Spokane Health & Rehabilitation: Call Light Failures - WA
The resident in that room, identified in inspection records only as Resident 65, had already fallen five times.
The first fall came on February 5, 2024, one hour and fifty minutes after the resident was admitted to Spokane Health & Rehabilitation on North Assembly Street. Four more followed: February 13, 2025, February 28, 2025, March 12, 2025, and March 14, 2025. The facility's own incident log recorded each one.
After those falls, the care plan spelled out what staff were supposed to do: anticipate the resident's needs, keep the bed in the lowest position against the wall, put common items within reach, and educate the resident on safe transfers. The instructions were written down. They were in the plan.
Inspectors arrived on April 14, 2025, and found the bed's right side pushed against the wall. The call light was pinned to the cord coming out of the wall, unreachable from the left side of the bed by someone sitting in a wheelchair. They noted the same thing at 10:09 that morning. They came back the following day, April 15, at 8:47 AM and again at 10:37 AM. The call light was still pinned to the wall cord, still out of reach.
On April 16, the bed was in a high position. The call light was on the floor behind it. Inspectors recorded the same finding at 12:06 PM and 2:38 PM that day. They returned April 17 at 8:37 AM. The call light was on the floor. They came back April 21 at 7:48 AM and 10:25 AM. The call light was on the floor.
Six separate observation windows across eight days. The same problem each time.
On April 21 at 10:37 AM, a nursing assistant identified in the report as Staff P was standing in the room when an inspector pointed to the call light lying on the floor. Staff P said the call light needed to be left where the resident could use it to call for help.
Seventeen minutes later, the facility's administrator said the same thing. Staff were expected, the administrator said, to leave call lights where residents could reach them.
What the administrator expected and what inspectors observed, six times across eight days, were not the same thing.
A call light on the floor behind a bed does not help a resident who needs to call for help. It does not help someone who has already fallen five times, whose care plan exists precisely because the falls kept happening. The plan anticipated the problem. The plan named the solution. The solution did not get implemented.
The inspection covered the period ending April 24, 2025, and cited the facility under Washington state regulation WAC 388-97-2280, which addresses resident care and safety measures. The deficiency was classified as causing minimal harm or potential for actual harm, affecting some residents.
Resident 65 fell within two hours of arriving at the facility. They fell again six weeks before inspectors showed up. They fell twice in a two-day stretch in March. Through all of it, the call light kept ending up somewhere a person in a wheelchair could not reach it, or on the floor behind a bed, where it was useful to no one.
The facility's plan of correction was not included in the inspection record. For information on the plan, CMS directs the public to contact the nursing home or the state survey agency directly.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 26, 2026 · Our methodology
SPOKANE HEALTH & REHABILITATION in SPOKANE, WA was cited for violations during a health inspection on April 24, 2025.
The resident in that room, identified in inspection records only as Resident 65, had already fallen five times.
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.