Federal inspectors found multiple medication safety violations during their April 24 visit to the facility on North Assembly Street. The problems ranged from basic storage failures to more serious lapses in tracking controlled substances like Ativan, which has high potential for abuse.
In the facility's medication room, two of three emergency kits were found unsealed, each containing multiple vials and bottles of Ativan used to treat anxiety. Assistant Director of Nursing Staff C told inspectors the kits should have been sealed and acknowledged the controlled medication was not being counted to prevent diversion.
The facility also used a locked drop box to store medications awaiting destruction, including controlled drugs. Staff C confirmed that once medications were placed in the safe, no counts were performed to ensure controlled substances weren't being stolen during the waiting period before disposal.
On medication carts throughout the facility, inspectors discovered expired insulin that should have been discarded weeks earlier. Cart 1 on the Med Bridge unit contained opened Humalog insulin dated March 21 and Novolin insulin dated March 18 — both well beyond their 28-day expiration period.
Licensed Practical Nurse Staff H acknowledged the insulin was expired and should have been thrown away.
Cart 2 revealed additional problems. The top drawer contained a medication cup with a resident's name handwritten on it, holding six unidentified pills. Nearby sat an unlabeled bottle of nitroglycerin tablets and an EpiPen in a plastic bag marked only with a resident's name — no pharmacy labels with proper identification information.
Staff C admitted the medications needed proper labeling and believed they had been improperly removed from the emergency cart.
The medication violations extended to residents' rooms. Inspectors found Resident 95 with two Imodium tablets sitting openly on their bedside table during an April 14 visit. The resident said they hadn't used the anti-diarrhea medication since August.
The next day, the same tablets remained on the bedside table when Licensed Practical Nurse Staff X confirmed they should not be unsecured in the room. Resident 95 then revealed five additional generic loperamide tablets hidden in their coin purse, brought by family members.
Staff X confirmed no doctor had ordered either medication and the resident had no permission to keep drugs at bedside. "The family should know not to bring in medications and if we find them, we take them or have family come pick them up," Staff X told inspectors.
The facility's problems extended beyond medication safety to basic staffing transparency requirements. For four consecutive months, Spokane Health & Rehabilitation failed to consistently post daily staffing information where residents and families could see it.
During multiple observations from April 14 through April 21, inspectors found no daily staffing information posted in prominent locations. When confronted, Staffing Coordinator Staff N and Assistant Director Staff C each thought the other was responsible for posting the information.
Staff N provided what records existed, but documentation stopped completely after March 14. January showed gaps on 13 different dates, February missed 15 days, and March had no information for the first 13 days of the month.
Administrator Staff A acknowledged the facility was required to post daily staffing levels but had clearly failed to do so consistently.
The inspection also revealed serious gaps in nutrition services that put vulnerable residents at risk. Four of five sampled residents experienced problems with nutritional assessments, weight monitoring, or supplement provision.
Resident 60's case illustrated the most concerning failures. Hospital records from March 9-10 showed the resident weighed between 162 and 168.6 pounds. But when facility staff finally obtained a weight on March 17 — seven days after admission — it was just 149.4 pounds, representing an 8 percent weight loss.
Despite facility policy requiring re-weighing to confirm significant weight changes, staff never verified the dramatic drop. The resident continued refusing to be weighed on multiple occasions, with nurses documenting refusals on March 12, March 31, and other dates.
Registered Dietitian Staff HH completed a nutritional assessment acknowledging the 149.4-pound weight but answered "does not know" when asked about weight loss in the previous three months. The assessment noted "Need updated weight" but showed no effort to reconcile the hospital weights with the facility's measurements.
During an April 18 interview, Resident 60 said they didn't know their current weight and that staff hadn't involved them in dietary decisions. "Not really," they responded when asked if the facility included them in food preference discussions.
Staff HH later calculated the 8 percent weight loss but explained the resident "did not trigger for the significant weight loss" because hospital weights weren't entered in the electronic system's weight summary section.
Resident 88 faced different nutrition problems related to dialysis treatments. Doctor's orders required Nepro supplement before each dialysis session on Tuesdays, Thursdays, and Saturdays. Nepro is specifically designed for dialysis patients with higher protein and lower potassium and phosphorus levels.
But Resident 88 told inspectors the supplement was "horrible" and "watered down," making them sick to their stomach. "I wouldn't wish it on my worst enemy," they said during an April 21 interview.
Instead, the resident purchased their own Ensure Plus supplements and took them to dialysis. Licensed Practical Nurse Staff TT confirmed Resident 88 refused the prescribed Nepro because of taste, but nutrition meeting notes continued documenting that the resident accepted the supplement "100% of the time."
Staff HH, the dietitian, admitted being unaware that Resident 88 disliked and wasn't consuming the prescribed Nepro, despite reviewing medication records that should have revealed the pattern of refusals.
Resident 313 experienced the most delayed nutritional assessment. Admitted March 25 with diagnoses including malnutrition and adult failure to thrive, the resident didn't receive a comprehensive nutritional evaluation until April 16 — 22 days later.
The resident's representative explained they had been purchasing and bringing Ensure because they understood the facility's nutritional drinks weren't available to their loved one. Meal monitoring records showed Resident 313 refused meals on 12 of their first 25 days at the facility.
When inspectors observed Resident 313 on April 15, an untouched vanilla protein drink sat on the bedside table while the very thin resident lay in bed watching television.
Staff HH acknowledged being "behind on getting them completed" when asked about the delayed assessment and admitted not speaking with Resident 313's representative about dietary preferences, despite the resident's diagnoses requiring immediate nutritional intervention.
The facility also failed basic employee oversight requirements. Three nursing assistants hired between April 2023 and December 2023 had no annual performance evaluations in their personnel files, despite facility expectations that reviews occur yearly.
Administrator Staff A acknowledged the missing evaluations when confronted by inspectors, confirming that Staff K, L, and M lacked required performance reviews that should inform ongoing training needs.
These systematic failures across medication safety, staffing transparency, nutrition services, and employee oversight created an environment where residents faced multiple risks to their health and safety. From controlled drugs sitting unsealed to residents losing significant weight without proper monitoring, the violations revealed gaps in fundamental care processes that nursing homes must maintain to protect vulnerable residents.
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
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