Colville Health And Rehabilitation Of Cascadia

Findings included .

Review of the facility policy titled, Discharge Planning Process revised April 2025 showed, the interdisciplinary team (IDT), including the resident and resident advocate, identify the discharge needs of each resident to develop interventions to meet the needs the resident's discharge goals and needs to ensure a smooth and safe transition form the facility to the post-discharge setting.

Discharge planning began at admission ad was based on the resident's assessment, goals for care, desire to be discharged , and the resident's capacity for discharge.

Discharge planning included procedures for determining the resident was discharged to a location that safely met their needs and preferences.

For residents who desired to discharge to a location that was determined to not be feasible, the medical record must contain information about who made the decision and the rationale for the decision.

The policy further showed discharge planning included identifying changes in the resident's condition, which may have an impact on the discharge plan, warranting revision to interventions.

The IDT was to consider caregiver's availability and the resident's or caregiver's capacity and capability to perform required care, as part of the identification of discharge needs process.

The IDT was to timely document basis on the resident needs, and document in the clinical record the evaluation of the resident's discharge needs, the discharge plan, and discussions with the resident and/or the resident's advocate.

BASIS FOR DISCHARGE

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

Findings included .

The revised 08/01/2023 facility policy COVID-19 Vaccination for Residents and Staff documented staff were educated of the risks and benefits associated with the COVID-19 vaccine so they could make an informed decision regarding immunization.

Education and re-education was documented in the employee file.

Staff have the opportunity to accept or refuse a vaccine or booster and may change their decision at any time.

During an interview on 05/22/25 at 4:09 PM, Staff F, Infection Preventionist, Licensed Practical Nurse, was asked if they were the one that kept track of staff COVID vaccinations.

Staff F stated the facility did offer the COVID vaccines the year prior but referred the surveyor to Staff QQ, Human Resources, and thought Staff QQ kept track of staff vaccines.

During an interview on 05/23/2025 at 09:48 AM, with Staff QQ and Staff RR, Business Office Manager, Staff QQ stated they offered a COVID-19 to new employees only and was unsure who offered the staff vaccines when boosters came out or yearly.

They would only have a form in a new employee's file and was unsure if nursing had records of all employees COVID vaccination statuses. A request was made to observe Staff RR's employee file.

Staff RR stated when the COVID vaccines first came out they were offered the vaccine but had not been offered one in several years. A review of the employee file had forms dated from the year 2020 that documented Staff RR had declined the COVID vaccine.

Staff RR stated they did not get vaccines and did not sign a declination each year that documented they had been educated regarding the risks/benefits of COVID vaccines.

During a follow-up interview on 05/23/2025 at 10:10 AM, Staff F stated they began working in Infection Prevention for the facility in February of 2025 and the position had been vacant prior to that but was unsure for how long.

Staff F was able to locate on the facility computer an Excel spreadsheet that documented staff COVID vaccinations, but the documentation had not been updated since 2023.

Reference: WAC 388-97-1320(1)

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

F-F689 for additional information):

The facility failed to provide effective monitoring and supervision and implement adequate interventions to prevent Resident 19, Resident 50, and Resident 60 from falling and experiencing adverse and injurious sequalae related to falls, to include transfers to the hospital.

Specifically, Resident 19 sustained repeated harm because of 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 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.

Additionally, Resident 60 fell three times and experienced a fracture to their eye socket and left lower leg.

These failures placed the residents at risk for further repeat serious injuries such as fractures, disability, or death and represented an immediate jeopardy (IJ) that was called on 05/20/2025. In addition, the facility failed to assess, evaluate, and implement interventions for potential risks associated with substance use disorders (SUD) for 1 of 3 sampled residents (Resident 49), reviewed for SUD.

Behavioral Health Services (Please refer to

Findings included .

The ISMP, or the Institute for Safe Medication Practices, is a recognized leading authority in medication safety information. It is dedicated to preventing medication errors and promoting safe medication practices.

According to the ISMP, insulin and anticoagulants (blood thinners) are considered high alert medications.

High alert medications are drugs that bear a heightened risk of causing significant harm to the resident when they are used in error.

The consequences of an error can be devastating to residents.

<Insulin>

<Resident 34>

The 04/08/2025 Admission assessment documented Resident 34 had diagnoses that included diabetes, and end-stage kidney disease dependent on dialysis (use of a machine to filter toxins from the body when the kidneys no longer functioned). Resident 34 was cognitively intact and received insulin injections (medications that lowered blood sugar levels) daily.

During an initial interview on 05/13/2025 at 10:18 AM, Resident 34 was observed seated on the edge of their bed.

Their half-eaten breakfast tray remained on their overbed table.

The resident was alert, pointed to a container of orange juice and stated normally they were supposed to limit their fluids but were given orange juice because they were given too much insulin that morning.

A review of the record documented the following:

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

F-F725 for additional information):

The facility failed to repeatedly ensure the facility had enough staff to provide 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.

Specifically, Resident 19 sustained repeated harm because of 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 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. Resident 60 fell three times and experienced a fracture to their eye socket and left lower leg.

Additionally, the facility failed to identify, report, protect, assess and prevent a pattern of resident-to-resident verbal and physical abuse by Residents 19 towards 10 different peers (Resident 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41).

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.

These failures placed all residents at risk for further repeat serious injuries such as fractures, repeat abuse, potentially avoidable accidents and diminished quality of life.

QAPI Program/Plan, Disclosure/Good Faith Attempt (Please Refer to

Findings included .

Review of the facility assessment reviewed May 2025 showed, the facility provided care to residents who required assistance with activities of daily living such as toileting, transfers, ambulation and fall prevention.

The assessment further showed facility staffing included nurse managers, licensed nurses, nursing assistants, and ancillary department staffing.

Staffing levels were determined by acuity and regulatory requirements that met the minimum staffing requirements.

Staffing was reviewed daily to ensure appropriate staffing ratios to meet requirements and acuity level of current resident population which consisted of residents that may require additional staff to help mitigate falls and manage behaviors.

The facility utilized staffing agencies to meet the facility staffing goals and additional staffing efforts were coordinated under the facility Quality Assurance and Performance Program (QAPI) via a Performance Improvement Plan (PIP).

<Resident 19>

According to the 04/10/2025 quarterly assessment, Resident 19 had severe cognitive impairment with inattention and disorganized thinking.

The assessment further showed Resident 19 exhibited worsening verbal and physical behaviors directed towards others that significantly interfered with Resident 19's care, participation in activities or social events, placed others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. Resident 19 sustained two or more non-injury falls since their admission.

RESIDENT-TO-RESIDENT ALTERCATIONS

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

Findings included .

Review of the facility assessment reviewed May 2025 showed, the facility provided care to residents who were diabetic, received blood thinners, had histories of SUD, trauma/PTSD, anxiety, cognitive impairment, and other medical conditions related to mental health.

The facility provided person-centered/directed care by building relationships, providing emotional and mental well-being support, support helpful coping mechanisms, determining resident preferences and routines and incorporating the information into the care planning process.

The assessment further showed staff competencies were completed during new employee orientation for new hires.

Staff received the mandatory 12 hours of required topic training and as needed training conducted when the need was identified.

<Staff P>

Review of Staff P's, Licensed Practical Nurse (LPN), personnel file showed they were hired on 04/17/2025.

Review of Staff P's training records showed no training or competency documentation related to diabetes management, medication administration, PTSD (a mental health condition that could develop after witnessing or being part of an extremely stressful or terrifying event), SUD, GDR [when psychotropics (medications that affect the brain, feelings, and emotions) were slowly and carefully decreased to find the lowest effective therapeutic dose to prevent unnecessary medication use], trauma informed care, fall management, or incident root cause analysis.

In an interview on 05/20/2025 at 11:37 AM, Staff P, LPN, acknowledged they did not receive adequate training and did not have their skills and/or competencies assessed.

<Staff L>

Review of Staff L's, Registered Nurse, personnel file showed they were hired on 03/31/2025.

Review of Staff L's training records showed no training or competency documentation related to diabetes management, medication administration, PTSD, SUD, GDRs, trauma informed care, fall management, or incident root cause analysis.

<Staff AA>

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

F-F740 for additional information):

The facility failed to ensure behavioral health services were provided for 2 of 8 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.

Residents are Free of Significant Medication Errors (Please refer to

Findings included .

The 11/28/2017 facility policy Resident Change of Condition documented that upon recognition of a potentially life-threatening condition or significant change in status, the nurse was to communicate with other health care providers.

The physician was to be informed at the time of the event as soon as possible.

Notification should occur immediately if any symptom, sign or apparent distress is sudden in onset, or a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. In addition to others, staff were to document the resident assessment, care provided, physician response, orders, and resident status and response.

<Resident 34>

The 04/08/2025 admission assessment documented Resident 34 had diagnoses that included end-stage kidney disease dependent on dialysis (a mechanical way of ridding the body of toxins when the kidneys no longer functioned) and diabetes. Resident 34 was cognitively intact and received daily insulin injections.

The 04/02/2025 Diabetes Care Plan instructed staff to consult with the Registered Dietician regarding dietary restrictions and compliance with nutritional regimen as indicated, administer diabetic medications as ordered and monitor for side effects. If hyperglycemic (a blood sugar level greater than 300 milligrams per deciliter, mg/dl) follow insulin medication orders or contact the provider and follow orders. If hypoglycemic (a blood sugar level less than 70mg/dl) treat according to the hypoglycemic protocol.

Document the treatment, interventions, symptoms and assessment in progress notes.

Resident 34 had the following provider orders:

-04/02/2025 check fingerstick blood sugar levels before meals and at bedtime. If result is below 70mg/dl, initiate hypoglycemic protocol and notify the provider. If greater than 400mg/dl, notify the provider and follow directives.

-04/02/2025 hypoglycemic protocol-if able to take oral, give 15mg fast-acting carbohydrate (a type of nutrition that contains sugar), recheck blood sugar in 15 minutes. If still less than 70, give another 15gm fast acting carbohydrate.

Recheck in 15 minutes. If still less than 70mg/dl, notify the provider.

Once above 70mg/dl, give a protein snack or assist to next meal.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

F-F760 for additional information):

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) ordered for a different resident.

Additionally, Resident 34 received the wrong dose of medication used to decrease diarrhea, and Resident 61 did not receive doses of a blood thinner and an injectable medication that managed weight and blood sugar.

This failure caused harm to Resident 34 when they experienced an extended period of symptomatic hypoglycemia (extremely low blood sugar) and required administration of rescue medications on five different occasions and created the potential for unintended health consequences for the residents.

Infection Prevention and Control (Please Refer to

Findings included .

Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) revised April 2024 showed, the facility monitored quality deficiencies related to facility operations and practices causing negative outcomes through the QAPI process.

The QAPI committee served as a preventative function by reviewing and improving facility systems and took actions toward enhancing quality of care and quality of life for facility residents.

The QAPI framework was established through five elements: 1) design and scope, 2) governance and leadership, 3) feedback, data systems and monitoring, 4) Performance Improvement Projects (PIPs), and 5) systematic analysis and systemic action.

The committee was to meet monthly to identify performance improvement opportunities through tracking and trending of data that necessitated quality assessment and assurance activities against state and national benchmarks.

The QAPI committee was to prioritize action plans and evaluate effectiveness of the process improvement activities.

The policy included a list of potentially preventable events the facility may monitor including various high-risk medication use to include blood thinners and diabetes medications, care events such as falls, elopements, instances of abuse, neglect or misappropriation and infection such as respiratory infections and infectious diarrhea.

The facility QAPI committee reported routinely to the governing body.

During the unannounced Recertification Survey conducted from 05/12/2025 to 05/23/2025, the following areas of deficiency were identified by the survey team:

Free from Abuse and Neglect (Please refer to

F-F865 for additional information):

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.

QAA Committee (Please Refer to

Findings included .

<Resident 34>

The [DATE] admission assessment documented Resident 34 had diagnoses that included end-stage kidney disease dependent on dialysis (a mechanical way of ridding a body of toxins when the kidneys no longer function), diabetes, and alcohol dependence. Resident 34 was cognitively intact, made their own decisions regarding their care, had no behaviors and did not reject their care.

A Level II Behavioral Health Preadmission Screen and Resident Review (PASRR, a screening completed prior to skilled nursing facility admissions that determined a need for behavioral health services for residents) Notice of Determination dated [DATE] documented Resident 34 had a mental health diagnosis, met requirements for nursing facility level of care, and may benefit from specialized behavioral health services.

At the time of the record review on [DATE] at 12:12 PM, the Level II PASRR Psychiatric Evaluation Summary, a document that detailed a resident's specific behavioral health needs and recommendations, was not included in Resident 34's electronic medical record (EMR).

The [DATE] provider History and Physical documented Resident 34 had transferred to the facility from a nursing facility in an adjacent county, had been non-compliant with their dialysis and medications and continued their non-compliance at the facility.

The resident had a social history of alcohol and illicit drug use and provided vague answers when interviewed by the provider.

The [DATE] care plan documented Resident 34 had a history of substance abuse.

Staff were instructed to set clear expectations with the resident, discuss with the resident and their family any issues that may lead to substance abuse/misuse, and if the resident appeared intoxicated or under the influence remove them from involvement with other residents.

On [DATE], the care plan was updated to include Resident 34 exhibited potential mood disturbance, anger, and irritability and verbal abuse toward staff.

Staff were instructed to analyze the circumstances and triggers and what de-escalated the behavior and document, assess the resident's coping skills and support system.

The care plan did not include goals and interventions developed related to Resident 34's behavioral health needs.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

Findings included .

Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) revised April 2024 showed, the facility monitored quality deficiencies related to facility operations and practices causing negative outcomes through the QAPI process.

The QAPI committee served as a preventative function by reviewing and improving facility systems and took actions toward enhancing quality of care and quality of life for facility residents.

The committee was to consist of the Administrator, Director of Nursing, a physician, the infection preventionist, and three additional facility staff responsible for direct resident care and services.

Review of the July 2024 through April 2025 QAPI Committee Minutes showed the following:

- 07/21/2024 No input from the Infection Preventionist related to infection prevention and control data.

The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required.

- 10/29/2024 a soft tissue infection trend was identified, no other infection prevention and control data was found.

The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required.

- 01/21/2025 No input from the Infection Preventionist related to infection prevention and control data.

The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required.

- 04/30/2025 No input from the Infection Preventionist related to infection prevention and control data.

The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required.

Review of the facility GI outbreak line listing showed the facility identified a Norovirus outbreak on 05/03/2025.

The outbreak included 24 residents and 25 staff who experienced GI symptoms.

In an interview on 05/22/2025 at 4:09 PM, Staff F, Infection Preventionist, stated the QAPI committee met quarterly.

Staff F acknowledged they were not monitoring any infection control practices for trends, did not have any infection control Performance Improvement Projects and had not participated in any QAPI meetings as of that date.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

Findings included .

The Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated September 2024 and retrieved from https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html documented facilities were to implement contact + standard precautions for a minimum of 48 hours after the resolution of symptoms or to control institutional outbreaks.

Standard precautions were based on the principle that all blood, body fluids and secretions may contain infectious agents, and included the use of hand hygiene, and donning (to put on) personal protective equipment (PPE) to include gowns, gloves, masks and eye protection if exposure could be anticipated, such as by splashes for example.

Contact precautions prevented transmission of organisms spread by direct or indirect contact with the patient or their environment.

Healthcare personnel were to don a gown and gloves when entering a room to care for a resident on contact precautions and discard the PPE before exiting the room.

The CDC 2011 Norovirus Prevention and Control Guidelines for Healthcare Settings retrieved from https://www.cdc.gov/infection-control/hcp/norovirus-guidelines/index.html recommended ill staff be excluded from work for a minimum of 48 hours after the resolution of symptoms.

The CDC 07/12/2002 Implementation of Personal Protective Equipment (PPE, gloves, disposable gowns, eye protection or masks, for example) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended the use of Enhanced Barrier Precautions (EBP) as an infection control intervention. EBP recommended the use of gown and gloves during high contact resident care activities when Contact Precautions did not apply for residents with wounds or indwelling medical devices, such as feeding tubes or catheters.

High contact care activities included dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505275 B.

Wing 05/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Colville of Cascadia, LLC 1000 East Elep Street Colville, WA 99114

Findings included .

A review of the 30-day Staffing Pattern from 04/12/2025 through 05/12/2025 showed there was no RN on duty a minimum of eight hours a day, as required, for the following dates: 04/12/2025, 04/19/2025, 04/26/2025, 05/08/2025, and 05/10/2025.

In an interview on 05/22/2025 at 11:35 AM, Staff M, Licensed Practical Nurse (LPN), acknowledged they had worked without an RN on duty.

Staff M explained most LPNs can handle most of the same things as an RN but the facility contacted the Director of Nursing as needed, when there was no RN on duty.

In an interview on 05/22/2025 at 3:00 PM, Staff D, Resident Care Manager, acknowledged there had been days without an RN on duty but they were on-call in case of emergencies.

In an interview on 05/22/2025 at 3:12 PM, Staff X, Staffing Coordinator, reviewed the 30-Day staffing pattern.

Staff X acknowledged some days had no RN on duty.

Staff X stated, getting RN coverage is hard.

Staff X explained they notified the Staff B, Director of Nursing, when unable to staff RN coverage, as required.

In an interview on 05/22/2025 at 3:43 PM, Staff B reviewed the 30-Day staffing pattern.

Staff B acknowledged some days did not have RN coverage, as required.

Staff B further stated they expected staff to schedule an RN on duty, as required.

In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected staff to schedule an RN on duty, as required.

Reference WAC 388-97-1080 (3)(a)

Refer to