Spokane Health & Rehabilitation: Bed Hold Failures - WA
The resident, identified in inspection records only as Resident 90, had been admitted to Spokane Health & Rehabilitation with a bloodstream infection serious enough to cause organ-wide spread, and lungs that could no longer exchange oxygen correctly. She had severe cognitive impairment. On March 9, 2025, at 12:21 p.m., a progress note recorded that she had developed difficulty breathing and a fever. Her family asked that she be sent to the emergency room. Sixteen minutes later, she was in an ambulance.
What happened to her bed was never addressed.
Federal inspectors reviewing her medical record found no documentation that a bed hold had been offered to her family representative at any point after the transfer. The omission wasn't an isolated mistake by one nurse on a busy shift. It reflected something the facility's own assistant director of nursing acknowledged out loud to inspectors: the facility was inconsistent about offering bed holds and inconsistent about completing the paperwork that would record them.
Staff H, a licensed practical nurse, told inspectors on April 22 that the nurse who handled Resident 90's transfer simply did not offer bed hold information when the ambulance was called. Staff H added that at the facility, bed holds were typically handled by nurse management, but only if a resident was still out of the building after midnight.
That framing matters. A resident transferred at 12:37 in the afternoon, whose family might need to make a decision about her room and her belongings and her place in the facility within hours, would fall entirely outside the informal system Staff H described. The bed hold conversation, under that approach, would only happen if nobody had come back by the following day.
Staff C, the assistant director of nursing, offered a slightly different account. Residents were supposed to be offered a bed hold at the time of transfer, Staff C said. If that didn't happen, staff were supposed to follow up the next day. Then Staff C acknowledged that neither was happening reliably.
The administrator, identified as Staff A, told inspectors the expectation was clear: staff should offer the bed hold at the time of transfer. The expectation and the practice were not the same thing.
A bed hold is not a bureaucratic formality. For a family navigating a sudden hospitalization of a cognitively impaired loved one, the question of whether that person's room will still exist when they're discharged is immediate and consequential. Nursing home beds are not easily replaced. Losing one during a hospitalization can mean a transfer to a different facility, a longer discharge process, or a placement that doesn't match the resident's needs or the family's geography. The information about whether a hold is available, what it costs, and how long it lasts belongs in a family's hands the moment the ambulance leaves.
Inspectors cited the facility under Washington state regulation WAC 388-97-0120(4), which governs the rights of residents during hospital transfers. The deficiency was tagged at the level of minimal harm or potential for actual harm, affecting some residents.
Whether Resident 90's family was ever told, after the fact, that a hold had been available, the inspection record does not say. Whether she returned to the facility, or to a different one, or not at all, the record does not say that either. What it says is that on the day she was most vulnerable, the conversation her family needed to have never happened, and the people responsible for making it happen couldn't agree on whose job it was.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spokane Health & Rehabilitation from 2025-04-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 29, 2026 · Our methodology
SPOKANE HEALTH & REHABILITATION in SPOKANE, WA was cited for violations during a health inspection on April 24, 2025.
She had severe cognitive impairment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.