In a matter of six months, Frances Overbay went from growing irises, working part time and donating food to becoming bed-bound and dying in her room at a Spokane Valley nursing home.
“Every day, my world gets smaller and smaller,” Overbay said to her friend Maureen Smith as she came to realize she would never go home.
Overbay was 84 when Smith took her to the hospital in March 2024 for surgery to remove a benign tumor from her abdomen. Doctors were confident in her recovery, but things took a turn for the worse when she was transferred to Spokane Valley Health and Rehabilitation of Cascadia.
Physical therapy was an important part of Overbay’s recovery, but after a few visits, it was taken away. Each time the physical therapists visited Overbay, it was when she was waiting for food or medicine, so she would tell them to come back later, Smith recalled.
Smith later learned that each time Overbay said this, the nursing home noted it as the patient denying care. Once it was reported that the patient denied physical therapy enough times, her insurance took it away altogether.
“She felt like she wasn’t listened to. Nobody was ever going to help her get up. She was never going to walk again. If she was never going to walk again, she was never going to be able to go home and she was never going to be able to work again,” Smith said. “She gave up.”
Overbay spent the rest of her life between visits to the hospital for various infections and in her bed covered in sores. Eventually she shunned her medicine and rarely ate, which Smith blamed on her lack of care leading up to that point.
Smith said during one of her last visits, Overbay didn’t speak.
“She just wasn’t there anymore,” Smith said.
Two days after her 85th birthday, Overbay died in her room.
“It was atrocious watching her fade away,” Smith said.
Nursing homes struggle in Spokane
In Spokane County, nursing homes often have higher health citations than the rest of the nation and are sometimes higher than the rest of the state, according to numbers from Medicare.gov.
Health citations are given after inspections from the Department of Health and Human Services and the Centers for Medicare and Medicaid Services find a facility in violation for skilled nursing facility regulations.
Citations can range from infractions including not doing enough to prevent accidents in a nursing home to abuse and even death. More severe offenses can lead to fines and sometimes Medicare and Medicaid payment suspensions.
The national average of health citations in nursing homes within the past year tracked by the Centers for Medicare and Medicaid Services is 9.6. All but one nursing home in Spokane County have more citations than that, with the worst offender – Spokane Health and Rehabilitation – topping at 58.
The Washington state average is higher at 18.2, and over half of all Spokane County nursing homes are above that.
Medicare.gov also tracks facilities that have citations related to abuse, reporting that 35% of nursing homes in Spokane County received such citations.
Richard Danford, a retired regional ombudsman for Eastern Washington Long-Term Care, has worked in many parts of the country, addressing resident complaints in nursing homes and acting as their advocate.
He is now on the board of directors of the National Association of Local Long-term Care Ombudsmen and published a book in June called, “Be Aware of That Nursing Home: How We Got Here … and What to Know.”
Danford said the problems seen in Spokane aren’t unique, and nursing homes across the country have been struggling since their inception.
“In this country, we’ve never valued our seniors,” Danford said. “We’ve done everything to ignore the whole subject matter. ‘We’ve got to find a home for mom, because it’s going to interfere with our daily routine a little too much to take care of somebody.’ It’s just tragic.”
Danford said he’s grown more worried, as things haven’t seemed to get much better and these facilities are coming to a point where they’ll be needed more than ever.
The number of Americans 65 and older is expected to grow from 58 million in 2022 to 82 million in 2050, according to the U.S. Census Bureau. The Administration for Community Living also said on its website that people turning 65 have a 70% chance of needing some form of long-term care in the future.
The future of long-term care is further complicated by the “One Big Beautiful Bill Act” that is projected to cut Medicaid spending by $1 trillion and also put a moratorium on minimum staffing levels for skilled nursing facilities issued by the Centers for Medicare and Medicaid Services.
While the Medicaid cuts aren’t supposed to target people 65 and older, some nursing home administrators worry it may inadvertently impact their facilities.
“We just got to wake up to the reality of what’s happening,” Danford said. “The numbers of people will, I hope and I pray, cause people to start coming up with solutions that really allow for people to anticipate and expect a quality of life all the way up to the end.”
Fines and regulations
In the past three years, Spokane County nursing homes have been issued more than $1.3 million in fines.
Residential Care Services Director Amy Abbott has worked for the Washington State Department of Social and Health Services for the past 18 years licensing and certifying all of the long-term care facilities in Washington State. Abbott said the high citations in Spokane don’t necessarily mean facilities in the area are worse than others across the state or the nation, but are a byproduct of multiple factors.
One reason, Abbott said, was the COVID-19 pandemic. Inspectors weren’t allowed to come into the facilities for a while, she said, causing a lot of problems to go unnoticed.
Nursing homes were also put under a lot of strain and prioritized keeping the virus out and residents alive. That led some of the more specific regulations to fall by the wayside.
“Now that we’re going back in and doing our health survey, we’re finding some of those things maybe aren’t still being done or aren’t being done as well as they should be,” Abbott said. “So there’s some citations there.”
Washington state regulations for nursing homes are more strict than most, requiring workers like Abbott to investigate more complaints and leading to an increase in citations.
Abbott also noted that regulatory agencies in other states are understaffed, causing them to fall behind on inspections and thus citation issuances. Washington’s regulatory agency is fully staffed because they pair federal and state licensing visits at the same time, she said, allowing them to receive federal and state funding.
Steve LaForte, chief financial officer of Cascadia Healthcare, a company that owns more than 40 skilled nursing facilities across five states including Spokane Valley Health and Rehabilitation of Cascadia, described Washington’s survey system as more punitive than other states.
LaForte said that while it is important nursing homes have regulations, he said it doesn’t make sense to punish an already struggling facility with fines that make operations more difficult.
“Why don’t you have a system where … you have to take $150,000 and put it back into the facility to fix the issues that we’re talking about, and then you have to come up with metrics-based evidence that you’ve done that?” LaForte said.
While Danford agreed that enforcement seems to be ramping up coming out of the pandemic, he said it has been severely lacking for many years, and oftentimes bigger facilities seem to budget for the fines treating them more like a slap on the wrist.
But Abbott said even if fines aren’t issued, the nursing homes don’t like to receive citations because it affects their star rating on Medicare.gov, which is a system potential residents can use to weigh their options.
“A layperson will go in and they’ll be looking for a home and say, ‘Well, this home only has an overall rating of one star, whereas this home has a four-star rating,’ ” Abbott said. “So they do care about the citations, even if there’s no enforcement.”
This five-star review system evaluates a facility based on things like number of health citations, staffing levels, turnover and quality of care. Nursing homes in Spokane County had an average star-rating of 2.65.
Kathleen Paukert, a lawyer with Paukert and Troppmann PLLC who takes nursing home abuse cases in Spokane, said former residents oftentimes seek legal action against nursing homes.
Paukert said it’s important to note that not every nursing home is bad and has the same struggles, but she’s seen facilities in Spokane leave patients with bed sores, make dramatic medication errors that worsen the residents’ health and even hire workers with criminal records.
Neither Paukert nor her clients could speak more specifically about these issues, as she said nursing homes often agree to pay large settlements, sometimes in the millions, and in exchange, plaintiffs commonly sign confidentiality agreements barring them from talking about the case.
“Those are the most vulnerable people, and you need the best caregivers there in that unit,” Paukert said. “In my experience, that doesn’t always happen.”
A culture of not caring?
One reason Spokane nursing homes may be struggling to meet regulations leading to more health citations could be a common problem experienced in the health care industry: staff-shortages.
Despite not being happy with the quality of care Overbay received, Smith didn’t blame the workers for her death.
“I mean, the nurses, bless their hearts, try so hard. It’s just that they’re so overworked and there are just not enough workers,” Smith said.
This became apparent for Smith when she visited and noticed that pressing the call button for a nurse would sometimes not get a response for hours. The food often seemed sparse and flavorless. Smith recalled one meal as a small hamburger with one slice of tomato. But worst of all was the lack of physical therapy, she said.
Smith also remembered there being what felt like pressure for Overbay to stay in her room.
One time, Smith visited Overbay and found her crying. Smith remembers her friend saying that she had wheeled herself out of her room to refill her water cup, as she was recovering from a Clostridioides difficile infection.
She got two rooms away before being stopped by a nurse’s aide who asked her what she was doing out of her room. Smith said there were no restrictions or reasons Overbay wouldn’t be allowed to leave, but the aide told her “Go back to your room and push the call button. That’s how you get things. You stay in your room.”
Combined with the food, Smith said this is what caused Overbay to get weaker and led to her eventual death.
“There was nobody to help her,” Smith said. “She was never going to leave.”
Danford said that staff shortages are common nationwide.
“I can tell you, having worked with thousands of residents, families and community people, that if you ask any family member or resident ‘What’s the number one problem in nursing homes,’ you will get a universal answer: not enough staff,” Danford said.
A 2024 survey of 441 nursing home providers by the American Health Care Association found that 72% of facilities said their current workforce levels are lower than before the COVID-19 pandemic.
Minimum staffing levels have been proposed but are often shot down, as nursing homes struggle to meet what would be the new requirements.
Washington did pass minimum staffing levels in 2016 requiring skilled nursing facilities to provide residents with at least 3.4 hours of care per day. This number was calculated by taking the total number of staff hours per day divided by the number of residents.
At the federal level, CMS announced in April 2024 that skilled nursing facilities would be required to provide 3.48 hours of nursing care per day to receive Medicare and Medicaid funding.
It also wanted to require a registered nurse to be on staff 24 hours a day and 7 days per week, but both of these decisions were met with pushback, resulting in the “One Big Beautiful Bill” Act halting the enforcement of the decisions until 2034.
LaForte said the moratorium was a good thing for nursing facilities as they already struggle to keep staffing levels up, and the ones CMS proposed would be “impossible” to meet.
LaForte used the example of his Idaho facilities, where nursing aides went from making an average of $14 an hour to $22, while Medicaid reimbursements remained static.
“I think the codification of the repeal of the staffing mandate that was highly problematic and highly irrational to the point of being impossible to have ever administrate, was Congress acknowledging how integral the care we provide is,” LaForte said.
He also acknowledged that while more staffing would be nice, his facilities focus on the quality of each staff member, citing the fact that Cascadia homes won four out of six gold quality awards in the past three years for the American Health Care Association/National Center for Assisted Living National Quality Award Program.
“Operators love staff. We would love more staff. Our reimbursement limits staffing,” LaForte said. “We need to focus on quality, and we focus on quality with the staffing that we have.”
Danford said even if the requirements passed, they are still too careless. In 2001, CMS did a study recommending 4.1 hours of nursing care per day, which was considered a minimum threshold to meet residents’ needs.
Out of 17 nursing homes in Spokane County, 58% did not meet the 4.1 hours per day, according to numbers from the Medicare Care Compare website.
Aurora Valley Care and Spokane Health and Rehabilitation also fell just below Washington state standards.
Jessica Nelson, Washington DSHS spokesperson, said that the state evaluates the numbers differently, so those seen on Medicare.gov are different.
Nelson said Spokane Health and Rehabilitation and Spokane Valley Health and Rehabilitation of Cascadia fell below staffing requirements in quarter one of 2024.
Staff turnover is also an issue in Spokane nursing homes, with the average rate being 55.93% over a year.
Cassandra Frederick, a home care aide who has done contract work with Spokane nursing homes, found herself on the other end of care last year when she fractured both hips in a car crash.
Frederick said the experience of being bed-bound in a rehabilitation wing of a nursing home made her realize the importance of staffing levels and turnover rates.
She spent a blurry 10 days in a hospital following the crash, where they treated her for internal bleeding and performed a surgery re-securing her pelvis to her tailbone.
“From the scene of the accident to the hospital, I kept screaming out for somebody to hold my legs. Somebody literally had to bear hug my legs,” Frederick said. “Any movement and I was in agony.”
After the hospital stay, she was transferred to Spokane Health and Rehabilitation for 23 days of “anger, frustration and tears.”
Frederick was nervous going into it, as friends had jokingly called the place “Death Manor,” in reference to the facility previously being named Manor Care. Within her first 24 hours in the nursing home, Frederick awoke to chaos as someone died across the hall.
“When you’re bed-bound, there’s only so much you can do to advocate for yourself,” Frederick said. “If they don’t want to do anything for you, all they have to do is ignore you.”
During her short stay, Frederick said she was constantly bombarded by new faces and inconsistencies that made her experience worse.
Frederick said there were a few certified nursing aides who were consistent and did a good job, but for the most part, the home was full of agency workers on temporary contracts who largely had no familiarity with any of the residents or what they needed.
Oftentimes, Frederick said she wouldn’t get pain medication for hours, her prescriptions would change – including removing a medicine she had taken for years prior to the accident – and call lights wouldn’t be responded to, forcing Frederick to either attempt to get herself into a bed pan or have family members do it for her.
“I would have literally wet my bed, and that would have been an incredibly hard hit to my dignity, because it would have been no fault of my own,” Frederick said. “I’m relying on these people to take care of me, and there’s nobody coming.”
As someone who works in the care industry, Frederick said she understood the struggles but just wished they were communicated better to her.
Frederick said her stay made her realize how important having more staffing, more training and familiarity with residents is to quality of care. Frederick said she especially worries for older folks who spend the rest of their lives in those conditions.
“If I had to stay there for a longer situation than I did, I literally would have went insane,” Frederick said. “There’s no way that I could handle it. It would be different if there was continuity of care, but there’s not.”
Dustin Blewett‑Beckvold, administrator for Spokane Health and Rehabilitation, declined to be interviewed. He began working for the facility three weeks ago and said he was still familiarizing himself with Washington’s regulations after moving from a facility in Idaho.
Blewett-Beckvold replied via email, though, that the survey process for evaluating skilled nursing facilities is valued at his facilities, despite sometimes being disruptive.
“Whenever I speak to staff, especially those who are new to Skilled Nursing, I always tell them, it’s not a problem to have a problem, it IS a problem to have a problem that we are not working towards addressing,” Blewett-Beckvold wrote.
“Humans taking care of humans is never an easy thing to do, especially when often, we are our residents’ biggest advocates, their friends or even their families. Sometimes, we are their only connection to the outside world, and that is what we focus on the most.”
Danford said that high turnover rates affected many residents with whom he worked, as no culture or familiarity could grow with the facility when new faces were constantly coming in and leaving.
“A lot of the folks have been in these nursing homes for extended periods of time. They develop relationships with the staff, with the CNAs, the caregivers, and they become family,” Danford said. “Well, that’s out the window when you get these kinds of facilities, because the turnover in the staff is much higher.”
On top of demanding working hours, Danford said low pay is another reason he’s seen workers leave the field.
According to a 2024 report by the Washington Workforce Training and Education Coordination Board, almost every position in a skilled nursing facility pays less than if they were to work in any other medical industry in Washington.
Registered nurses, one of the higher-paid positions, take a 38% pay cut if they choose to work in a skilled nursing facility, making $71,157 a year, on average, as opposed to $115,525 across all other industries.
The same goes for licensed practical nurses, whose pay drops by 17%, and certified nursing aides, who on average make about the same as a retail worker in Washington , according to the report.
On top of pay, LaForte said it’s hard to find staff who want to work at facilities that they may view as a place where “old people go to die.”
“Everybody wants to age in place, but 70% of the population over 80 at some point are going to need skilled nursing or long-term care,” LaForte said. “But there is a perception problem we have, and that trickles down to staffing.”
Danford said that low pay and large turnover directly affects the quality of care in a facility, giving an example of a nursing home that struggled as a result of that.
“All of that combined creates a culture that’s not caring,” Danford said. “… Residents in that facility who were bed-bound weren’t getting bathed for up to three weeks. They’re left overnight, often in their own urine and feces. Their breakfast is served and it’s cold, or it’s the wrong one. The whole thing just snowballs. The culture is just unacceptable.”
The future of long-term care
The U.S. Department of Health and Human Services announced they laid off 10,000 employees in March, including 300 at CMS, in response to an executive order from President Donald Trump on government efficiency.
With this and looming cuts to federal health care spending, Danford and nursing home administrators worry about the future of long-term care.
Medicaid covers more than 60% of residents in nursing homes, and Medicare covers around 14%. The median monthly cost for a nursing home room in Washington in 2024 was $12,714. A 2023 Seattle Times article said Washington has around 12,000 people in long-term care. Using the median monthly cost, a rough estimate puts Medicaid paying out over $1 billion a year in the state of Washington alone.
In reaction to the “One Big Beautiful Bill” Act, LeadingAge President and CEO Katie Smith Sloan released a statement criticizing the health care funding cuts.
“Make no mistake: This harmful, cold-hearted bill will wreak havoc on our country’s fragile aging services infrastructure – at a time when demand for the Medicare and Medicaid supported services it delivers is growing,” Sloan said.
LaForte agreed the cuts will impact long-term care but said much of it will be determined on the state level. Each state will be faced with a decision on where to cut Medicaid, which could result in lower reimbursements for nursing homes in the future.
“With immediacy, is there a negative impact? No,” LaForte said. “In the long term, is there going to be difficulties and likely negative impact? Probably, unless the states are willing to open up their coffers and more adequately fund Medicaid for long-term care.”
LaForte said more funding alongside efforts to bolster the workforce will be very important as the older demographic rises in the United States.
“We’re now at the start of the age wave,” LaForte said. “Every year, 4 million people are going to age into the cohort of people who enter nursing homes for care, and we are struggling to find staff nationally.”
During 40 years of working in long-term care, Danford said he hasn’t seen conditions get any better. And with the future in limbo, he only sees it getting worse.
Danford did say there are some good things happening in long-term care. Smaller not-for-profit homes are cropping up and seem to yield a higher quality of care. And legislators are working to address understaffing and other issues through the law.
Danford encouraged people seeking a good nursing home to look for things like turnover, staffing ratios, whether or not they are for profit and also the ownership.
“I’m tired,” Danford said. “It’s hard for me to see where things are going, particularly what’s happening in D.C. right now. We’ve got bad situations that are on the threshold of things getting significantly worse. It’s hard to be optimistic.”
For Smith, watching her friend’s health slowly degrade made her lose faith in the nursing home industry. Smith said once she gets to the point of needing that care, she’d rather spend the rest of her life on a street corner .
“All of these puzzle pieces aren’t fitting together,” Smith said. “Nobody is paying attention to the fact that you need some sort of consistent care.”
Smith said she wished there was more she could have done. Before Overbay’s surgery she worked part time at a dollar store and often brought smiles to each of her customers.
Overbay offered Tupperware on her local “Buy nothing” Facebook group that promoted less consumerism, which was how she and Smith met. Overbay donated and kept street food pantries near her home stocked up.
“When she was still home and working, Frances had a lot of love for life, her independence, and for everyone who needed help,” Overbay said in a Facebook post.
Overbay loved any excuse she had to go outside and grew irises in her yard. Smith wished she could have taken her to see them again but had to show her pictures instead.
All of this was waiting for her, Smith said, but Overbay spent the rest of her life in the bed of a nursing home.