Spokane Falls Care: Elopement Risk Failures Cited - WA
Inspectors cited the facility on November 18, 2025, following a complaint investigation into how the home handled elopement risk for a resident staff acknowledged should never leave unattended.
The first disappearance that inspectors focused on happened in June. The resident left and did not come back when expected. Staff could not locate them. The facility called the family. Then they called the police. The resident turned up in an emergency room, having gone there on their own because of chest pain.
Staff E, whose title the report does not specify, confirmed to inspectors on September 26 that after the June incident, an updated elopement risk assessment should have been completed. It wasn't. Not then.
The resident had also left the facility unattended on a separate occasion. Staff E acknowledged both incidents, describing the other departures from the building as times the resident had been accompanied by family. But at least twice, the resident had gone out alone, and at least once, nobody knew where they were.
The care planning process the facility described was informal at best. When therapy identified a concern, it would send a message to nursing. Nursing would bring it up at stand-up, the brief daily meeting where staff review residents. Staff E said the resident "was often discussed in stand up" and that staff "discussed a care plan."
But when inspectors asked to see one, Staff E could not find a care plan that existed before the investigation began. The only updated care plan on record was the one completed after inspectors started asking questions.
Staff F, another employee whose role the report does not identify, told inspectors they were not present when the resident was admitted and were not at the facility during the June elopement. That detail matters because the risk the resident posed was something staff said they understood. The resident had poor decision-making. The resident had no safe reasoning. Those were the words staff used to describe someone who, by their own account, should not have been allowed to walk out the door alone.
The gap between what staff said they knew and what the records show they did is the core of what inspectors found. A resident whose cognitive limitations were recognized, whose history of leaving unattended was known, and whose disappearance had already required a police notification and an emergency room visit, still did not have a documented, updated safety plan until after investigators came looking.
Inspectors classified the violation under F0689, which covers accidents and supervision, and rated the level of harm as minimal harm or potential for actual harm, with few residents affected. That classification reflects the regulatory framework, not the experience of being a family member waiting to hear where your loved one went after they didn't come back when they said they would.
Staff E's account of the June incident was matter-of-fact. The resident hadn't returned when expected. The facility contacted the family when they could not locate the resident. The police were notified. The resident had gone to the emergency room because of chest pain.
A person with documented cognitive limitations, alone, in an emergency room, because a facility that knew the risk hadn't put a plan on paper.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spokane Falls Care from 2025-11-18 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 31, 2026 · Our methodology
SPOKANE FALLS CARE in SPOKANE, WA was cited for violations during a health inspection on November 18, 2025.
The first disappearance that inspectors focused on happened in June.
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.