was notified of any of the resident's five hospital transfers.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Complete Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three nursing assistants, as required by policy. Personnel files for these staff members did not contain documentation of yearly performance reviews, despite their employment or re-hiring dates indicating that such evaluations were due. Interviews with the Administrator, Director of Nursing, and Resident Care Manager confirmed that annual evaluations were expected but not completed for these staff. Documentation for one staff member's evaluation was only produced after the survey had concluded, indicating it was not completed within the required timeframe.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the use of a psychotropic medication, Duloxetine, prior to its administration to a resident diagnosed with depression. The resident was cognitively intact and able to verbalize needs. The care plan required staff to educate the resident about the risks and benefits of antidepressant medication and to monitor for adverse reactions. Despite this, review of the resident’s medical record and medication administration records showed that Duloxetine was administered 55 times over a two-month period without documented consent. Interviews with facility staff, including a registered nurse, resident care manager, and director of nursing, confirmed that consent for psychotropic medications was required prior to administration. Staff were unable to locate documentation of consent for Duloxetine prior to its use, and acknowledged that the consent was not obtained until after the medication had already been administered multiple times. This failure was identified during interviews and record reviews, and was in violation of state regulations requiring informed consent for psychotropic medication use.
Failure to Maintain Clean, Odor-Free Environment Due to Inadequate Response to Incontinence and Care Refusals
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment free of institutional odors for a resident who was frequently incontinent of urine and required substantial staff assistance for toileting and hygiene. The resident was cognitively intact, able to verbalize needs, and often refused care such as brief changes, bathing, and hygiene multiple times per week. The care plan instructed staff to check and change the resident every 90-120 minutes and as needed, and to notify the nurse and reapproach if care was refused. However, there was no documentation showing how strong odors resulting from care refusals were minimized or addressed. Multiple observations over several days noted a strong urine odor emanating from the resident's room into the hallway. Staff interviews confirmed that the room had a persistent urine odor, the mattress had been saturated and replaced, and a puddle of urine was found under the bed. Housekeeping deep cleaned beds on shower days, but it was unclear if cleaning frequency was increased in response to care refusals. The DON acknowledged the odor issue and the recent disposal of the soiled mattress, but no odor-eliminating interventions had been care planned.
Failure to Complete Timely PASRR Screenings After Exempted Hospital Stays
Penalty
Summary
The facility failed to ensure timely completion of Pre-admission Screening and Resident Review (PASRR) processes for residents with mental disorders or intellectual disabilities following exempted hospital stays. For one resident with end stage renal disease and depression, the initial PASRR indicated an exempted hospital discharge, but the required section of the form was not completed. After the resident was readmitted from the hospital, a new PASRR was not completed as required, despite the resident remaining in the facility beyond the 30-day exemption period. The Social Services Director confirmed that a new PASRR should have been completed upon the resident's readmission. Another resident with medically complex conditions, depression, and dementia was admitted from the hospital with a Level I PASRR indicating exemption due to a hospital stay. However, the resident remained in the facility beyond the 30-day exemption period, and an updated Level I PASRR was not completed until two months after the required timeframe. The Social Services Director acknowledged that the updated PASRR was not completed within the required period and could not locate documentation of timely completion.
Failure to Provide Consistent Shaving and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to consistently provide shaving and nail care for two residents who required assistance with activities of daily living (ADLs). For one resident with severe cognitive impairment and unclear speech, multiple observations over several days showed the presence of facial stubble, indicating that shaving was not consistently performed. The resident’s care plan included interventions for bathing, toileting, oral care, and dressing, but lacked specific instructions or interventions for grooming or shaving. Documentation of personal hygiene care did not specify which aspects of care were provided or refused, and staff interviews confirmed that shaving was expected to be completed during morning care or bathing, but the care plan did not reflect this need. Another resident with a history of stroke and left-sided paralysis required partial to moderate assistance with personal hygiene and had a care plan instructing staff to keep fingernails short. Observations revealed long fingernails with black matter under the right hand, and the resident reported that staff did not clean their fingernails during weekly showers. Documentation showed that nail care was provided to the left hand, but there was no record of nail care for the right hand during the review period. Staff interviews confirmed that nail care was expected to be provided as needed, but this was not consistently done for the resident’s right hand.
Failure to Develop and Implement Edema Management Care Plans and Monitoring
Penalty
Summary
The facility failed to develop and implement care plan goals and interventions for two residents with edema, as well as to monitor their condition as required. One resident, who had diagnoses including lymphedema and osteomyelitis, was admitted with significant lower leg edema and a surgical incision on the left heel. The care plan addressed skin impairment and general skin care but did not include specific interventions or monitoring for lymphedema or lower leg edema. Although an order was given for Tubi-grips to manage edema, the resident consistently refused them, and no alternative interventions or monitoring were documented. Observations showed persistent edema and discoloration, and the resident reported a lack of other measures to address swelling. Another resident, admitted with high blood pressure and irregular heartbeat, also exhibited lower extremity edema. This resident had received Lasix, which was later discontinued with instructions for monitoring blood pressure and fluid status, but documentation showed only one progress note during the monitoring period and no evidence of edema monitoring in the medication administration records. The care plan did not address the resident's edema, and repeated observations showed ongoing swelling, redness, and fluid leakage from the legs. Staff interviews confirmed that interventions such as compression stockings, elevation, and monitoring should have been in place, but these were not documented or observed. The Director of Nursing and other staff acknowledged that care plans and monitoring for edema were lacking for both residents. The facility did not have a specific policy for lymphedema and edema management, relying instead on standard practices. The absence of individualized care planning and monitoring for edema in these cases constituted a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Maintain Ordered Oxygen Saturations and Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain oxygen saturations according to provider orders and did not ensure that respiratory equipment, specifically a CPAP mask, was cleaned and maintained for a resident with respiratory and heart failure. The resident, who was cognitively intact and dependent on supplemental oxygen, was observed wearing oxygen at higher flow rates than ordered, with documentation showing administration of 3-5L of oxygen when the provider's order specified 1-2L per minute. Additionally, the resident's oxygen saturations were recorded above the recommended range for individuals with COPD, and there was no evidence that staff adjusted the oxygen back down or re-checked and documented the saturations as required. The CPAP mask used by the resident was observed to have white spots inside, and the resident reported that the facility had not cleaned the CPAP. There were no orders for cleaning the CPAP mask in the medication or treatment administration records, and staff interviews confirmed that cleaning protocols were not consistently documented or followed. The Director of Nursing acknowledged the absence of cleaning orders and the importance of routine cleaning to prevent infection. These failures were identified through observation, interview, and record review, and placed the resident at risk for illness and decreased quality of life.
Unrepaired Kitchen Floor Creates Safety and Infection Control Deficiency
Penalty
Summary
The facility failed to maintain the kitchen floor in the dishwashing area, resulting in a large section of torn and missing linoleum measuring approximately 4 feet by 4 feet, with exposed wood underneath. This condition was observed during a kitchen inspection and confirmed by the Dietary Manager, who acknowledged the area as both an infection control issue and a safety hazard. The Director of Nursing stated they were unaware of the floor's condition because they did not enter that part of the kitchen. The exposed wood surface was not cleanable, and the torn flooring created a potential tripping hazard for staff.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockwood South Hill | 1.6 mi | ★★★★★ | 1 | 0 |
| Spokane Health & Rehabilitation | 1.6 mi | ★★★★★ | 1 | 0 |
| Spokane Falls Care | 1.8 mi | ★★★★★ | 34 | 0 |
| Royal Park Health And Rehabilitation | 2.7 mi | ★★★★★ | 15 | 0 |
| Spokane Veterans Home | 3.3 mi | ★★★★★ | 1 | 0 |
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