Spokane Health & Rehabilitation: Ombudsman Notification Failures - WA
Nearly a year of hospital transfers and discharges, and the ombudsman's office had been told about exactly one of them.
The finding emerged during an April 2025 inspection at the facility on North Assembly. Inspectors were looking at how the home handled notification requirements when residents were sent to the hospital or discharged, and what they found was a system that had effectively stopped functioning, with nobody inside the building willing to claim ownership of the problem.
The administrator, identified in the inspection report as Staff A, told inspectors on April 22 that they believed social services was handling ombudsman notifications at the end of each month. Thirteen minutes later, the Social Service Director, Staff V, told inspectors something different: they were unsure who was responsible for notifying the ombudsman at all.
The ombudsman herself settled the question. She told inspectors she had gone back through her records and found the single December notice. The facility had not sent notifications to her office. Not monthly, not occasionally. Once, in eleven months.
One of the residents whose hospitalization went unreported was Resident 16, a person with heart failure and muscle weakness who was described in a March 2025 assessment as cognitively intact and able to clearly communicate their needs. On February 4, 2025, nursing notes recorded that Resident 16 was ashy in color, unresponsive, had a rising temperature, and had dropping oxygen levels. Staff transported them to the hospital.
The ombudsman was not notified.
The ombudsman's office exists specifically to serve as an outside advocate for nursing home residents, a check on a setting where residents are often isolated from family and unable to navigate complaints on their own. When a resident is hospitalized, the ombudsman is supposed to know. When a resident is discharged, the ombudsman is supposed to know. The notification requirement is not a formality. It is how an independent office tracks whether residents are being harmed, discharged inappropriately, or lost in transitions between facilities.
None of that oversight was possible for the better part of a year at Spokane Health & Rehabilitation.
The inspection also flagged a documentation gap involving a second resident. Resident 41 had a diagnosis of spinal stenosis of the neck, a narrowing of the spinal canal that was compressing the spinal cord, and was scheduled for surgery on April 18, 2025. Nursing staff left no progress notes for that day. When an inspector checked the room at 8:50 that morning, Resident 41 was gone and the bed was stripped. A check at 10:47 AM found the same thing. When inspectors returned on April 21 at 6:16 in the morning, the room was still empty.
A licensed practical nurse confirmed on April 18 that Resident 41 had left for a surgery appointment. There was no documentation of the departure, no nursing notes tracking what happened before or after a resident went out for spinal cord surgery.
The inspection report rated the deficiencies as causing minimal harm or the potential for actual harm, and noted that the violations affected many residents. The facility's plan of correction was not included in the inspection record reviewed.
What the ombudsman found when she looked back was the shape of a gap, eleven months wide, during which residents at Spokane Health & Rehabilitation were hospitalized, discharged, and moved without the one outside office charged with watching over them ever being told.
Resident 16 went to the hospital unresponsive, with oxygen levels falling. The ombudsman found out about it in April 2025, more than two months later, because a federal inspector asked.
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 27, 2026 · Our methodology
SPOKANE HEALTH & REHABILITATION in SPOKANE, WA was cited for violations during a health inspection on April 24, 2025.
Nearly a year of hospital transfers and discharges, and the ombudsman's office had been told about exactly one of them.
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.