Spokane Veterans Home

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic medication was administered to the resident for which it had been prescribed, and not diverted from use, for 1 of 3 sample residents (Resident 1) reviewed for medication administration. This incident constituted a Past-Non-Compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility immediately and thoroughly investigated, made appropriate notifications, took appropriate safety actions to ensure resident safety. Education of all nursing staff on the proper administration and documentation for narcotic medications was completed by 07/11/2025. The facility was notified of the past non-compliance on 02/20/2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, comfortable, safe and homelike environment for 3 of 4 sampled residents (Resident 92, 58 and 35), reviewed for environment. Specifically, Resident 92's wall in their room was in disrepair and had a screw that protruded out of the wall, and Resident 58 and 32's walls were in disrepair. These failures placed all residents at risk for avoidable injuries and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents or their representatives were provided the opportunity to participate in care planning for 2 of 3 sampled residents (Resident 29 and 35) whose medical records were reviewed for care planning. This failure placed the residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Failure to ensure expired foods were discarded for 1 of 3 refrigerators, 1 of 1 dry storage areas, opened dates were placed on food items in the refrigerator and freezer, appropriate hair coverings were worn, and hand hygiene was performed when indicated. The facility further failed to ensure the kitchen was cleaned and dishwasher temperatures were maintained at the appropriate temperatures. These failures placed residents at risk for food-borne illnesses and food served from unsanitary conditions.

Inspectors wroteBased on interview and record review, the facility failed to promote and facilitate resident self-determination by honoring resident choices and/or refusals for 1 of 3 sampled residents (Resident 94), reviewed for choices. This failure placed residents at risk of being unable to exercise their rights, not having their choices honored, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to address required documentation for advance directives for 1 of 4 sampled residents (Resident 49) reviewed for Advance Directives. This failure placed the resident at risk of losing their right to have their preferences/decisions regarding end-of-life care followed.

Inspectors wroteBased on observations, interview and record review, the facility failed to develop and implement care plan interventions for aspiration precautions (measures taken to prevent food, liquid, or other substances from entering the lungs instead of the stomach) for 1 of 2 sampled residents (Resident 81), reviewed for hospitalization. In addition, the facility failed to follow care planned interventions when providing cares for Resident 91. This failure placed residents at risk of aspiration, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to identify, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 2 of 3 sampled residents (Resident 95 and 2), reviewed for substance use disorder (SUD). In addition, the facility failed to monitor for injury and add interventions to the care plan after a fall was sustained, and failed to ensure a position change alarm was in working order for 2 of 6 sampled residents (Residents 13 and 92), reviewed for falls. These failures placed residents at risk of leaving the facility without staff knowledge, potentially avoidable accidents, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received appropriate treatments and services to restore bladder continence to the extent possible for 1 of 2 sampled residents (Resident 69) reviewed for bowel and bladder incontinence. Failure to comprehensively assess the causes of incontinence and provide treatments and services to restore bladder function, placed the resident at risk for continued decline in urinary function, skin issues, and embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received doses of Ozempic, a medication used to control blood sugar levels, as ordered, and failed to notify the provider timely after the omissions for 1 of 5 sampled residents (Resident 36), reviewed for unnecessary medications. This failure placed residents at risk of complications secondary to high blood sugar levels, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure meals were served at palatable temperatures for 1 of 6 sampled residents (Resident 12) reviewed and 1 of 1 meal test trays sampled. This failure put residents at risk of decreased enjoyment of their meals, and possible reduced dietary intake. Findings inculded . According to the Washington State Food Handlers Guide Website, the Washington State Department of Health Safety and Licensing Division recommended that all potentially hazardous foods be held at a temperature of 41°F or below in commercial refrigerators and freezers. This included meats, fish, poultry, eggs, dairy products, cooked vegetables, cooked rice and pasta, cut melons, and other perishable items. All frozen foods were to be stored at 0°F or below. Hot food items were to be held at a temperature of 140°F or above. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that consents for psychotropic medications (drugs that affected behavior, mood, thoughts or perception) were completed accurately for 1 of 5 residents (Resident 43) reviewed for unnecessary medications. Specifically, some consents were not documented as late entries, and two consents were not completed before the medication was resumed. Failure to ensure clinical records were accurate placed residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were followed during meal service to include performing hand hygiene (HH) when indicated. In addition, staff did not follow Enhanced Barrier Precautions (EBP) when indicated for 1 of 3 sampled residents (Resident 91), reviewed for infection control. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences.

Inspectors wroteBased on interview and record review, the facility failed to provide timely follow-up for resident representative reported concerns (grievances) for 1 of 3 sampled residents (Resident 1), reviewed for grievances. This failure placed the resident at risk of having unresolved grievances and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement standards of care to prevent elopement (leaving a facility without notice or supervision) for 1 of 3 sampled residents (Resident 2), reviewed for accidents/supervision. This failure placed the resident at risk of injury, becoming lost, and/or exposure to the elements.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of a significant change in condition for 1 of 3 sampled residents (Resident 4), reviewed for quality of care. This failure placed the resident at risk of receipt of inadequate care and diminished quality of life.

Inspectors wroteBased on interview and record review, 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 1 of 3 sampled residents (1) reviewed for neglect. This failure placed the resident at risk for potential deterioration in their medical condition and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure catheter care was provided in a dignified manner for 1 of 1 sampled residents (31), reviewed for use and care of a urinary catheter (a flexible tube that passes through the urethra and into the bladder to drain urine). This failure placed the resident at risk for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included a recapitulation/synopsis of the resident's stay as required, for 1 of 1 sampled residents (94), reviewed for community discharge. This failure placed the resident at risk for having an incomplete medical record.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents with fluid balance concerns were monitored for 1 of 3 sampled residents (89) reviewed for fluid restrictions. This failure placed residents at risk for adverse health events and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Registered Dietician (RD) had completed comprehensive nutritional assessments as required for 2 of 4 sampled residents (4, 83) reviewed for nutrition. This failure placed the residents at risk for unplanned weight loss and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received their scheduled medications on the mornings they had dialysis for 1 of 7 sampled residents (15) reviewed for medication administration. This failure put residents at risk for worsening of their chronic health conditions or unintended adverse events.

Inspectors wroteBased on observation and interview, the facility failed to ensure controlled medications (medications that have a high risk for abuse such as narcotics, anti-anxiety, hypnotic and hallucinogenics) stored in the medication refrigerators were secured in a permanently affixed container for 2 of 2 medication rooms reviewed for medication storage. This failure placed the facility at risk for potential diversion or misappropriation of narcotic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary staff had the required qualifications (current Food Worker Cards) for two of nine sampled dietary staff (L, M). This failure had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared and served in a sanitary manner during 2 of 2 meal preparations observed. One staff member with a beard was not wearing a beard covering. This failure caused potential risk of contamination of food and exposure of all residents to food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate hand hygiene was performed during the meal service for 1 of 2 dining rooms, during wound care for 1 of 2 sampled residents (31) reviewed for wounds and during personal care for 1 of 1 sampled residents (36). These failures placed the residents at risk for infections and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure equipment to allow residents to call for staff assistance was provided for 1 of 19 sampled residents (44) reviewed for resident call systems. This failure placed residents at risk of having unmet care needs, accidents, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 7 sample residents (Resident 4), reviewed for abuse, were treated with dignity and respect by all facility staff. This failure placed the resident at risk for feeling disrespected and having a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), reviewed for medication administration, received medications appropriately, in accordance with a valid physician's order. This failure resulted in a significant medication error which placed the resident at risk for discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 sample residents (Resident 3), reviewed for abuse, were treated with dignity and respect by all facility staff. This failure placed the resident at risk for feeling disrespected, and having a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 8 sampled residents (Resident 1) reviewed for medication administration received a provider ordered increased dose of their diuretic medication (rids the body of excess fluid). This resulted in harm as Resident 1's edema increased during the time they missed the ordered increase in medication and may have contributed to the need for emergency care due to complications from heart disease. Resident 1 developed increased lower leg edema (swelling), skin breakdown of their right calf, and increased shortness of breath, requiring further evaluation in the emergency department. This failure placed residents at risk for deterioration of their chronic health conditions, physical distress and discomfort, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure incidents of potential abuse/neglect were reported to the State Survey Agency within the required two-hour time frame for 5 of 6 sampled resident (37, 13, 49, 73, 47), reviewed for abuse. Failure to report allegations of abuse placed the residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure investigations related to allegations of abuse/neglect were initiated, thorough, and completed timely for six of six sample residents (30, 73, 47, 49, 37, 13), reviewed for abuse. These failures placed the residents at risk for repeated incidents and potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy monthly medication reviews were done for 4 of 5 sampled residents (53, 30, 47, 43), reviewed for unnecessary medications. This failure placed the residents at risk for experiencing adverse medication side effects and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to assess the facility water system and implement measures to prevent the growth of Legionella (a bacteria that grows in water and causes lung infections) and other waterborne pathogens that were based on nationally accepted standards for 81 residents at risk for waterborne illnesses. This failure placed residents at risk for illness and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for 1 of 1 sampled residents (45), reviewed for environment. Specifically, the bedrail padding and fall mat were dirty, unsanitary, and in poor condition. This failure placed Resident 45 at risk for possible injury, illness from unclean equipment, a lack of dignity, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of six sampled residents (49, 73), investigated for abuse were free from abuse, and protected from further abuse after staff were notified of the allegations. This failure resulted in a second allegation from a different resident about the same staff member, when that staff member was not removed from resident care. Additionally, those residents were not monitored for emotional harm following the allegations of abuse. These failures placed the residents at risk of unrecognized emotional harm and potential additional abuse.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the hospital transfer of one sampled resident (21), reviewed for hospitalization, as required. This failure disallowed the resident additional advocacy per 42 CFR 483.15(c)(4)(ii)(D) from the State Long-Term Care Ombudsman.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure falls were thoroughly investigated, and/or fall prevention interventions specific to resident needs were identified and consistently implemented, for one of two sampled residents (30), reviewed for accidents. Failure to comprehensively evaluate possible root causes, and revise and implement interventions to meet the resident's needs, placed the resident at risk for continued falls.

Inspectors wroteBased on interview and record review, the facility failed to monitor and notify the physician of the absence of urinary output, for one sampled resident (21), reviewed for hospitalization. This failure placed all residents at risk for lack of monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that continuous positive airway pressure (CPAP, a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) respiratory equipment was cleaned and maintained according to professional standards for 1 of 4 sampled residents (1), reviewed for respiratory care. This failure placed Resident 1 and other residents that required CPAP therapy at risk for lung infections and deterioration of their health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety by assessing the risk for entrapment, reviewing risks and benefits of bed rails (side rails), and obtaining informed consent prior to the use of them for one of two sampled residents (30), reviewed for accidents. These failures placed the residents at risk for injury and diminished quality of life.

Inspectors wroteBased on observation and record review, the licensed nursing staff failed to recognize significant changes in 1 of 1 sampled residents (11), reviewed for a change in condition. This placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews at least once every 12 months, and provide in-service education based on the outcome of the reviews , as required, for one of five sampled staff (G), whose records were reviewed. This failure placed residents at risk for receiving care from inadequately trained staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health services related to depression, for one of five sampled residents (11), reviewed for behavioral and emotional health. This failure placed the resident at risk for worsening mental health, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess if a resident's change of condition was the result of a progression of a medical condition or a side effect of the prescribed psychotropic medications, (medication that can affect the mind, emotions, and behaviors), for one of five sampled residents (43), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medication, unmet care needs, and a decreased quality of life.