Spokane Health & Rehab: Unsecured Ativan Kits Found - WA
That is what a federal inspector found at Spokane Health & Rehabilitation on the morning of April 24, 2025, at just after nine o'clock.
The first unsealed kit held two vials of injectable Ativan and three bottles of oral liquid Ativan. The second held two vials of injectable Ativan and two bottles of oral liquid. A third kit in the same room was sealed. When the inspector asked the staff member present, identified in the report as Staff C, whether nurses were counting the Ativan in those kits to make sure none of it was being diverted, Staff C said the kits should have seals on them and confirmed the Ativan was not being counted.
Diversion is the theft or misuse of controlled substances by healthcare workers. It is among the more difficult problems to detect in a care setting precisely because it depends on consistent, documented counts to catch discrepancies before they compound. Ativan, the brand name for lorazepam, is a benzodiazepine with a recognized potential for abuse and dependency.
The unsealed kits were not the only concern the inspector found that morning.
The same medication room contained a locked drop-box safe used to hold medications waiting to be destroyed or returned to the pharmacy, including controlled substances. Staff C explained that only two keys existed to open the safe and that both were kept by nurse managers. The design of the safe, a drop slot that allowed medications to go in but not come back out without a key, might suggest the contents were secure. But when the inspector returned to the question of controlled substances just before ten o'clock that morning, Staff C confirmed that once a controlled medication was dropped into the safe, no one was counting it.
The medications sat there, untracked, until someone with a key decided to open the safe.
That gap matters because the waiting period before destruction or pharmacy return can stretch across days or longer, and a safe that accepts deposits but never inventories them offers no way to know whether what went in is still there. Staff C did not indicate how long medications typically remained in the safe before being removed, and the inspection report does not specify what controlled substances were inside it at the time of the visit.
Together, the two findings describe a medication storage environment where controlled substances existed in at least two separate locations without any counting mechanism to detect whether they were being taken. The emergency kits were unsealed and unmonitored. The destruction safe accepted controlled drugs and then, from a tracking standpoint, lost them.
Spokane Health & Rehabilitation is located at North 6025 Assembly Street in Spokane. The inspection was conducted as a health survey, and the level of harm was assessed as minimal harm or potential for actual harm, affecting some residents. The deficiency was cited under Washington Administrative Code provisions governing medication management.
The facility's plan of correction was not included in the inspection report. Readers seeking that information can contact the facility or the Washington State Department of Health.
What the inspection captured was a staff member who knew the kits were supposed to be sealed, said so directly when asked, and acknowledged that the counting simply was not happening. Not a policy gap discovered after the fact. A practice that had not been followed, confirmed out loud, in the medication room, on a Thursday morning in April.
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.
That is what a federal inspector found at Spokane Health & Rehabilitation on the morning of April 24, 2025, at just after nine o'clock.
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.