Colville Health and Rehabilitation of Cascadia

Inspectors wroteBased on interview and record review, the facility failed to routinely provide pharmaceutical service that ensured accurate dispensing and administration of medications for 3 of 3 sampled residents (Resident 1, 2, and 3), reviewed for medication administration. This failure placed residents at risk for potential medication errors, misappropriation of opioid medications (also referred to as narcotic, powerful pain medication used to treat severe pain) and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of potential abuse was reported as required to the State Survey Agency within two hours after the allegation was made, for 1 of 3 sampled residents (Resident 1), reviewed for abuse and/or neglect. Failure to report an allegation of potential abuse placed Resident 1, and other residents in the facility, at risk for additional abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, report, protect, assess and prevent a pattern of resident-to-resident verbal and physical abuse. This included identifying a known pattern of aggressive behaviors by Residents 19. Abusive behaviors identified by staff included hitting, punching, kicking, ramming into other residents with a wheelchair (w/c), verbal abuse, threats and intimidation of other residents. The facility failed to recognize these instances as abuse, analyze the circumstances of these abusive behaviors, or implement plans for prevention or recurrence of abuse for 11 of 12 sampled residents (Resident 19, 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41), reviewed for abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide effective monitoring and supervision, implement interventions, develop adequate and effective interventions to prevent repeated falls with adverse and injurious sequelae related to those falls for 3 of 7 sampled residents (Residents 19, 50, and 60), reviewed for falls. Resident 19 experienced harm when they had repeated falls as evidenced by a dislocated hip on 09/12/2024, a right femur (leg bone) fracture on 01/14/2025, and a back fracture on 03/03/2025. Resident 50 experienced harm when they fell a total of 36 times between 04/04/2024 to 05/17/2025 and sustained a range of injuries, to include hospital transfers for their treatment. Resident 60 experienced harm when they fell and sustained a fracture to their eye socket and left lower leg and had a delay in discharge to the community. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently ensure the facility had enough staff to provide adequate supervision and safe care according to the facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 3 of 7 sampled residents (Resident 19, 50, and 60), reviewed for falls. Resident 19 experienced harm from repeated falls as evidenced by a dislocated hip on 09/12/2024, a right femur (leg bone) fracture on 01/14/2025, and a back fracture on 03/03/2025. Resident 60 experienced harm when they fell three times and sustained a fracture to their eye socket and left lower leg. Resident 50 experienced harm when they fell a total of 36 times from 04/04/2024 to 05/17/2025 and experienced a range of injuries, to include hospital transfers for their treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered as prescribed for 2 of 6 sampled residents (Residents 34 and 61) reviewed for medication administration. Resident 34 received an injection of Lantus insulin (a type of insulin used to treat high blood sugar that provided a consistent level of insulin over a 24-hour period and mimicked the body's natural insulin production) that was 7.2 times their prescribed dose that was ordered for a different resident (Resident 42). Resident 34 experienced harm when they had an extended period of symptomatic hypoglycemia (extremely low blood sugar) that required administration of rescue medications on five different occasions to normalize their blood sugar level and symptoms. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered Nurse (RN) was on duty a minimum of eight consecutive hours a day, seven days a week, as required. This failure placed all residents at risk of lack of RN oversight for care provided, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to effectively use its resources to maintain facility compliance with Federal regulatory requirements to ensure potential situations of abuse were identified and proper measures were taken for 11 of 12 sampled residents (Residents 19, 31, 49, 21, 43, 27 37, 33, 45, and 3) reviewed for abuse, provide adequate nursing staff to supervise residents and complete care timely for 3 of 7 sampled residents (Residents 19, 50, and 60) reviewed for falls, provide behavioral and/or mental health services for 2 of 8 sampled residents (Resident 34 and 40) reviewed for mood and behavior, administer medications as prescribed for 2 of 6 sampled residents (Residents 34 and 61) reviewed for medication administration, and implement appropriate infection control measures for 3 of 3 nursing units reviewed for infection [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that identified deficiencies, implemented good faith efforts for corrective actions, and evaluated implemented corrective actions or performance improvement activities for effectiveness. The facility's QAPI program failed to timely recognize already compromised care and services that resulted in a potential for a pattern of resident harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assessment and Assurance Program (QAA) that identified deficiencies and implemented appropriate preventative or corrective actions. The facility's QAA program failed to timely recognize already compromised care and services that resulted in a potential for a pattern of resident harm.

Inspectors wroteBased on interview and record review the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that met at least quarterly and included the Infection Preventionist who was a required member of the QAA committee. This failure minimized the effectiveness of the interdisciplinary QAA team ' s ability to identify processes and outcomes related to infection control practices and disease management. Additionally, this failure resulted in 27 of 61 residents and 33 staff members contracted Norovirus (highly contagious, gastrointestinal (GI), infectious illness that caused nausea, vomiting, and diarrhea).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection control program that identified, reported, and controlled the spread of communicable diseases for residents and staff during a Norovirus [a highly contagious gastro-intestinal (GI, affected the stomach and intestines) virus that caused nausea, vomiting and diarrhea] outbreak and to implement basic infection prevention interventions that included enhanced barrier precautions, transmission-based precautions, prompt reporting of a laboratory confirmed Norovirus outbreak to the State Survey Agency and local health departments, and exclusion of staff members from work according to the recommended standards. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain a resident call light system that was functionable and audible, as required. This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure direct care staff were provided the mandatory effective communication training for 10 of 10 sampled staff (Staff P, L, AA, R, BB, K, CC, DD, EE, and FF) reviewed for communication training. This failure placed all residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their representatives about their right to have their bed held while hospitalized for 2 of 4 sampled residents (Residents 51 and 19), reviewed for hospitalizations. This failure precluded the residents and/or their representatives to participate in decisions regarding their right to return to the same facility upon hospital return, and the right to know how much the facility would charge for holding their bed.

Inspectors wroteBased on interview and record review the facility failed to repeatedly implement the facility abuse prevention policy to include identification of potential instances of abuse, reporting allegations to the State Survey Agency as required, thoroughly investigate allegations, review interventions for effectiveness, revise interventions as needed, and communicate, coordinate, review, and track allegations of abuse through the Quality Assurance and Performance Improvement (QAPI) program for 1 of 11 sampled resident (Resident 19), reviewed for abuse. This failure placed residents at risk of abuse, psychosocial harm, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate with the State designated authority to ensure residents with a mental disorder received integrated care based on their needs for 3 of 7 sampled residents (Residents 34, 37, and 40) reviewed for Pre-admission Screening and Resident Review (PASRR, a two part screening; Level I determined presence of a Severe Mental Illness, SMI, or Developmental Disability and if present required a Level II evaluation by a specialized evaluator to determine if nursing home placement was the appropriate level of care, and what behavioral health or other community services were recommended. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided consistently and routinely met professional standards of practice for 2 of 4 sampled residents (Resident 51 and 19), reviewed for hospitalizations. Specifically, the facility failed to repeatedly ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider. This failure placed residents at risk of potential delays in emergent hospital treatment, unmet care needs, and potential complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff notified the provider for 3 of 3 sampled residents (Resident 34, 40 and 61) reviewed for change in condition. Specifically, the staff failed to notify the provider when Resident 34 experienced extremely low blood sugars, Resident 40 experienced significantly low blood pressures (BP), and Resident 61 experienced elevated blood sugars. This failure precluded the provider's involvement in coordinating care and placed the residents at risk of further adverse or deteriorating clinical outcome.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques related to diabetes management, medication administration, Post Traumatic Stress Disorder (PTSD), Substance Use Disorders (SUD), Gradual Dose Reductions (GDR), trauma informed care, fall management, or incident root cause analysis to ensure staff provided necessary care and responded to each resident's individualized needs for 8 of 10 sampled staff (Staff P, L, AA, BB, CC, DD, EE, and FF), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure behavioral health services were provided for 2 of 3 sampled residents (Residents 34 and 40), reviewed for mood and behavior. This failure created risk for residents to experience a decline in their psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate medically related social services were provided to meet residents' needs at the time of transfer to the hospital or discharge to the community. Specifically, Social Services failed to ensure the basis for discharge was supported by documentation in the medical record for 1 of 4 sample residents (Resident 4), reviewed for discharge. This failure placed the resident at risk of placement in an unsuitable environment, increased risk of harm, and psychological distress. Additionally, Social Services failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protect and promote the resident rights under federal and state law and regulations) of 37 transfers to the hospital for 5 of 5 months (January, February, March, April and May 2025) reviewed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff performed the required hand hygiene (HH) during meal service for 1 of 2 dining rooms (DR) observed. This failure placed the residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the governing body acted with disregard to the well-being of the residents of the facility; by not providing adequate oversight and monitoring of the appointed Corporate Officers/Administrator and/or the Director of Nursing. Failure to identify potential incidents of abuse, provide adequate nursing staff to supervise residents and complete care timely, provide mental health services, administer medications as prescribed, address and follow up timely on identified concerns, and implement appropriate infection control measures created multiple situations that caused harm to residents, and two separate situations of an immediate jeopardy (IJ: a situation that had occurred that could result in harm, serious injury and/or death). related to abuse and accident hazards.

Inspectors wroteBased on interview and record review, the facility failed to maintain minimum documentation that staff were educated regarding risks and benefits of the COVID-19 (a viral illness that caused fever, difficulty breathing or possibly death) vaccine, were offered the vaccine, and the COVID-19 vaccine status of the staff as required for 1 of 1 staff reviewed. This failure placed staff and residents at risk of and exposure to illness from COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure the mandatory Quality Assurance and Performance Improvement (QAPI) training was provided as required for 10 of 10 sampled staff (Staff P, L, AA, R, BB, K, CC, DD, EE, and FF) reviewed for training requirements. This failure placed all residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the mandatory Compliance and Ethics training was provided as required for 9 of 10 sampled staff (Staff P, L, AA, R, BB, K, CC, DD, EE, and FF) reviewed for training requirements. This failure placed all residents at risk for unmet care needs and a diminished quality of life. Review of the following employee files found no documentation that showed the mandatory Compliance and Ethics training had been provided: [...]

Inspectors wroteBased on interview and record review the facility failed to maintain financial information in a secure manner to prevent unauthorized access for 1 of 2 sampled residents (Resident 49), reviewed for personal property. This failure placed residents at risk of misappropriation, financial exploitation and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure a homelike and safe environment and equipment that was in good repair for 2 of 2 halls and 2 residents (Resident 36 and 50). Failure to ensure floor tiles were replaced, the ends of metal wheelchair brake extenders were covered, and room walls and base board heater paint were intact, placed the residents at risk of injury and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was not administered as needed injectable antipsychotics (medication that affected the brain, emotions, or behaviors) unless the medication was necessary to treat a specific condition documented in the clinical record for 1 of 6 sampled residents (Resident 19), reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to identify, assess, and address potential signs and/or symptoms of Post Traumatic Stress Disorder (PTSD) for 1 of 8 sampled residents (Resident 19), reviewed for mood and behavior. This failure placed residents at risk of re-traumatization, unmet behavioral health needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were labeled in accordance with accepted professional standards and expired medications were removed from inventory. Specifically, insulin pens were not labeled with the date opened in one of two medication carts, and expired Bisacodyl suppositories (a medication to treat constipation) were found in one of two medication carts and the only medication room. This failed practice placed residents at risk of receiving expired medications, that may not have been fully effective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 3 sample residents (Resident 1) reviewed for elopement. The facility failed to adequately monitor a resident, who had expressed the desire to leave the facility. This placed the resident at risk for exiting the building without staff knowledge, and potential injury.

Inspectors wroteBased on interview and record review, the facility failed to notify the police of an allegation of sexual abuse. This failure placed residents at risk for potential abuse and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide showers for 4 of 5 sampled residents (Resident 1, 2, 3, 4), reviewed for bathing. This failure placed residents at risk for poor hygiene and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for accidents, was free from injury. Resident 1 experienced harm when they were transferred in a sit to stand (designed to assist patients who have some mobility but need help to rise from a sitting position) by staff, the resident's arm sling got caught and wrapped around their neck causing them to become unresponsive; staff left the resident unattended in the lift to get help, the resident fell out of the lift, and was found on the floor. This failure placed the residents at risk for falls and serious injury

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 6 sample residents (10, 20), reviewed for Pre-admission Screening and Resident Review (PASARR) [an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services] was completed accurately and if indicated, a referral for additional screening had been made. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan, to address a resident with wounds for 1 of 3 sample residents (33), whose care plans were reviewed. This failure placed the resident at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance during mealtimes for 1 of 1 sampled resident (16), reviewed for activities of daily living. This failure placed the resident at risk for decreased food and fluid intake, and possible unintended weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sample residents (15) reviewed for activities, was engaged in meaningful activities that met their interests. Failure to engage the resident in meaningful activities placed the resident at risk for boredom and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide effective bowel management for 2 of 3 residents (26, 37), reviewed for constipation. These failures placed residents at risk of unmet care needs and resulted in an emergency room visit for Resident 26, for further medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assess a resident for smoking safety for 1 of 2 sampled resident (37), reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to provide needed pain management for 1 of 3 sampled residents (6), reviewed for pain. This failure placed residents at risk of uncontrolled pain and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently collaborate care with the dialysis center, and accurately monitor the fluid restriction for 1 of 1 sampled resident (33) reviewed for dialysis care. These failures placed residents at risk of unrecognized complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from the pharmacist were addressed in a timely manner, for 1 of 5 sample residents (30), reviewed for unnecessary medications. These failures placed residents at risk for receiving an inaccurate dosing of medication, adverse side effects, and the risk of receiving a medication longer than medically necessary.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent for 2 of 4 sampled residents (2, 9), observed during medication pass. Specifically, 2 errors were made during 27 medication administration opportunities, resulting in an error rate of 7.41 percent. Errors in medication administration placed residents at potential risk for not receiving the full therapeutic effect of the medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate hand hygiene was performed during the meal service for 1 of 2 dining rooms. These failures placed the residents at risk for infections and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that direct care staffing information was correctly electronically submitted to the Centers for Medicare and Medicaid Services (CMS), for Quarter 3 of 2023, reviewed for Payroll Based Journal (PBJ mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for 2 of 3 sampled residents (Resident 1 and 2), reviewed for urinary catheters (a tube inserted in the bladder that allowed urine to drain). This failure placed the residents at risk for possible urinary tract infections (UTI's).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), reviewed for accidents, was free from injury. Resident 1 was transferred by a Hoyer lift (a power lift using a sling) independently by Staff B, Nursing Assistant. The Hoyer sling was improperly placed which caused Resident 1 to slide down during the transfer and their arms were pulled upward. Resident 1 experienced harm when they had pain and was sent to the hospital for evaluation where it was determined they sustained a fracture of their left arm. This constituted a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) at harm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program that provided a safe and sanitary environment, and helped prevent the spread of communicable diseases such as COVID-19 (a highly infectious virus that causes respiratory illness, possible difficulty breathing, pneumonia, hospitalization, or death) for 6 of 13 residents (17, 22, 18, 25, 37, 42), assisted during a meal service. In addition, the facility failed to ensure hand hygiene was completed and gloves were changed between clean and dirty tasks for 2 of 2 sampled residents (35, 18), reviewed for incontinence care and toileting. This failure to correctly use personal protective equipment (PPE-masks and gloves), and to complete hand hygiene, placed residents at risk for infectious diseases, potential serious infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (ADLs) services for 2 of 5 sampled residents (7, 32), reviewed for dependence on staff for care. Resident 7 was not supervised or cued during oral care and had large amounts of food debris stuck on their dentures, and Resident 32 was not provided grooming for long, thick nasal hairs. These failures placed the residents at risk for a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards by implementing a system for securing and storing hazardous potentially toxic chemicals in an area in 2 of 2 shower rooms (1 & 2), 1 of 2 soiled utility rooms (1), and the boiler room. This failure placed residents at risk for avoidable injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's food was stored and served in a sanitary manner and in accordance with professional standards for food service safety. The failure to ensure 1 of 1 nourishment unit refrigerators was free of expired, unlabeled, and undated food products, and failure to ensure staff performed adequate hand hygiene during resident meal assistance placed residents at risk for unsavory food, food-borne illness, and communicable disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident nurse call light system was functional and accessible in toilet and bathing rooms. The failure to ensure nurse call pull cords were no more than six inches from the floor in 5 of 7 sampled resident bathrooms (Rooms 42, 43, 45, 46, 14) and 2 of 2 shower rooms (1, 2), as well as to ensure the same 2 shower rooms had both a visible nurse call light outside the room and a functioning audible alert sound that could be heard in a centralized care area, placed residents at risk for unmet care needs and a delay of staff assistance in the event of an emergency.