Resident 19 punched, grabbed, kicked, and scratched other residents from October 2024 through May 2025 at Colville Health and Rehabilitation of Cascadia. The attacks left one resident with a bleeding scratch requiring first aid, another with a skin tear to their arm, and multiple residents with scratches and injuries from being grabbed, hit, and kicked.
The pattern of violence continued even after staff placed Resident 19 on 15-minute safety checks around the clock in November 2024.
On February 10, Resident 19 grabbed Resident 31's neck collar and called them a "fucking asshole." Resident 31 slapped Resident 19 in the face. Two months later, the same two residents fought again in the dining room while staff were present but failed to observe the altercation. Resident 31 sustained a skin tear to their arm.
The attacks were unprovoked and random. On February 27, Resident 19 spontaneously grabbed, hit, scratched, and kicked Resident 49 while self-propelling their wheelchair down the hall. Resident 49 sustained a scratch that bled and told staff they didn't know why Resident 19 attacked them.
On April 11, Resident 19 began punching Resident 45 with a closed fist in the hallway as the victim rolled past in their wheelchair.
Federal inspectors found the facility failed to identify, report, protect, assess, and provide staff supervision to prevent the pattern of abuse.
While Resident 19 terrorized peers, they also fell repeatedly, sustaining three major fractures that required hospitalization and surgical repair.
Resident 19 fell 15 times between September 2024 and May 2025. On September 12, 2024, they fell near their bed while self-transferring to the bathroom and dislocated their recently surgically repaired hip. The hip required sedation to reinsert back into the socket.
On January 14, 2025, Resident 19 fell again while reaching for an item out of reach at the nurses' station. The fall fractured their right femur around the artificially replaced hip, requiring surgical repair.
On March 3, 2025, Resident 19 fell out of their wheelchair, sustaining a significant back fracture. Medical imaging showed the fracture was likely new, given the history of the fall and tenderness.
Despite the repeated falls and fractures, staff failed to adequately revise Resident 19's care plan after each incident. The plan included interventions like keeping the room door open, reinforcing safety awareness, and maintaining a clutter-free floor. After multiple bed falls, staff added a fall mat, but Resident 19 continued falling on the opposite side of the mat.
By March 2025, staff added a note to the care plan stating "Resident has the right to fall."
The facility's staffing crisis extended beyond Resident 19's case.
Resident 50 fell 36 times between April 2024 and May 2025, sustaining abrasions, contusions, lacerations, closed head injuries, skin tears, and requiring three emergency department transfers. Staff identified that Resident 50 was "impulsive and forgetful to use their call light" and "self-transferred in and out of bed or wheelchair" but continued asking the resident to use the call light.
"I fall quite frequently," Resident 50 told inspectors. "I have progressive palsy and they've gone over things that I do that cause the falls like how I turn and so forth."
Resident 60, admitted with stroke and diabetes, fell three times and sustained fractures to their eye socket and left lower leg. On May 3, 2025, a nursing assistant helped Resident 60 to the toilet and stepped outside for privacy despite a care plan requiring staff to "stay with patient when on toilet to decrease risk of falls." Resident 60 fell while reaching for wipes, fracturing their left orbital bone.
Twelve days later, staff ran a wheelchair over Resident 60's left foot while transporting them down the hallway. The aide didn't notice the resident's foot had fallen off the wheelchair footrest and pushed three times against resistance before realizing they had run over the foot. Resident 60 sustained a fracture to their left fibula.
"I want to go to the hospital," Resident 60 repeatedly told staff after the wheelchair incident.
The Resident Council told inspectors the facility was "severely undermanned." Council members said they experienced "excessively long call light wait times" and staff didn't answer call lights during mealtimes, forcing residents to wait until meals ended or have incontinent episodes. Some residents waited up to an hour for call light responses.
A resident's spouse who attended council meetings acknowledged they "often toileted their spouse to help direct care staff because staff were too busy with other residents and there is not enough staff."
Staff confirmed the crisis. A registered nurse working night shift told inspectors they were "lucky if they worked with two-three nursing assistants." When residents needed one-on-one monitoring for behaviors, "they would have to pull a nursing assistant off the floor to provide the needed increased monitoring which left the floor short so I take a section."
A licensed practical nurse said they routinely worked as a nursing assistant three out of five workdays due to short staffing.
The Resident Care Manager acknowledged "some falls and resident-to-resident altercations could have been prevented if the facility had more staff." The facility attempted to staff four nursing assistants for day and evening shifts and two for night shift "but that was not enough staff."
The Staffing Coordinator, who also worked as a nursing assistant, said they "had not had a full weekend off in a month" and acknowledged staff concerns: "We are struggling, we are having a rough time with staffing."
Despite utilizing agency staffing daily, the facility's staffing guide was based on counting residents rather than their care needs. "We count heads [residents] not acuity," the coordinator explained.
The facility's grievance log showed complaints about excessively long call light wait times in November 2024, March 2025, and April 2025.
Federal inspectors found the facility failed to consistently ensure adequate staff supervision and safe care according to residents' acuity levels and care plans, placing residents at risk for repeat serious injuries, abuse, and diminished quality of life.
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
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