Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colville Tribal Convalescent C during CMS and state inspections, most recent first.
Staff failed to serve meals at required temperatures, with hot foods below 135°F and cold foods above 41°F. The Dietary Manager confirmed the standards but permitted cold items to be served above the safe temperature, while only reheating hot foods. The DON recognized the importance of proper food temperatures for preventing foodborne illness.
Surveyors found expired and undated food items in dry storage, the refrigerator, and the freezer, including expired bean sprouts, nonfat dry milk, corn starch, couscous, salmon, and grape juice, as well as undated lettuce, sandwiches, whipped topping, and various frozen foods. Dietary staff confirmed that items should be dated and expired foods discarded, but these procedures were not consistently followed.
Staff failed to consistently perform hand hygiene and follow Enhanced Barrier Precautions during meal service, medication administration, and resident transfers. Two residents requiring EBP due to medical devices did not receive care with proper gown and glove use, and a mechanical lift was not sanitized between uses. Staff also handled food trays and administered medications without appropriate hand hygiene, increasing the risk of infection transmission.
A resident with Parkinson's disease, arthritis, and depression was repeatedly unable to access their call light while in bed and in a wheelchair. The call light was found stuck behind the bed or otherwise out of reach, and the resident, who had a low voice, was unable to call for help when needed. Staff, including a nursing assistant, LPN, and DON, all acknowledged the importance of keeping the call light within reach, but this was not consistently done.
A resident with diabetes, hypertension, and end stage kidney disease did not receive several prescribed medications, including Velphoro, Lispro insulin, Semglee insulin, and Norvasc, as indicated by blank entries in the MAR. There was no documentation or explanation for the missed doses, and both nursing staff and the DON confirmed the omissions and lack of required documentation.
Expired rosuvastatin and Debrox ear drops were found in a medication cart, and staff confirmed these medications had not been removed after expiration. An LPN stated that nurses are responsible for checking expiration dates, but the expired items were missed. Additionally, the medication room lacked a thermometer to monitor storage temperature, as confirmed by an RN and the DON.
A resident's personal refrigerator and the dining room freezer were found to be unclean, with expired or improperly stored food and significant ice buildup. Staff, including an LPN and the DON, confirmed that expired food was not being discarded and freezer temperatures were not monitored, resulting in inadequate maintenance of food storage areas.
The facility failed to submit PBJ data to CMS for FY Q4 2023 due to firewall issues blocking the CMS software. Instead, data was submitted to the Department Office of Rates, which is non-compliant. Staff interviews confirmed the issue, and documentation showed a misunderstanding of the required quarters for submission.
The facility failed to complete discharge summaries that included a physician recapitulation/summary of the resident's stay for two residents. One resident with anxiety and a psychotic disorder and another with diabetes, heart failure, and schizophrenia were discharged without the required summaries. Staff acknowledged the oversight during interviews.
The facility failed to ensure that the Food Service Manager had the required kitchen manager certification. The Food Service Manager admitted to not having the certification, and the Administrator confirmed this, acknowledging the deficiency. This placed all residents at risk for receiving dietary services from staff without the required competencies.
The facility failed to adhere to food safety standards, with a cook not changing gloves or performing hand hygiene after touching contaminated surfaces, and placing discarded gloves on a clean counter. Additionally, the sanitizing solution was improperly monitored, and meat sandwiches in the refrigerator were not labeled with dates.
The facility failed to submit the Payroll Based Journal (PBJ) data for the first fiscal quarter of 2024 as required by CMS. The Administrator and Business Office Manager believed their email submission to the department Office of Rates was sufficient, but an inquiry confirmed no PBJ data had been submitted in 2023 or 2024.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
During a lunch meal service, the facility failed to serve food at the required safe and palatable temperatures. Observations showed that pureed carrots and goulash were served at 129.5°F and 129.3°F, respectively, which is below the required hot holding temperature of 135°F. Additionally, mixed berries and milk were served at 48.3°F and 50.1°F, both above the required cold holding temperature of 41°F or less. The food was placed on a cart and prepared for service to residents at these temperatures. When questioned, the Dietary Manager confirmed the required temperature standards but allowed the cold items to be served as they were, and only reheated the hot food. The DON acknowledged the importance of serving food at appropriate temperatures to prevent foodborne illnesses.
Failure to Discard Expired and Undated Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by the presence of expired and undated food items in both dry storage and refrigerated areas. During a kitchen tour, surveyors observed a can of bean sprouts, eight packages of nonfat dry milk, six boxes of corn starch, and a box of couscous in the dry storage area, all of which were past their expiration dates. In the main kitchen refrigerator, a bag of salmon with a past use-by date, a bag of wilted lettuce with no date, four containers of grape juice past their expiration date, four half sandwiches, and an opened bag of whipped topping without dates were found. The freezer contained opened bags of French fries, corn dogs, broccoli, and dinner rolls, none of which were labeled with open or expiration dates. Staff interviews confirmed that dietary staff were expected to date items when opened and discard expired foods, but these practices were not consistently followed.
Failure to Follow Infection Control Practices During Care, Meal Service, and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during meal service, medication administration, and resident transfers. Staff did not consistently perform hand hygiene when indicated, such as after removing gloves, before and after resident contact, after touching inanimate objects, or after picking up items from the floor. During meal service, staff delivered trays, handled residents' personal items, and picked up garbage without performing hand hygiene between tasks or before serving food to other residents. Staff also failed to follow hand hygiene protocols in the small assisted dining room, where gloves were changed without hand hygiene, and new gloves were donned without prior cleaning of hands. Enhanced Barrier Precautions (EBP) were not followed for residents with specific medical needs. One resident with a feeding tube and another dependent on dialysis with a fistula required EBP, including the use of gowns and gloves during high-contact care activities. However, staff were observed flushing a feeding tube and transferring a resident without wearing the required gown. Staff interviews confirmed a lack of understanding or adherence to EBP protocols, despite signage and care plan instructions indicating the need for these precautions. Sanitation of shared equipment was also deficient. A mechanical lift used to transfer a resident was not sanitized before being used for another resident. During medication administration, a registered nurse failed to perform hand hygiene before and after resident contact, after blowing their nose, and after touching potentially contaminated surfaces. The nurse also donned gloves that had been dropped on the floor and continued to administer medications without cleaning their hands. Staff interviews confirmed that the expected standard was not met in these instances.
Call Light Inaccessibility for Resident with Mobility Impairments
Penalty
Summary
The facility failed to ensure that the call light was accessible for one resident with diagnoses including Parkinson's disease, arthritis, and depression. On multiple occasions, the resident was observed unable to reach the call light while in bed and in a wheelchair. During one observation, the resident had spilled water and was wet but could not find the call light to request assistance. The call light was found stuck behind the bed, out of the resident's reach. In subsequent observations, the resident was again unable to access the call light, either from the bed or from the wheelchair, and stated that if help was needed, they would try to yell, despite having a very low voice. Staff interviews confirmed the importance of keeping the call light within reach to allow residents to request help and prevent accidents. Both a nursing assistant and an LPN acknowledged that some residents, especially those with low voices, may not be heard if they call out verbally. The Director of Nursing also stated the necessity of keeping the call light accessible so residents can easily find it and call for help. Despite this, the resident's call light was repeatedly found out of reach during the survey period.
Failure to Administer Medications as Ordered and Lack of Documentation
Penalty
Summary
A review of medication administration for one resident with diagnoses including diabetes, hypertension, and end stage kidney disease revealed that multiple prescribed medications were not administered as ordered. The resident was supposed to receive Velphoro, Lispro insulin, Semglee insulin, and Norvasc according to active physician orders. The March 2025 medication administration record (MAR) showed omitted entries for these medications on several occasions, with blank spaces indicating they were not given. Further examination of the MAR and nursing progress notes found no documentation or administration codes explaining the missed doses. During interviews, both a registered nurse and the Director of Nursing confirmed that the medications were not administered as ordered and acknowledged the lack of documentation for the omissions. The staff emphasized the importance of administering these medications as prescribed for the management of the resident's chronic conditions.
Expired Medications and Lack of Temperature Monitoring in Medication Storage
Penalty
Summary
Expired medications were found in one of two medication carts in use during an observation on the 300 Unit. Specifically, a blisterpack sleeve of rosuvastatin calcium with an expiration date of 03/31/2025 and two boxes of Debrox 6.5% ear wax removal solution with an expiration date of 03/20/2025 were present in the cart for use by residents. Staff E, an LPN, confirmed that nurses are expected to check medication expiration dates before administration, but these expired medications remained in the cart. The Debrox drops were rarely used, which contributed to their presence past expiration, and the expired rosuvastatin was overlooked. Additionally, the medication room where various medications are stored at room temperature did not have a thermometer to monitor the room's temperature. This was confirmed during an observation and interview with Staff F, an RN, who acknowledged the absence of a thermometer. The DON also stated that monitoring the medication room temperature is important due to its potential impact on stored medications and the refrigerator containing medications.
Failure to Maintain Clean and Safe Refrigeration for Resident and Facility Food Storage
Penalty
Summary
The facility failed to maintain resident personal refrigerators and a dining room freezer in a clean and safe manner. During multiple observations, a resident's personal refrigerator was found to contain a frozen hamburger with ice crystals that had been stored for a month or more, and the freezer compartment was filled with ice crystals. The resident confirmed the length of time the food had been stored. Additional observations confirmed the ongoing presence of ice crystals and the frozen hamburger over several days. The dining room freezer was also observed to have nutritional drinks frozen with ice crystals covering the walls. Interviews with staff revealed that both nurses and housekeepers were responsible for discarding expired food, but freezer temperatures were not being monitored. Staff acknowledged the importance of discarding expired food and monitoring freezer temperatures to prevent foodborne illnesses and maintain food quality, but confirmed that these practices were not being followed. The Director of Nursing also stated that routine maintenance, such as defrosting freezers and monitoring temperatures, was not being performed.
Failure to Submit PBJ Data Due to Firewall Issues
Penalty
Summary
The facility failed to ensure the submission of the Payroll Based Journal (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) for the Fiscal Year Quarter 4 of 2023. This deficiency was identified through observation, interview, and record review, revealing that no data was submitted for the specified quarter. The issue arose because the facility's network systems blocked the usage of the CMS software due to increased firewall protection, preventing the successful submission of PBJ data. Instead, the facility was submitting hours to the Department Office of Rates, which is not in compliance with CMS requirements. Interviews with facility staff, including the Administrator, Business Office Manager, and Director of Nursing, confirmed the inability to submit PBJ data directly to CMS due to the firewall protection. The facility's documentation showed a misunderstanding of the quarters used for PBJ data collection and submission, as they were using state quarters instead of federal or fiscal year quarters. The facility's records lacked auditable and verifiable data, which contributed to the deficiency in PBJ data submission.
Failure to Complete Discharge Summaries
Penalty
Summary
The facility failed to complete a discharge summary that included a physician recapitulation/summary of the resident's stay for two of three sampled residents reviewed for discharge. Resident 31, who was cognitively intact and had diagnoses including anxiety and a psychotic disorder with hallucinations, was discharged without a completed recapitulation of stay. The Transition of Care/Discharge summary form signed by the resident on the date of discharge had the area for the Recapitulation of Stay left blank, and no physician summary of care was found elsewhere in the medical record. Similarly, Resident 82, who had moderately impaired cognition and diagnoses of diabetes, heart failure, and schizophrenia, was discharged without a completed recapitulation of stay. The Transition of Care/Discharge summary form included information on follow-up appointments but left the area for the Recapitulation of Stay blank. During interviews, staff members acknowledged that a physician recapitulation of stay had not been completed for these residents, indicating a failure to ensure necessary information was communicated at the time of discharge.
Food Service Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Food Service Manager had the required credentials, specifically a kitchen manager certification. During an interview, the Food Service Manager admitted to not having the certification. The Administrator confirmed that while a Registered Dietician was employed and worked closely with the Food Service Manager, the latter had not completed the necessary education to become certified. This deficiency was acknowledged by the Administrator, placing all residents at risk for receiving dietary services from staff without the required competencies.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. During meal preparation, a cook was observed multiple times touching their clothing, eyeglasses, and refrigerator door with gloved hands and then continuing to handle food without changing gloves or performing hand hygiene. Additionally, the cook placed discarded, contaminated gloves on a clean food prep counter. The cook acknowledged the need for hand hygiene and glove changes but cited a lack of space for a garbage can as the reason for placing dirty gloves on the counter. Furthermore, the sanitizing bucket solution was not properly monitored, with the concentration of bleach exceeding the required levels, and the cook was unaware of the correct concentration or the need to log the results. In the dining room refrigerator, four meat sandwiches were found individually wrapped but not labeled with a made or discard by date. The Food Service Manager confirmed that without proper labeling, it was impossible to determine if the food was too old and should be discarded. The manager also reiterated the expectation for staff to change gloves after touching contaminated surfaces and to discard used gloves in the trash. These failures placed residents at risk for consuming contaminated foods and food-borne illness.
Failure to Submit Payroll Based Journal (PBJ) Data
Penalty
Summary
The facility failed to ensure the submission of the Payroll Based Journal (PBJ) per the Centers for Medicare and Medicaid Services (CMS) requirements for the first fiscal quarter of 2024. This failure resulted in CMS having inaccurate data related to nursing home staffing levels, which had the potential to impact the care and services provided to all residents in the facility. The review of the CMS PBJ Staffing Data Report for FY Q1 2024 showed no data was submitted for the referenced quarter. The documents provided to the state agency survey team included a summary of hours without any documented auditable and verifiable data. During an interview, the Administrator and Business Office Manager explained that their routine method of submission was by email to the department Office of Rates, which they believed to be a successful submission of the PBJ. They attempted to submit the PBJ via the CMS software once but were unsuccessful due to the facility's network/system blocking the usage of the software. After the unsuccessful submission, they reverted to submitting the hours to the department Office of Rates, thus not meeting the requirement for electronic PBJ submission directly to CMS. An inquiry to CMS confirmed that the facility had not submitted PBJ data in 2023 or 2024.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nespelem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Omak | 32.1 mi | — | 4 | 0 |
| Regency Harmony House Rehab & Nursing | 37.4 mi | — | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Colville Tribal Convalescent C.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.