Spokane Health & Rehabilitation: Fall Monitoring Failures - WA
The April 2025 federal inspection of Spokane Health & Rehabilitation on North Assembly found that after Resident 69 fell in September 2024, the facility's own neuro monitoring sheet recorded ten omissions. Where checks should have been documented, the sheet listed the resident as asleep. No further progress notes about the fall appeared anywhere in the resident's record after the initial report.
Resident 69 had high blood pressure, anxiety, and a documented history of repeated falls. A care plan written in December 2024 identified the resident as at risk for falls related to weakness, poor vision, incontinence, and functional impairments. Multiple interventions had been written into that plan. The resident was cognitively intact and able to communicate their own needs.
That matters. When the resident fell on September 19, 2024, they told staff exactly what happened. They said they had fallen in their room, gotten themselves up, and landed on their right side. A nurse documented initiating neurological checks. Then, ten times, those checks didn't happen, or weren't recorded, or were noted only as the resident being asleep.
A neuro monitoring sheet exists for a reason. After a fall, particularly one where a resident lands on their side and gets up without help, the concern is what may not be visible immediately. Head injuries, internal bleeding, fractures, changes in consciousness. The checks are how staff catch what the resident can't report and what no one witnessed.
Ten omissions means ten windows where that information was never gathered.
After the initial progress note from the day of the fall, the record went silent. No follow-up notes. No documentation of how the resident was doing in the days after. The care plan had interventions. The monitoring sheet had blank spaces where entries should have been. The record had nothing more to say about what happened to Resident 69 after they picked themselves up off the floor.
Inspectors rated the harm level as minimal or potential for actual harm, meaning the violation did not rise to the level of causing documented serious injury. Some residents were affected, according to the inspection findings.
The facility's address is North 6025 Assembly in Spokane. The inspection was completed April 24, 2025.
What the record doesn't show is whether anyone reviewed those omissions before federal inspectors arrived. Whether a supervisor looked at the monitoring sheet and saw the gaps. Whether anyone asked why there were no follow-up notes after a fall involving a resident already flagged for repeated falls, poor vision, and weakness.
Resident 69 was able to make their needs known. They did. They told the nurse what happened, where they landed, that they had gotten up alone. After that, the documentation stopped, and ten checks went unrecorded.
The resident was still living at the facility when inspectors reviewed the records.
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.
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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.
Where checks should have been documented, the sheet listed the resident as asleep.
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.