Colville Health and Rehabilitation of Cascadia

In the surveyor’s words

From the most serious findings on record at Colville Health and Rehabilitation of Cascadia, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600May 23, 2025

  Based 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. […]

• Immediate jeopardy, patternF689May 23, 2025

  Based 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. […]

• Actual harm, patternF725May 23, 2025

  Based 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. […]

• Actual harm, isolatedF760May 23, 2025

  Based 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). […]

• Actual harm, isolatedF689Jun 25, 2024

  Based 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 Findings included . Review of a facility assessment, dated 04/01/2024, showed Resident 1 had diagnoses to include heart disease and Diabetes. […]