Colville Health: Alcoholic Left Facility Twice - WA
Federal inspectors found the facility violated requirements to provide necessary mental health care for two residents, including one who told staff he feared returning to his "old ways" as an alcoholic and addict but received no counseling support.
Resident 34 had been admitted with end-stage kidney disease requiring dialysis, diabetes, and alcohol dependence. A state screening determined he needed specialized behavioral health services, but the Social Services Coordinator never received the required psychiatric evaluation summary and made no referrals.
The resident's behavior deteriorated rapidly. He became argumentative and belligerent when staff refused extra drinks not allowed on his restricted diet. He refused scheduled dialysis sessions, dietary restrictions, and blood sugar medications, yelling and swearing at staff who tried to encourage compliance.
Nobody offered behavioral health support.
On one occasion, staff accidentally gave Resident 34 a large dose of long-acting insulin meant for another patient. Over the next week, his blood sugar plummeted dangerously low five separate times, requiring emergency rescue medications. He became pale, lethargic, and sweaty with altered consciousness.
"I felt like I was going to die," he told an inspector the morning after one severe episode. He said he had been talking but not making sense during the night.
The next day, Resident 34 was afraid to sleep. "I thought I would not wake up if I did," he said. He would catch himself dozing off, then startle awake feeling unable to breathe and anxious.
That's when he made his plea for help.
Resident 34 told inspectors he wanted to get better, walk again, and eliminate his need for oxygen so he could qualify for a kidney transplant. "I knew I would have to work hard and needed support because I was an alcoholic and addict," he said. "Without support it was easy for me to go back to my old ways, and I did not want to do that."
He said he knew missionaries in the area and planned to ask them to visit.
Staff E, the Social Services Coordinator, was unaware of these statements during an interview with inspectors. She had never discussed alcohol dependence with Resident 34 despite his documented history and care plan noting substance abuse concerns.
"The resident's history and refusals of care and medications could have been a flag that they needed behavioral health services," Staff E admitted.
On the evening of May 20, Resident 34 left the facility around 8:00 PM without signing out. He departed with an unfamiliar man in an older Suburban-type vehicle. Staff didn't discover his absence until 1:00 AM the next day, when they decided to wait until morning to see if he returned on his own.
Three days earlier, he had left with the same man without signing out but returned at 11:00 PM.
When inspectors arrived at the facility on May 23, they found Resident 34's bed made with two packed bags of belongings on top. The administrator explained he had left again the previous evening and hadn't returned. The family and police had been notified. The dialysis center confirmed he had missed his scheduled session.
At 2:25 PM, police informed the facility they had located Resident 34 with a friend.
He returned to the facility on May 24 at 4:45 PM smelling of marijuana. Staff placed him on alert monitoring for withdrawal symptoms after a family member warned that he became agitated "when he came down from drinking." Resident 34 denied substance use but agreed to toxicology screening and makeup dialysis.
During interviews with facility leadership, the Director of Nursing admitted she hadn't followed up on the toxicology results.
The facility's behavioral health provider only offered remote telehealth sessions, which many residents declined. Staff acknowledged they were changing providers but couldn't explain why Resident 34 never received the specialized services his screening had recommended.
A second resident faced similar neglect.
Resident 40 had lived at the facility since early 2023 with major depressive disorder, psychotic symptoms, and delusional disorder following a stroke. She experienced hallucinations, believing she had snakes and pet dogs in her room, and suffered from delusions that caused her distress.
State screening twice determined she needed Level II psychiatric evaluation for specialized behavioral health services. The facility never received those evaluations.
Resident 40 remained socially isolated, spending days in bed with her privacy curtain pulled closed. When an inspector asked how she was doing, she responded, "How much time do you have?" then declined to elaborate. She said she didn't use her wheelchair and didn't like leaving her room.
Her delusions continued unabated. Progress notes documented her claiming to adopt 14 children and have a "famous multi-billionaire fiance," then crying uncontrollably after believing her son died in a car accident that turned out to be a dream.
The facility's behavioral health provider only offered telehealth sessions, which Resident 40 declined. Staff acknowledged her delusions were "distressing" and "potentially harmful psychologically" but provided no alternative interventions.
Staff E, the Social Services Coordinator, said she believed "a counselor was the best one to help Resident 40 navigate their mental illness" but made no effort to find in-person providers.
The facility's care plans for both residents lacked specific goals and interventions to address their behavioral health needs, despite documented mental health diagnoses and ongoing symptoms.
"Care plans were to be reviewed and if interventions were not effective others should be implemented," Staff E told inspectors. She acknowledged the facility had planned weekly meetings to ensure timely care plan reviews but admitted "those had not happened."
The Clinical Resource Nurse stated both residents were scheduled to be seen by new behavioral health providers beginning in late May, but couldn't explain why services had been delayed for months while residents suffered.
Federal regulations require nursing homes to provide necessary behavioral health care and services. The facility's failure to do so created risk for residents to experience decline in their psychosocial well-being, according to inspectors.
For Resident 34, that risk became reality when his untreated addiction led him to leave the facility twice, potentially endangering his life-sustaining dialysis treatment. For Resident 40, it meant months of distressing delusions and social isolation with her privacy curtain pulled closed, asking visitors how much time they had but declining to explain her suffering.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colville Health and Rehabilitation of Cascadia from 2025-05-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Colville Health and Rehabilitation of Cascadia in COLVILLE, WA was cited for violations during a health inspection on May 23, 2025.
Resident 34 had been admitted with end-stage kidney disease requiring dialysis, diabetes, and alcohol dependence.
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.