Spokane Health & Rehabilitation: Fall Monitoring Failures - WA
Inspectors who visited Spokane Health & Rehabilitation in April 2025 found that the neurological monitoring sheet completed after the fall contained 10 omissions. For several of those missed checks, staff had written that the resident was asleep. No further progress notes about the fall appeared anywhere in the resident's record.
The resident, identified in inspection records only as Resident 69, was cognitively intact and able to communicate her needs. Her diagnoses included high blood pressure, anxiety, and a documented history of repeated falls. A care plan put in place in December 2024 listed her fall risks specifically: weakness, poor vision, incontinence, and functional impairments. Multiple interventions were written into that plan.
None of that documentation changed what happened on the night of September 19, 2024.
A progress note from that date recorded that the resident reported falling in her room and had gotten herself up off the floor before staff arrived. She said she had landed on her right side. The nurse noted that neurological checks, standard monitoring used to detect signs of head injury or internal trauma after a fall, had been initiated.
They were not completed.
Ten checks were skipped. The monitoring sheet, the only record of what was supposed to happen next, listed the resident as asleep for some of those gaps. Whether staff checked on her and chose not to wake her, or simply did not check at all, the inspection report does not say. What it does say is that after those initial entries, the record goes silent. No progress notes. No documented follow-up. No indication that anyone returned to the fall in writing.
Neurological monitoring after a fall exists for a specific reason. A resident who has landed on her side, who is elderly, who has poor vision and a history of falling, faces real risk of injury that does not always announce itself immediately. Changes in alertness, confusion, unequal pupils, complaints of headache or neck pain, these are the things such monitoring is designed to catch. Ten gaps in that monitoring mean ten windows where a change could have gone undetected.
The inspection report rates the level of harm as minimal harm or potential for actual harm. That rating reflects what inspectors could document, not necessarily what the resident experienced in the hours when nobody was writing anything down.
A March 2025 significant change assessment, completed roughly six months after the fall, noted that Resident 69's diagnoses still included high blood pressure, anxiety, and repeated falls. The assessment confirmed she remained cognitively intact.
What it could not confirm, and what the record as a whole cannot confirm, is what those ten missed checks might have caught.
The facility's address is listed as North 6025 Assembly, Spokane, Washington. The inspection was completed April 24, 2025.
Resident 69 got herself up off the floor that September night, told someone what had happened, and then the system designed to watch over her afterward failed to do so ten separate times. The care plan had the interventions. The monitoring sheet had the blanks. The record had nothing more to say.
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 29, 2026 · Our methodology
SPOKANE HEALTH & REHABILITATION in SPOKANE, WA was cited for violations during a health inspection on April 24, 2025.
For several of those missed checks, staff had written that the resident was 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.