Inspection Reports for
Red Cliffs Post Acute

The facility failed to ensure adequate supervision and effective person-centered fall prevention interventions for two residents (#5 and #7) out of four reviewed, resulting in repeated falls despite multiple interventions and a Performance Improvement Plan. Observations and record reviews revealed inconsistent implementation of fall prevention measures and lack of resident-specific intervention effectiveness.

The complaint investigation substantiated physical abuse of Resident #34 by Resident #53. The abuse was intentional pushing. The investigation included interviews with residents and staff, review of records, and identified failures in timely reporting and intervention.

The facility substantiated a physical abuse incident where Resident #53 intentionally pushed Resident #34. The investigation revealed missed opportunities to intervene earlier despite verbal altercations and threatening behavior. The facility separated the residents and provided abuse training to staff.

The facility was found to have multiple deficiencies including failure to maintain resident dignity, inadequate bathing and personal care according to resident preferences, failure to notify residents about personal funds nearing Medicaid limits, lack of accessibility to survey results, substantiated physical abuse between residents, improper medication administration, incomplete neurological assessments after falls, inadequate catheter care, failure to implement person-centered dementia care, poor hand hygiene practices in food service, incomplete explanation of arbitration agreements to residents, and failure to implement an effective water management plan.

The complaint involved allegations of verbal abuse between Resident #2 and Resident #3 on 9/1/24 and 9/16/24. The facility failed to report the allegations to the State Agency, did not conduct thorough investigations, and did not implement interventions to prevent further incidents. Additionally, concerns were raised about Resident #1's excessive alcohol use, lack of supervision, and safety risks including falls and unauthorized exits from the facility.

The facility failed to protect Resident #2 from verbal abuse by Resident #3 on two occasions and did not thoroughly investigate or report the allegations. Additionally, the facility failed to provide adequate supervision and implement effective care plans for Resident #1 related to excessive alcohol consumption, resulting in safety risks including falls and unauthorized exits from the facility.

The complaint investigation was substantiated in part with findings of failure to promptly address grievances, failure to prevent emotional distress from staff actions, failure to provide treatment per physician orders, failure to supervise smoking residents adequately, and failure to prevent falls through proper investigation and interventions. The abuse allegation was not substantiated as physical abuse but emotional distress was noted.

The facility failed to promptly address resident grievances, ensure residents were free from abuse, provide appropriate treatment and care according to physician orders, maintain safe smoking practices with supervision, and implement effective fall prevention interventions. Multiple deficiencies were noted including failure to follow up on grievances, emotional distress caused by staff actions, treatment without physician orders, inadequate supervision of a high-risk smoker, and incomplete fall investigations and interventions.

The facility was found deficient in multiple areas including resident dignity and respect, grievance follow-up, abuse prevention, PASRR screening, change of condition assessments, smoking safety, fall prevention, nutritional monitoring, pain management, trauma-informed care, dementia care, and food safety practices in the kitchen.

The complaint investigation involved five residents (#1 through #5) who reported various forms of inappropriate behavior by CNA #1, including inappropriate touching, kissing, tickling, and intrusive care. The facility failed to fully investigate these allegations, failed to interview key staff and family members, and failed to implement adequate protective measures. Some allegations were unsubstantiated despite resident discomfort. CNA #1 was suspended and ultimately not allowed to return to work due to repeated abuse allegations and staffing constraints.

The facility failed to thoroughly investigate all allegations of abuse involving CNA #1 for five residents, failed to provide clear corrective actions and monitoring plans, and failed to interview key staff and family members. Despite multiple complaints, the facility unsubstantiated some allegations and did not adequately protect residents from further distress. CNA #1 was ultimately suspended and not allowed to return to work due to repeated abuse allegations and staffing issues.

The facility was found deficient in multiple areas including failure to protect a resident from abuse, failure to provide adequate activities, failure to provide appropriate treatment and care, failure to monitor and assess pressure injuries, failure to maintain residents' range of motion, failure to prevent falls and provide adequate supervision, failure to ensure proper medication administration including insulin pen priming, failure to maintain proper medication storage temperatures, failure to ensure palatable and properly served food, failure to maintain infection control practices including equipment disinfection and hand hygiene, failure to ensure proper respiratory care, failure to implement gradual dose reductions for psychotropic medications, failure to perform required COVID-19 testing and vaccination tracking for staff and outside providers.