Spokane Health & Rehabilitation: Medication Safety Failure - WA
That was the finding when federal inspectors visited Spokane Health & Rehabilitation in April.
Resident 22 had been prescribed Tums E-X 750 milligram chewable tablets, two tablets twice daily as needed, under an order dating to November 2022. The prescription was for gastrointestinal upset. What the resident's record did not contain, at any point in the nearly two and a half years since that order was written, was an assessment determining whether the resident could safely manage those tablets on their own, or a physician order permitting self-administration.
On April 14, an inspector observed Resident 22 lying in bed, the bottle of Tums sitting on the overbed table within reach. The resident said they took them whenever they needed them.
The bottle was still there the next day at 12:12 in the afternoon. It was there again on April 16 at 9:11 in the morning and again just before noon. It was there April 17 at 8:56 in the morning. It was there April 21 at 8:44 in the morning. Six observations over eight days.
The April 2025 medication administration record showed no documented Tums administrations at all. Nobody on staff had been recording the doses, because nobody on staff had been giving them. The resident was handling it alone, without authorization and without anyone having determined whether that was appropriate.
The significance of that gap is not small. Resident 22 had Parkinson's disease, a condition affecting movement and coordination, and was assessed as having moderate cognitive impairment, though able to communicate their needs. Whether that combination made unsupervised, untracked antacid use safe was precisely the question the facility was supposed to answer before leaving the bottle in arm's reach. It never did.
The facility's own Resident Care Manager, interviewed on April 22, described exactly how the process was supposed to work. Residents who wanted to self-administer medications needed to be assessed by a provider, have an order obtained, and complete a self-medication assessment. If approved, they received a lock box to store their medications securely. The manager said the assessments mattered because they established whether a resident could take their own medications safely. Then the manager said Resident 22 should have had that assessment completed.
Should have. Hadn't.
The concern with unmonitored antacid use in this context is not theoretical. A resident with moderate cognitive impairment and no documented self-administration protocol could take too many tablets, too frequently, or at times that interfered with other medications, without any staff awareness. The medication administration record would show nothing, because it was already showing nothing. There was no system in place to catch a problem.
Inspectors cited the facility for failing to assess the resident's ability to self-administer medications safely, a deficiency classified as having minimal harm or potential for actual harm. One resident was identified in the finding.
Spokane Health & Rehabilitation is located at North 6025 Assembly in Spokane.
The Tums were still on the table on the sixth day inspectors looked.
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 was the finding when federal inspectors visited Spokane Health & Rehabilitation in April.
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.