Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Spokane Veterans Home during CMS and state inspections, most recent first.
A resident with chronic back pain was prescribed Norco 10/325 mg, but multiple RNs signed out doses on the narcotic log and documented administration that was not supported by the resident’s recollection or by a subsequent urine drug screen, which was negative despite lab confirmation that the drug should have been detectable. A pouch containing Norco tablets was found on the floor near the nurse’s station, and review of the MAR and narcotic records showed missing documentation for at least one signed-out dose, leading to the determination that narcotic diversion had occurred and that the resident did not receive all prescribed pain medication.
The facility failed to maintain a homelike environment for three residents, with issues such as damaged walls and a protruding screw. Observations revealed that the walls in two residents' rooms had gouges and peeled paint, while another resident's room had a protruding screw. Staff interviews indicated a lack of awareness and no work orders for repairs, compromising the residents' safety and comfort.
The facility failed to involve residents or their representatives in care planning, as evidenced by two residents who did not participate in care conferences. One resident, cognitively intact with complex medical conditions, had not been involved in a team care plan meeting for over a year. Another resident with severe cognitive impairment had not participated in a care planning conference since August 2023. An audit revealed that 84 out of 97 residents had not participated in care planning conferences, contrary to facility policy.
The facility failed to store and handle food according to professional standards, with expired and undated food items found in storage areas. Sanitary practices were inadequate, as a staff member did not perform hand hygiene after wiping their nose, and the dishwasher did not consistently reach the required temperature. Additionally, incomplete cleaning schedules and lack of hair coverings for staff handling food were observed, posing risks of food-borne illnesses.
A facility failed to respect a resident's refusal of a bed position change alarm, despite the resident being cognitively intact and clearly expressing their wishes. The resident removed and damaged the alarm on multiple occasions, yet staff continued its use. Observations confirmed the alarm's presence, and staff interviews revealed uncertainty in handling such refusals.
A facility failed to document and follow up on a resident's advance directives, despite indications of the resident's impaired cognition and lack of knowledge about their healthcare Power of Attorney. The Social Services Director acknowledged the oversight, which placed the resident at risk of not having their end-of-life care preferences respected.
The facility failed to implement care plan interventions for a resident requiring aspiration precautions, leading to non-compliance with dietary and positioning orders. Additionally, another resident's care plan, which required care in pairs due to behavioral issues, was not followed, as care was provided by a single staff member. These deficiencies highlight a lack of adherence to established care plans.
The facility failed to address risks associated with SUD and falls for residents. A resident with a history of alcohol abuse was admitted without proper interventions in their care plan. Another resident consumed marijuana edibles brought by their spouse, leading to an elevated heart rate, but their care plan lacked documentation of alcohol abuse history. Additionally, residents at risk of falls were not properly monitored, with one resident's safety alarm failing to sound and another's care plan missing necessary interventions.
A resident with a history of stroke and moderate cognitive impairment was frequently incontinent of urine, yet the facility failed to implement a toileting program or other interventions to address the issue. Despite the resident's care plan indicating the need for assistance and a urinal at the bedside, these measures were not effectively executed, leading to continued incontinence and moisture-associated skin damage. Staff interviews revealed a lack of comprehensive assessment and intervention for the resident's incontinence.
A resident with diabetes did not receive two doses of Ozempic as ordered due to the medication being unavailable, and the provider was not notified timely. The facility failed to authorize an early refill for this specialty medication, leading to missed doses and potential health risks.
The facility failed to serve meals at palatable temperatures, affecting a resident with obesity, high blood pressure, and diabetes. The resident reported that meals in their room were sometimes cold, unlike those in the dining room. Kitchen logs showed missing temperature records for cold foods, and a lunch meal observation found food temperatures below acceptable levels. The Food Supervisor emphasized the importance of checking food temperatures for safety.
A facility failed to ensure accurate documentation of consents for psychotropic medications for a resident with Parkinson's, depression, and anxiety. Consents for medications like Quetiapine and Lorazepam were not documented as late entries, and some were not completed before resuming medication. Staff interviews confirmed the need for consents before administration and when medications are reordered, but this was not adhered to, resulting in a deficiency.
The facility failed to follow infection control practices during meal service, with staff not performing hand hygiene between handling meal trays and after touching contaminated surfaces. Additionally, Enhanced Barrier Precautions were not followed for a resident with an indwelling urinary catheter, as staff did not wear gowns during high-contact care activities. These lapses in protocol increased the risk of infection spread among residents.
A resident's representative reported concerns about respiratory equipment management, but the facility failed to document these as formal grievances or provide timely follow-up. Staff believed the issues were resolved informally, leading to a lack of documentation in the grievance logs.
A resident with dementia and a history of wandering eloped from the facility despite having a WanderGuard device. The alarm was triggered, but staff did not investigate further as the resident was not visible. The facility's policy lacked specific instructions for alarm response, and a malfunctioning door lock contributed to the incident.
A resident was transferred to the hospital due to a foot fracture, but the facility failed to notify the resident's representative, who had medical power of attorney. The resident, who was somewhat confused, returned to their former residence after hospitalization and was found with injuries from falls. Staff interviews revealed that the notification was delayed, and the facility had documentation of the power of attorney.
The facility failed to follow up with a physician's order to advance a catheter and obtain an order to increase the oxygen rate for a resident with benign prostatic hyperplasia and COPD. Despite instructions from the urology clinic and multiple instances of administering oxygen above the ordered amount, necessary follow-up actions were not taken, and the catheter was not advanced.
A resident with urinary retention and aspiration pneumonia was discharged without a recapitulation summary of their stay. The discharge packet included a referral to a wound care provider and a list of prescribed medications, but lacked the required summary. The Resident Care Manager confirmed the omission.
A facility failed to monitor a resident with cirrhosis, ascites, and general edema for fluid intake as per physician orders. Despite fluid restrictions, the resident had access to a water pitcher and ice chips, and staff did not consistently document fluid intake, leading to significant weight fluctuations and potential fluid retention issues.
A resident with end-stage renal disease, atrial fibrillation, and Parkinson's disease did not receive scheduled medications on dialysis days. The omission was documented by a Registered Nurse, who noted the resident was out of the facility and did not send the medications with the resident. The issue was not discussed with the provider, putting the resident at risk for adverse events.
The facility failed to secure controlled medications in permanently affixed containers within medication refrigerators. Controlled medications were found in open plastic baskets and on shelves inside the refrigerator doors, not separated from other medications. Staff interviews revealed a lack of awareness and compliance with the requirement to store narcotic medications securely.
The facility failed to ensure dietary staff had current Food Worker Cards, with one staff member working without a valid card and another with an expired card. The Dietary Manager confirmed the absence of a renewal process, risking unsafe food handling practices.
The facility failed to ensure sanitary food preparation and service as a staff member with a beard was observed not wearing a beard covering on two occasions. The staff member was unaware of the requirement and availability of beard covers. The Dietary Manager emphasized the importance of beard coverings to prevent food contamination.
The facility failed to ensure appropriate hand hygiene during meal service, wound care, and personal care, placing residents at risk for infections. Staff members did not follow hand hygiene protocols, as confirmed by interviews with the infection control nurse.
The facility failed to ensure that a resident with COPD, dementia, and a history of falls had their call light within reach, as observed multiple times over several days. The DON acknowledged the need for call lights to be accessible for resident safety.
The facility failed to ensure catheter care was provided in a dignified manner for a resident with a neurogenic bladder. The urine collection bag was observed multiple times without a privacy bag, and the catheter was emptied without ensuring privacy by pulling the curtain. Staff interviews confirmed that proper procedures were not followed.
The facility failed to ensure that the RD completed comprehensive nutritional assessments for two residents. One resident had a significant gap in nutritional monitoring, and another had an incomplete Admission Dietary Assessment and no comprehensive assessments since admission. Staff acknowledged the lapse in required assessments.
Narcotic Diversion and Failure to Administer Prescribed Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed narcotic medication (Norco 10/325 mg) was administered to the resident for whom it was ordered and not diverted for other use. A clear pouch containing two Norco tablets was found on the floor at the second-floor nurse’s station by the Administrator at 7:00 AM, and review of all residents’ medication orders showed that only one resident in the facility had an active prescription for this medication. Review of the narcotic logbook showed that a registered nurse had signed out doses of Norco for this resident during the night, including one dose at 11:30 PM and another at 5:00 AM. The Medication Administration Record documented that the 11:30 PM dose was given, but there was no documentation that the 5:00 AM dose was administered. When interviewed, the nurse stated the medication had been given and could not explain the pouch found on the floor. The resident, who had chronic back pain, reported not recalling receiving pain medication and not being awakened during the night for care or medication. Further review of records identified that two additional registered nurses had also signed out Norco for the same resident and documented administration over several days. A urine drug screen was ordered for the resident to check for the presence of narcotic medication, and the result was negative. The facility consulted with the laboratory and was informed that Norco would be detectable in urine within one to two days of administration. After additional consultation with the resident’s provider, it was determined that narcotic diversion had occurred. The facility’s investigation substantiated that the narcotic medication signed out for this resident had not been properly administered as ordered and had instead been diverted by nursing staff.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, safe, and homelike environment for three residents, leading to a deficiency in the quality of care provided. Resident 35's room had a 2 feet by 2 feet section of peeled and scraped paint on the wall next to their bed, likely caused by the bed's upper rail scraping the wall. This damage was observed multiple times over several days, with a cloth band-aid stuck over one of the gouges. Resident 58's room had gouges in the wall next to their bed, with some gouges deep into the drywall, exposing the chalky white material beneath the dark gray paint. These gouges were also observed on multiple occasions. Neither resident could verbalize how long the damage had been present, and staff interviews revealed that no work orders had been submitted for these repairs. Resident 92's room had multiple gouges in the drywall and a protruding screw within reach, which the resident stated did not feel homelike. The screw was observed to be pushed into the wall but not flush, remaining a safety concern. Staff interviews indicated that maintenance staff were unaware of the need for repairs in these rooms, and no work orders had been submitted. The Maintenance Director acknowledged the importance of a homelike environment and recognized the safety concern posed by the protruding screw.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents or their representatives were provided the opportunity to participate in care planning, as evidenced by the cases of two residents whose medical records were reviewed. Resident 29, who was cognitively intact and had complex medical conditions including heart failure and diabetes, reported that they had not participated in a team care plan meeting since January 2024. Instead, staff would bring a copy of the care plan and hang it in the closet without involving the resident in the process. The facility's records confirmed that the last care conference with Resident 29's participation was held over a year ago. Similarly, Resident 35, who had severe cognitive impairment and an appointed guardian, had not participated in a care planning conference since August 2023. An audit conducted by the Director of Nursing Services revealed that 84 out of 97 residents had not participated in care planning conferences. The facility's policy required that residents and their families be invited to participate in care planning conferences, but documentation showed that 47 out of 78 residents or their representatives were not offered this opportunity. The Social Services Director acknowledged the inconsistency in holding care planning conferences and stated that they were working on addressing the issue.
Deficiencies in Food Storage and Sanitary Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by the improper storage and handling of food items. During an inspection, it was observed that the dry storage area contained expired food items, including containers of grits and bottles of honey, as well as an opened box of spice mix cake without an open or expiration date. In the refrigerator, there was brown and wilted celery and mushrooms without a received or use-by date. The freezer contained multiple opened food items, such as blueberries, cinnamon rolls, and various other foods, all lacking open or expiration dates. Staff acknowledged the importance of dating opened food items and discarding expired products to prevent illness. Sanitary practices were also found lacking, as observed during a tray line operation where a staff member failed to perform hand hygiene after wiping their nose on their shirt and forearm. Additionally, the facility's dishwasher logs indicated that the final rinse temperature was below the required level on numerous occasions, which is necessary to kill germs. The kitchen cleaning schedules were incomplete, with missing documentation for daily cleaning. Furthermore, a staff member was observed handling food without wearing the required hair coverings, which is essential for maintaining sanitary conditions. These deficiencies collectively placed residents at risk for food-borne illnesses and unsanitary food service conditions.
Failure to Honor Resident's Refusal of Safety Device
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not respecting the choices and refusals of Resident 94, who was cognitively intact and able to clearly verbalize their needs. Despite having an active order for the use of a wheelchair and bed position change alarms, Resident 94 expressed clear refusals of the bed alarm on multiple occasions. On 02/13/2025, Resident 94 removed the position change alarm from their bed and tore the wire, stating they did not want it on their bed. Again, on 02/21/2025, Resident 94 broke the bed alarm pad when it beeped, indicating their refusal of the device. However, staff continued to use the bed position change alarm despite these documented refusals. Observations on 03/17/2025 and 03/18/2025 confirmed the continued presence of the position change alarm on Resident 94's bed. Interviews with staff revealed a lack of clarity and adherence to the facility's process for handling resident refusals of safety devices. Staff P, a Nursing Assistant, acknowledged the use of alarms and stated they would notify the Resident Care Manager (RCM) if a resident refused an alarm. Staff W, an LPN, was unsure of the process for residents with dementia refusing alarms and would refer to the RCM. Staff F, the RCM, confirmed awareness of Resident 94's refusals and stated they would assess and remove alarms causing distress, yet the alarms remained in use.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to properly document and follow up on the advance directives for a resident with moderately impaired cognition. Upon admission, the resident, along with family and significant others, participated in the assessment and goal setting of care. However, during the admission process, questions regarding the resident's healthcare Power of Attorney (POA) and advance directives were left unanswered, with notes indicating the resident's lack of knowledge or memory about these matters. Despite these indications, there was no documented follow-up by the facility to ascertain the resident's wishes regarding advance directives. The deficiency was further highlighted by the lack of documentation in the progress notes and care plan regarding the resident's advance directives status. The Social Services Director acknowledged the oversight and confirmed that no follow-up had been conducted to determine the resident's advance directives status. This lapse in documentation and follow-up placed the resident at risk of not having their end-of-life care preferences respected, as the facility did not ensure the necessary information was obtained and recorded.
Failure to Implement Care Plans for Aspiration Precautions and Behavioral Interventions
Penalty
Summary
The facility failed to develop and implement care plan interventions for aspiration precautions for Resident 81, who had a history of aspiration pneumonia and required a mechanically altered therapeutic diet. Despite hospital discharge orders specifying aspiration precautions, such as maintaining an upright position during oral intake and elevating the head of the bed post-meal, these were not included in the care plan. Observations showed Resident 81 eating while nearly flat in bed, and staff interviews revealed a lack of awareness and compliance with the aspiration precautions, indicating a failure to communicate and implement necessary interventions. Additionally, the facility did not adhere to care plan interventions for Resident 91, who required care in pairs due to behavioral issues and accusations towards staff. Observations noted that care was provided by a single staff member, contrary to the care plan's instructions. Interviews with staff confirmed the necessity of two-person care to protect both the resident and staff from allegations, yet this was not consistently followed, highlighting a failure to implement the care plan as intended.
Failure to Address SUD and Fall Risks
Penalty
Summary
The facility failed to identify, evaluate, and analyze risks, and implement safety interventions for residents with substance use disorder (SUD) and those at risk of falls. Resident 95, who had a significant history of alcohol abuse, was admitted without proper documentation or interventions in their care plan to address potential risks associated with their SUD. Despite showing exit-seeking behaviors and being identified as a high risk to wander, the care plan lacked interventions related to their alcohol abuse history. Resident 2, who had a history of alcohol and marijuana use, consumed an edible marijuana product brought in by their spouse, resulting in an elevated heart rate. The facility held a care conference and educated the resident and their spouse about the prohibition of cannabis on the premises. However, the care plan did not document Resident 2's history of alcohol abuse, and there was no assessment for potential risks associated with their SUD. The facility also failed to ensure proper monitoring and intervention for residents at risk of falls. Resident 13, with a history of falls, had an incident where they slid out of bed, but the intervention to prevent this was not added to their care plan. Similarly, Resident 92, who had severe cognitive impairments and a history of falls, was found on the floor after their safety alarm failed to sound. The alarm's malfunction was not investigated, and the care plan did not address this critical safety issue.
Failure to Address Resident's Incontinence
Penalty
Summary
The facility failed to provide appropriate treatments and services to restore bladder continence for a resident, identified as Resident 69, who was frequently incontinent of urine. The facility's policy required comprehensive assessment and interventions for residents with incontinence, but Resident 69 was not placed on any toileting program despite being frequently incontinent. The resident, who had a history of stroke and moderate cognitive impairment, required assistance for transfers and toileting but was not receiving scheduled toileting, prompted voiding, or bladder training. Observations and interviews revealed that Resident 69 experienced urinary incontinence multiple times a day and was not on a toileting program. Staff interviews indicated that the resident was considered continent if staff responded promptly, but incontinence occurred when staff did not arrive in time. The resident's care plan included interventions for incontinence, but these were not effectively implemented, as evidenced by the resident's continued incontinence and the absence of a urinal at the bedside, contrary to the care plan. The facility's failure to assess and address the resident's incontinence comprehensively was further highlighted by the lack of referrals to therapy or other disciplines for the mixed incontinence identified earlier. Staff acknowledged the need for a toileting schedule and confirmed that no interventions had been attempted to improve the resident's bladder continence. The resident also suffered from moisture-associated skin damage due to prolonged exposure to moisture from incontinence.
Failure to Administer Ozempic as Ordered
Penalty
Summary
The facility failed to ensure that a resident received their prescribed doses of Ozempic, a medication used to control blood sugar levels, as ordered. This deficiency involved Resident 36, who had diagnoses of diabetes and stroke and was cognitively intact. The resident was supposed to receive an Ozempic injection once weekly on Saturday mornings. However, the March 2025 Medication Administration Record (MAR) indicated that the resident did not receive the doses on two occasions, March 8 and March 15, 2025, due to the medication being unavailable. The facility did not notify the provider of the missed dose on March 8, 2025, until March 15, 2025. Interviews with facility staff revealed that the medication was not refilled in time due to a lack of authorization for an early refill, as Ozempic is a specialty medication requiring approval for early refills. The pharmacist confirmed that the medication was not due for a refill when ordered by the facility, and no authorization form for an early refill was documented. The Resident Care Manager (RCM) and Licensed Practical Nurse (LPN) acknowledged the failure to notify the provider timely and the lack of appropriate follow-up when the medication was unavailable. This oversight placed the resident at risk of complications from high blood sugar levels.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at palatable temperatures, which affected at least one resident and a meal test tray. Resident 12, who had diagnoses including obesity, high blood pressure, and diabetes, reported that meals served in their room were sometimes cold, whereas meals in the dining room were hot. During an interview, Resident 12 expressed that their breakfast, which included cold cereal, an English muffin, sausage patty, hard-boiled egg, and hashbrowns, could have been hotter. The kitchen food temperature logs for March 2025 showed that while temperatures for hot foods were documented, the temperatures for cold foods were not recorded, as indicated by a line through the box for cold items. An observation and sampling of a lunch meal revealed that the temperatures of the food items were below acceptable parameters, with buttered noodles at 119 F, oriental style mixed vegetables at 100 F, and cubed seasoned potatoes at 125 F. Staff S, the Food Supervisor, acknowledged the importance of checking both hot and cold food temperatures to ensure food safety.
Failure to Accurately Document Consents for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that consents for psychotropic medications were completed accurately for a resident reviewed for unnecessary medications. Specifically, the consents for medications such as Quetiapine, Prazosin, Trazodone, and Lorazepam were not documented as late entries, and two consents were not completed before the medication was resumed. This failure was identified during a review of the resident's medical records, which showed discrepancies in the dates of consent documentation and the actual administration of the medications. The resident involved had diagnoses of Parkinson's Disease, depression, and anxiety, and was alert and able to communicate their needs. The Medication Administration Record indicated that the resident was taking several psychotropic medications that required documented consents. However, the consents were either signed late or not redone when the medications were resumed after being discontinued. Interviews with facility staff confirmed that consents should be obtained before administering the first dose and redone if the medication is reordered, but this process was not followed, leading to the deficiency.
Infection Control Deficiencies During Meal Service and EBP
Penalty
Summary
The facility failed to adhere to proper infection control practices during meal service, as observed in multiple instances where staff did not perform hand hygiene when indicated. Staff G, a Nursing Assistant, was seen sanitizing their hands, handling meal trays, and picking up cups from the floor without performing hand hygiene before passing the tray to a resident. Similarly, Staff J, another Nursing Assistant, did not perform hand hygiene between handling different meal trays and after touching the trash can lid. Staff K also failed to perform hand hygiene between delivering meal trays to different rooms. Interviews with staff members, including Staff J, Staff H, and the Infection Preventionist, confirmed that hand hygiene was expected to be performed between passing meal trays and after touching potentially contaminated surfaces to prevent the spread of infection. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident 91, who had an indwelling urinary catheter and was at risk of infection. The resident's care plan required the use of gowns and gloves during high-contact care activities. However, during an observation, Staff L, a Nursing Assistant, assisted Resident 91 with transferring without wearing a gown, as required by the EBP policy. Staff L acknowledged the oversight and recognized the importance of wearing a gown to protect both the resident and themselves from germs. These deficiencies in infection control practices, including the failure to perform hand hygiene and adhere to EBP, placed residents at risk for the spread of infections and illnesses. The facility's policies on hand hygiene and EBP were not followed, as evidenced by the observations and staff interviews, highlighting a lapse in adherence to established infection prevention protocols.
Failure to Document and Follow Up on Resident Grievances
Penalty
Summary
The facility failed to provide timely follow-up for grievances reported by a resident's representative, which affected the quality of life for the resident. The policy in place allowed residents to voice grievances either formally or informally, with the expectation of a timely review and response. However, the facility did not document or follow up on the grievances reported by the representative of a resident concerning the management of respiratory equipment. Despite the representative voicing concerns to various staff members, including licensed nurses, nurse managers, and social services, there was no record of these grievances in the facility's logs during the resident's stay. Interviews with staff revealed that the concerns were acknowledged and additional staff training was implemented, but the grievances were not documented as formal grievances. Staff members, including the Resident Care Manager and Social Services, believed the issues were resolved informally and did not require formal documentation. The Administrator and Director of Nursing indicated that only issues requiring permanent fixes were documented as grievances, which led to the oversight in this case. This lack of documentation and formal follow-up was a deviation from the facility's grievance policy.
Failure to Prevent Resident Elopement Due to Inadequate Response to WanderGuard Alarm
Penalty
Summary
The facility failed to implement adequate standards of care to prevent the elopement of a resident with dementia, who was severely cognitively impaired and required supervision while walking. The resident, who had a history of wandering, was equipped with a WanderGuard device intended to trigger an alarm when near exit doors. Despite this precaution, the resident managed to leave the facility unattended, and was later found by local law enforcement at a nearby intersection, confused but uninjured. The facility's investigation revealed that the resident exited through the front door, and although a nursing assistant responded to the alarm, they did not investigate further as the resident was no longer visible. The facility's policy on WanderGuards required routine testing of the devices and monthly checks of door monitors by maintenance staff. However, the policy lacked specific instructions for staff on how to respond when an alarm sounded, particularly if no resident was found at the door. On the day following the incident, it was discovered that the front door's magnetic lock was malfunctioning, which was subsequently repaired. The Director of Nursing confirmed that staff responded to the alarm shortly after the resident exited, but the door was expected to lock automatically when the WanderGuard alarm was triggered, which did not occur.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the representative of Resident 4, who had medical power of attorney, about a significant change in the resident's condition. On the evening of June 20, 2024, Resident 4 was transferred to the hospital due to a foot fracture. However, there was no documentation indicating that the resident's representative was informed of this transfer. The resident returned to their former residence after hospitalization, where they were found by their representative with injuries from falls that occurred while the resident was alone. Interviews with facility staff revealed that Resident 4 was somewhat confused prior to the hospital transfer, exhibiting behaviors such as running over their own foot and hallucinating. Staff B, who received the physician's order for the hospital transfer, stated they left a message for staff to notify the resident's representative the next morning, as the decision to call representatives at night depended on the situation. Staff A, the Director of Nursing, confirmed that the facility had documentation of the resident's power of attorney and that staff were expected to notify representatives of hospital transfers, which did not occur in this case.
Failure to Follow Physician's Orders for Catheter Advancement and Oxygen Rate Adjustment
Penalty
Summary
The facility failed to follow up with a physician's order to advance a catheter and obtain an order to increase the oxygen rate for a resident. The resident had diagnoses including benign prostatic hyperplasia and chronic obstructive pulmonary disease (COPD) and required supplemental oxygen. On 08/01/2022, the urology clinic informed the facility that the resident's urinary catheter needed to be advanced into the bladder. Staff B, a Registered Nurse, received the instruction and left a message for the facility provider to obtain the order, but no further follow-up was documented, and the catheter was not advanced. Additionally, the resident's Medication Administration Records (MAR) for July and August 2022 showed multiple instances where oxygen was administered above the ordered amount. Staff interviews revealed that the facility's protocol required nurses to notify the provider for any changes in oxygen rate and to continue calling the provider if no response was obtained. However, the necessary follow-up actions were not taken, and the Director of Nursing confirmed that the provider had not returned the call, and no further follow-up was done regarding the catheter advancement or the oxygen rate adjustment.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay for a resident who was reviewed for community discharge. The resident, who had diagnoses including urinary retention and aspiration pneumonia, was admitted for physical and occupational therapy following deconditioning related to these diagnoses. The resident, who had moderate cognitive impairments and needed moderate to substantial assistance with activities of daily living, was discharged to home. A review of the discharge packet revealed that while the resident was discharged with a referral to a wound care provider and a list of prescribed medications, a recapitulation summary was not documented in the resident's record. This was confirmed in an interview with the Resident Care Manager, who acknowledged that the recapitulation discharge summary had not been completed.
Failure to Monitor Fluid Intake for Resident with Fluid Balance Concerns
Penalty
Summary
The facility failed to ensure that residents with fluid balance concerns were properly monitored, specifically for a resident with cirrhosis of the liver, ascites, and general edema. Despite physician orders to restrict the resident's fluid intake to 2000mls daily and to document extra fluids received each shift, the facility did not consistently record the resident's fluid intake. Observations revealed that the resident had access to a water pitcher and ice chips, contrary to the care plan, and staff did not accurately track the resident's fluid consumption. The resident's weight showed significant fluctuations, indicating potential fluid retention issues. Interviews with staff revealed a lack of consistent documentation and monitoring of the resident's fluid intake. Staff members were unclear about their responsibilities in tracking the resident's fluids, and there was a misunderstanding about whether ice chips counted towards the fluid restriction. The resident was aware of their fluid restriction but admitted to drinking extra water due to thirst. The facility's failure to adhere to the fluid restriction guidelines and properly monitor the resident's fluid intake placed the resident at risk for adverse health events related to fluid overload.
Failure to Administer Scheduled Medications on Dialysis Days
Penalty
Summary
The facility failed to ensure a resident received their scheduled medications on the mornings they had dialysis. Resident 15, who had diagnoses including end-stage renal disease (ESRD) dependent on dialysis, atrial fibrillation (AFIB), and Parkinson's disease, did not receive their medications on dialysis days. The medications omitted included a multivitamin, pantoprazole, apixaban, tamsulosin, carbidopa/levodopa, entacapone, Renvela, cholecalciferol, and Lispro insulin. The omission was documented by Staff P, a Registered Nurse, who noted that the resident was out of the facility at the time the medications were to be given and did not send the medications with the resident to their dialysis appointments. Staff P also stated that certain medications could not be given upon the resident's return from dialysis as it was too close to the next scheduled dose. This issue was not discussed with the provider to determine an appropriate course of action. During an interview, Staff G, the Resident Care Manager, reviewed the February and March medication administration records (MARs) for Resident 15 and acknowledged the need to discuss the omitted medications with the provider. The failure to administer the medications as scheduled on dialysis days put the resident at risk for worsening of their chronic health conditions or unintended adverse events. The deficiency was identified through observation, interview, and record review, highlighting a significant lapse in medication administration protocol for residents undergoing dialysis.
Failure to Secure Controlled Medications in Permanently Affixed Containers
Penalty
Summary
The facility failed to ensure controlled medications stored in the medication refrigerators were secured in a permanently affixed container. During an inspection of the second-floor medication room, it was observed that controlled medications such as Ativan and Marinol were stored in an open plastic basket on a shelf in the refrigerator, which had a padlock on the door. Similarly, in the first-floor medication room, controlled medications were found on a narrow shelf inside the refrigerator door, not separated from other medications. Staff P, RN, stated that there was no need to keep narcotics in a separate, locked box as both the medication room door and the refrigerator door were locked, and only the nurse had a key. Staff interviews revealed a lack of awareness and compliance with the requirement to store narcotic medications in a permanently affixed, secured box within the refrigerator. Staff I, LPN, was unaware of the need for such separation and security measures. Staff N, RCM, acknowledged the requirement and mentioned that the DON was looking into obtaining the necessary lockboxes. The DON confirmed awareness of the requirement and stated efforts were being made to acquire the lockboxes.
Failure to Maintain Valid Food Worker Cards for Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff had the required qualifications, specifically current Food Worker Cards, for two of nine sampled dietary staff members. Staff L was found to be working without a valid Washington State Food Workers card, and Staff M had an expired card. The Dietary Manager, Staff K, confirmed that there was no process in place to ensure food handler cards were renewed prior to expiration. This lapse in protocol had the potential to result in unsafe food handling practices, posing a risk to all residents for developing foodborne illnesses.
Failure to Ensure Sanitary Food Preparation and Service
Penalty
Summary
The facility failed to ensure food was prepared and served in a sanitary manner during two meal preparations observed. A staff member with a beard was not wearing a beard covering while preparing and serving food. This was observed on two separate occasions. During an interview, the staff member stated that in the five years they had worked at the facility, it had never been an issue, and they usually kept their beard shorter. They also mentioned not knowing if beard covers were available. The Dietary Manager confirmed the importance of beard coverings to prevent food contamination, especially for the vulnerable population served by the facility.
Inadequate Hand Hygiene During Care Activities
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during meal service, wound care, and personal care, placing residents at risk for infections. During a lunch observation, a nursing assistant donned gloves, pushed a resident to the table, and handled food items without performing hand hygiene. Another staff member touched a resident's coat and passed a tray without sanitizing their hands. Interviews with the staff confirmed that hand hygiene protocols were not followed as required. In wound care, a registered nurse handled dressings, a pen light, and a resident's wound without changing gloves or performing hand hygiene. Similarly, during personal care, a nursing assistant did not change gloves or sanitize hands after performing peri-care and before applying protective cream and handling other items. The infection control nurse confirmed that hand hygiene should have been performed between these tasks to prevent the spread of infection.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that equipment to allow residents to call for staff assistance was provided for one of the sampled residents. Resident 44, who had diagnoses including chronic obstructive pulmonary disease (COPD), dementia, and a history of falls, was observed multiple times with their call light not within reach. This was despite the care plan indicating that the call light should be within reach and the resident should be encouraged to use it. Observations on several occasions over multiple days showed the call light under the bed and not accessible to the resident. The Director of Nursing acknowledged that call lights needed to be placed within the reach of residents for their safety.
Failure to Provide Dignified Catheter Care
Penalty
Summary
The facility failed to ensure catheter care was provided in a dignified manner for a resident with a neurogenic bladder who utilized a urinary catheter. The urine collection bag was observed multiple times without a privacy bag, and the catheter was emptied without ensuring privacy by pulling the curtain. These observations were made on several occasions, and staff interviews confirmed that the proper procedures for maintaining the resident's dignity were not followed.
Failure to Complete Comprehensive Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the Registered Dietician (RD) completed comprehensive nutritional assessments as required for two residents. Resident 4, who had diagnoses including depression, diabetes, and stroke, was identified as being at nutritional risk. Despite this, the last annual comprehensive nutritional assessment was completed on 11/16/2022, and the last quarterly assessment was done on 04/26/2023. No further comprehensive assessments were documented after 04/26/2023, leaving a significant gap in the resident's nutritional monitoring and care planning. Resident 83, diagnosed with Parkinson's disease and dysphagia, was admitted on 10/25/2023. The Admission Dietary Assessment dated 01/04/2024 was not comprehensive, lacking evaluations of the resident's weights, oral intake, or estimated caloric and nutritional needs. No comprehensive RD assessments were documented since the resident's admission. Interviews with staff revealed that the facility had been using contracted/interim dieticians after the previous RD retired in May 2023, and acknowledged that nutritional assessments were not completed as required.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 213 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Hill Rehabilitation And Care Center | 0.3 mi | ★★★★★ | 2 | 0 |
| Touchmark On South Hill Nursing | 2.2 mi | — | 0 | 0 |
| Rockwood South Hill | 2.3 mi | ★★★★★ | 1 | 0 |
| Alderwood Manor | 2.3 mi | ★★★★★ | 24 | 0 |
| North Central Care Center | 3.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.