Inspection Reports for
Red Cliffs Post Acute
2901 N 12TH ST, GRAND JUNCTION, CO, 81506-2811
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
27.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
435% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding accident hazards and supervision to prevent falls, focusing on fall prevention interventions for residents at high risk.
Findings
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.
Deficiencies (1)
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically repeated falls for Residents #5 and #7.
Report Facts
Falls: 398
Falls: 404
Falls: 439
Falls: 412
Falls: 405
Falls: 402
Falls: 197
Fall risk score: 30
BIMS score: 12
BIMS score: 6
Number of residents reviewed for accident hazards: 11
Number of residents with inadequate supervision: 2
Number of falls for Resident #5: 11
Number of falls for Resident #7: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #5's fall risk and supervision |
| DON | Director of Nursing | Interviewed about facility's Performance Improvement Plan and fall prevention interventions |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #7's care and fall risk |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #7's care and fall risk |
| NHA | Nursing Home Administrator | Interviewed about facility's fall prevention efforts and Performance Improvement Plan |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding accident hazards and supervision to prevent falls in a nursing home setting.
Findings
The facility failed to ensure adequate supervision and effective person-centered interventions to prevent repeated falls for two of four residents reviewed. Multiple falls were documented for Residents #5 and #7, with deficiencies in implementing fall prevention measures such as proper footwear, call light accessibility, and wheelchair safety features.
Deficiencies (1)
F 0689: The facility failed to ensure two of four residents reviewed received adequate supervision to prevent accidents and repeated falls despite documented fall prevention care plans and interventions.
Report Facts
Falls: 398
Falls: 404
Falls: 439
Falls: 412
Falls: 405
Falls: 402
Falls: 197
Fall risk score: 30
BIMS score: 12
BIMS score: 6
Number of residents reviewed for accident hazards: 11
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #5's fall risk and supervision |
| DON | Director of Nursing | Interviewed about facility's Performance Improvement Plan and fall prevention efforts |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #7's care and fall risk |
| CNA #1 | Certified Nurse Aide | Interviewed about Resident #7's transfer and mobility needs |
| NHA | Nursing Home Administrator | Interviewed about fall prevention program and interventions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of physical abuse between two residents in the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to ensure Resident #34 was free from physical abuse by Resident #53.
Report Facts
Residents reviewed: 32
Residents affected: 3
Staff trained: 31
BIMS score: 13
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Supervisor LPN #1 | Licensed Practical Nurse | Identified as supervisor on 12/29/24 who was notified of threatening remarks by Resident #53 but did not notify DON |
| Nursing Home Administrator | NHA | Provided abuse policy, conducted interviews, substantiated abuse, and commented on missed opportunities for intervention |
| Director of Nursing | DON | Interviewed regarding reporting failures and staff training |
| Maintenance Director | MTD | Reported fixing television remote issue and was informed of tension between residents |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Jan 16, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
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.
Deficiencies (12)
Failure to ensure staff identify themselves when entering resident rooms and assist residents with dignity.
Failure to provide bathing and personal care according to resident preferences.
Failure to notify resident or legal representative when personal funds account neared Medicaid eligibility limit.
Failure to ensure residents and families had access to survey results and certifications.
Failure to prevent physical abuse between residents.
Failure to ensure enteric-coated medication was not crushed prior to administration.
Failure to implement timely fall care plans and complete neurological checks after unwitnessed fall.
Failure to provide appropriate catheter care and monitor for urinary tract infections.
Failure to implement person-centered dementia care to prevent resident-to-resident altercations.
Failure to ensure proper hand hygiene and glove use in food preparation and service.
Failure to thoroughly explain arbitration agreements to residents and inform them of their rights and rescission timelines.
Failure to implement an effective water management plan including flushing of dead legs and low-flow piping runs to prevent Legionella growth.
Report Facts
Residents reviewed: 32
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 8
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 6
Staff trained: 31
Staff trained: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding dignity, bathing, neurological assessments, and abuse reporting |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding dignity, bathing, neurological assessments, and catheter care |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, bathing, abuse, medication, falls, catheter care, dementia care, and arbitration agreements |
| NHA | Nursing Home Administrator | Interviewed regarding personal funds notification, abuse investigation, arbitration agreements, and water management |
| MTD | Maintenance Director | Interviewed regarding abuse incident and water management |
| CC | Corporate Consultant | Interviewed regarding bathing, catheter care, and infection control education |
| DA #4 | Dietary Aide | Observed and interviewed regarding hand hygiene deficiencies |
| DA #1 | Dietary Aide | Observed and interviewed regarding hand hygiene deficiencies |
| CK #1 | Cook | Observed and interviewed regarding hand hygiene deficiencies |
| RN #2 | Registered Nurse, Infection Control Nurse | Interviewed regarding hand hygiene and conducted hand hygiene audits |
| AC | Admissions Coordinator | Interviewed regarding explanation of arbitration agreements |
| MKD | Marketing Director | Interviewed regarding explanation of arbitration agreements |
| SSD | Social Service Director | Interviewed regarding dementia care and resident behavioral support |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
The investigation was conducted due to a complaint of physical abuse involving Resident #34 and Resident #53 in a shared room.
Complaint Details
The complaint investigation substantiated physical abuse of Resident #34 by Resident #53. The abuse was intentional pushing during a room altercation on 12/28/24. Prior verbal threats and aggressive behavior by Resident #53 were documented but not adequately addressed. The facility separated the residents and initiated abuse training for staff.
Findings
The facility substantiated physical abuse of Resident #34 by Resident #53 involving pushing during a room altercation. The investigation revealed missed opportunities to intervene earlier despite verbal altercations and threatening behavior prior to the physical incident. The facility separated the residents and provided abuse training to staff.
Deficiencies (1)
F 0600: The facility failed to protect Resident #34 from physical abuse by Resident #53, resulting in a substantiated incident of pushing on 12/28/24. The facility did not adequately follow up on verbal altercations and threats prior to the physical abuse.
Report Facts
Residents affected: 3
Staff trained: 31
BIMS score: 13
BIMS score: 10
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Jan 16, 2025
Visit Reason
Annual survey inspection of Red Cliffs Post Acute nursing home to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, bathing preferences, personal funds management, access to survey results, abuse prevention, medication administration, fall prevention, catheter care, dementia care, food safety, arbitration agreement understanding, and infection control related to water management.
Deficiencies (12)
F0550: Facility failed to ensure staff identified themselves to blind Resident #3 and assist Resident #44 with restroom use in a dignified manner.
F0561: Facility failed to honor bathing preferences for Residents #8, #11, and #47, not providing showers according to their requested frequency or time of day.
F0569: Facility failed to notify Resident #39 or legal representative when personal funds account neared Medicaid eligibility limit.
F0577: Facility failed to ensure residents knew where to access state survey results; the survey binder was inaccessible and unlabeled.
F0600: Facility failed to prevent physical abuse of Resident #34 by Resident #53 and did not adequately monitor or intervene in Resident #53's aggressive behaviors.
F0658: Facility failed to ensure Resident #10's enteric-coated omeprazole was not crushed prior to administration.
F0689: Facility failed to implement timely fall prevention interventions and did not complete neurological checks as required for Resident #8 after an unwitnessed fall.
F0690: Facility failed to provide proper suprapubic catheter care to Resident #50 and failed to monitor Resident #58 for UTI symptoms after antibiotic treatment completion.
F0744: Facility failed to implement person-centered dementia care to prevent resident-to-resident altercations involving Resident #53 and failed to monitor and intervene in aggressive behaviors.
F0812: Facility failed to ensure proper hand hygiene was performed by dietary staff before and after glove use and after touching potentially contaminated surfaces.
F0847: Facility failed to ensure residents and representatives were fully informed about the nature, implications, and rescission rights of the binding arbitration agreement before signing.
F0880: Facility failed to implement an effective water management plan including flushing of dead legs and low-flow piping runs to prevent Legionella growth.
Report Facts
Residents affected: 32
Residents affected: 5
Residents affected: 3
Residents affected: 6
Staff trained: 31
Days: 30
Days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Crushed Resident #10's enteric-coated omeprazole medication |
| RN #1 | Registered Nurse | Interviewed regarding neurological assessments and abuse reporting |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding neurological assessments and bathing preferences |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including abuse, bathing, catheter care, and fall prevention |
| NHA | Nursing Home Administrator | Interviewed regarding abuse investigation, arbitration agreement, and water management |
| MTD | Maintenance Director | Interviewed regarding water management and resident concerns |
| CC | Corporate Consultant | Provided education on catheter care and medication crushing |
| AC | Admissions Coordinator | Interviewed regarding arbitration agreement explanation |
| MKD | Marketing Director | Interviewed regarding arbitration agreement explanation |
| RN #2 | Registered Nurse, Infection Control Nurse | Observed and re-educated dietary staff on hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 2, 2024
Visit Reason
The inspection was conducted due to allegations of verbal abuse between residents and concerns about inadequate supervision related to alcohol use by a resident.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to protect Resident #2 from verbal abuse by Resident #3 on 9/1/24 and 9/16/24, failed to report and investigate the allegations, and did not implement interventions to prevent future verbal altercations.
Failed to implement an effective plan of care and provide adequate supervision for Resident #1 related to excessive alcohol consumption, failed to follow physician's orders for supervision when out of the facility, and failed to prevent Resident #1 from bringing and sharing alcohol in the facility.
Report Facts
Residents reviewed for abuse: 13
Residents reviewed for accidents: 13
Residents affected by verbal abuse: 2
Residents affected by accident hazards: 1
Residents in facility: 42
Residents who drank or used to drink: 26
BIMS score Resident #2: 5
BIMS score Resident #3: 15
BIMS score Resident #1: 12
Physician ordered alcohol limit: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided facility policies, interviewed regarding abuse allegations and alcohol use investigation |
| Social Services Director | SSD | Conducted interviews with residents and staff, involved in abuse investigations and alcohol use concerns |
| Licensed Practical Nurse #1 | LPN #1, Unit Manager | Interviewed about abuse investigation procedures and supervision concerns |
| Licensed Practical Nurse #2 | LPN #2 | Interviewed about concerns related to Resident #1's alcohol use and safety risks |
| Registered Nurse #1 | RN #1 | Interviewed regarding alcohol concerns and resident safety |
| Certified Nursing Assistant #2 | CNA #2 | Reported witnessing derogatory name calling and alcohol use by Resident #1 |
| Certified Nursing Assistant #3 | CNA #3 | Interviewed about alcohol policies and observations of Resident #1 |
| Maintenance Service Director | MSD | Reported finding bottles of alcohol hidden around the facility |
| Housekeeping Director | HKD | Reported finding empty alcohol bottles and observations of Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 2, 2024
Visit Reason
The inspection was conducted due to allegations of verbal abuse between residents and concerns about inadequate supervision related to alcohol use and fall risk.
Complaint Details
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 properly investigate, report, or intervene. The complaint also included concerns about inadequate supervision and safety risks related to Resident #1's alcohol use and leaving the facility unsupervised.
Findings
The facility failed to protect Resident #2 from verbal abuse by Resident #3, did not thoroughly investigate or report the abuse allegations, and failed to implement interventions to prevent future incidents. Additionally, the facility failed to provide adequate supervision and implement an effective care plan for Resident #1 related to excessive alcohol consumption, resulting in safety risks including falls and unauthorized leaving of the facility.
Deficiencies (2)
F 0600: The facility failed to protect Resident #2 from verbal abuse by Resident #3 on two occasions, failed to report and investigate the allegations, and did not implement interventions to prevent future verbal altercations.
F 0689: The facility failed to ensure Resident #1 received adequate supervision to prevent accident hazards related to excessive alcohol consumption and did not follow physician orders for supervision when Resident #1 left the facility.
Report Facts
Residents reviewed for abuse: 13
Residents reviewed for accidents: 13
Residents affected by verbal abuse: 2
Residents affected by accident hazards: 1
Resident #1 daily alcohol allowance: 5
Resident #1 BIMS score: 12
Resident #2 BIMS score: 5
Resident #3 BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding abuse investigation and alcohol use concerns |
| Social Services Director | SSD | Conducted interviews and investigations related to abuse allegations and alcohol use |
| Licensed Practical Nurse #1 | LPN #1, Unit Manager | Interviewed about abuse investigation procedures and resident supervision |
| Licensed Practical Nurse #2 | LPN #2 | Interviewed about concerns for Resident #1's alcohol use and safety |
| Registered Nurse #1 | RN #1 | Interviewed about alcohol concerns and resident safety |
| Certified Nursing Assistant #2 | CNA #2 | Interviewed about observations of Resident #1's intoxication and alcohol use |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 26, 2023
Visit Reason
The inspection was conducted due to complaints and grievances related to resident care, abuse allegations, treatment and care deficiencies, smoking safety, and fall risk management at the facility.
Complaint Details
The complaint investigation included grievances about unresolved resident council complaints, allegations of abuse to Resident #30 by a CNA, failure to provide physician-ordered treatment for Resident #40, unsafe smoking practices and lack of supervision for Resident #21, and inadequate fall prevention and investigation for Resident #44.
Findings
The facility failed to promptly address resident grievances, ensure residents were free from abuse, provide appropriate treatment for resident conditions, maintain safe smoking practices, and adequately prevent falls. Multiple residents experienced unresolved grievances, abuse allegations, untreated conditions, unsafe smoking without supervision, and repeated falls with incomplete investigations and insufficient interventions.
Deficiencies (5)
F 0565: The facility failed to act promptly on resident council grievances regarding call lights, staff responsiveness, and follow-up on complaints over the past three months.
F 0600: The facility failed to ensure Resident #30 was free from abuse by a staff member, resulting in emotional distress though physical abuse was unsubstantiated.
F 0684: The facility failed to assess and obtain a physician order for treatment of Resident #40's rashes on both arms, despite nurse-applied ointment.
F 0689: The facility failed to provide adequate supervision to Resident #21 during smoking breaks as required by his smoking assessment, resulting in unsafe smoking practices.
F 0689: The facility failed to conduct thorough fall investigations and implement effective interventions to prevent repeated falls for Resident #44, including inadequate monitoring and unresolved call light issues.
Report Facts
Deficiencies cited: 5
Fall risk score: 22
Fall risk score: 30
BIMS score: 10
BIMS score: 12
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Named in abuse allegation involving Resident #30; terminated following investigation. |
| CNA #6 | Certified Nurse Aide | Witnessed abuse incident involving Resident #30 and CNA #5. |
| Director of Nursing | Director of Nursing (DON) | Provided facility policies, interviewed regarding abuse and fall prevention. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding grievances, abuse investigation, and fall prevention. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding grievance process and abuse investigation. |
| Unit Manager | Unit Manager (UM) | Interviewed regarding smoking supervision and fall prevention. |
| Maintenance Service Director | Maintenance Service Director (MSD) | Interviewed regarding call light maintenance and audits. |
| Registered Nurse #3 | Registered Nurse (RN) | Provided treatment for Resident #40's rashes without physician order. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 26, 2023
Visit Reason
The inspection was conducted due to complaints and grievances related to resident care, abuse allegations, treatment and care deficiencies, smoking safety, and fall risk management at Red Cliffs Post Acute nursing home.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to act promptly upon grievances of the resident council concerning resident care and lift issues, including lack of follow-up on grievances.
Failed to ensure one resident was free from abuse by a staff member, causing emotional distress though physical abuse was unsubstantiated.
Failed to assess and obtain physician orders for treatment of resident's rashes before applying ointment.
Failed to provide adequate supervision to a resident during smoking breaks as required by smoking assessment, resulting in unsafe smoking practices.
Failed to conduct thorough fall investigations and implement effective interventions to prevent repeated falls for a resident at high fall risk.
Report Facts
Residents affected by grievance deficiency: 3
Residents affected by abuse deficiency: 1
Residents affected by treatment deficiency: 1
Residents affected by smoking deficiency: 1
Residents affected by falls deficiency: 1
Fall risk assessment score: 22
Fall risk assessment score: 30
Fall risk assessment score: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Named in abuse allegation involving rough care and emotional distress to Resident #30 |
| CNA #6 | Certified Nurse Aide | Witnessed abuse incident and intervened to complete care for Resident #30 |
| Social Services Director | Social Services Director (SSD) | Responsible for collecting and following up on grievances; interviewed regarding grievance process |
| Director of Nursing | Director of Nursing (DON) | Provided facility policies, interviewed regarding abuse investigation, grievance follow-up, and fall prevention |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding grievance follow-up, abuse investigation, and fall prevention |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding grievance process, abuse investigation, and smoking supervision |
| Unit Manager | Unit Manager (UM) | Interviewed regarding smoking supervision and fall prevention |
| Registered Nurse #3 | Registered Nurse | Provided treatment to Resident #40's rashes without physician order |
| Maintenance Service Director | Maintenance Service Director (MSD) | Interviewed regarding call light maintenance and audits |
| Administrator in Training | Administrator in Training (AIT) | Interviewed regarding smoking supervision and abuse allegation |
Inspection Report
Routine
Deficiencies: 11
Date: Oct 26, 2023
Visit Reason
The inspection was a routine regulatory survey of Red Cliffs Post Acute nursing home to assess compliance with federal and state regulations related to resident care, safety, and facility operations.
Findings
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.
Deficiencies (11)
Failed to treat Resident #13 with respect and dignity, including failure to communicate preferences for no male caregivers.
Failed to act promptly on grievances of the resident council regarding call lights, staff friendliness, and follow-up on grievances.
Failed to ensure Resident #30 was free from abuse by staff member CNA #5, including rough handling and verbal mistreatment.
Failed to obtain PASRR level II screening for Resident #20 to determine if facility could meet medical or mental health needs.
Failed to complete timely level I PASARR screening for Residents #41 and #44.
Failed to assess and treat Resident #40's rashes on both arms with physician orders prior to treatment.
Failed to provide adequate supervision to Resident #21 during smoking breaks and failed to conduct thorough fall investigations and interventions for Resident #44.
Failed to adequately manage Resident #27's chronic pain, including delayed administration of PRN pain medication and lack of non-pharmacological interventions.
Failed to provide trauma informed care for Residents #20 and #23, including failure to include PTSD in care plans, identify triggers, and involve residents in care planning.
Failed to provide appropriate dementia care for Residents #44, #13, and #40, including lack of meaningful activities, personalized behavior interventions, and discharge planning.
Failed to maintain safe and sanitary food preparation and service practices in the kitchen, including poor hand hygiene, improper food storage, unclean equipment, and missing temperature logs.
Report Facts
Weight gain: 22.7
Weight increase percentage: 17.1
Weight loss percentage: 12.37
Weight gain percentage: 22.19
Pain scale: 10
Pain scale: 7
Pain scale: 8
Fall risk score: 22
Fall risk score: 30
Fall risk score: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Named in abuse finding for rough handling and verbal mistreatment of Resident #30 |
| Director of Nursing | DON | Interviewed regarding multiple findings including abuse, pain management, fall prevention, trauma informed care, and dementia care |
| Assistant Director of Nursing | ADON | Interviewed regarding multiple findings including abuse, pain management, fall prevention, trauma informed care, and dementia care |
| Social Services Director | SSD | Interviewed regarding grievance follow-up, PASRR screening, trauma informed care, and dementia care |
| Dietary Manager | DM | Interviewed regarding kitchen sanitation and food safety deficiencies |
| Registered Dietitian | RD | Interviewed regarding nutritional monitoring deficiencies |
| Nursing Home Administrator | NHA | Interviewed regarding grievance follow-up, abuse, pain management, and trauma informed care |
| Administrator in Training | AIT | Interviewed regarding grievance follow-up, abuse, pain management, and trauma informed care |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding pain management and trauma informed care |
| Registered Nurse #2 | RN | Interviewed regarding pain management |
| Certified Nurse Aide #1 | CNA | Interviewed regarding trauma informed care and dementia care |
| Certified Nurse Aide #2 | CNA | Observed and interviewed regarding pain medication delay |
| Maintenance Service Director | MSD | Interviewed regarding call light maintenance and safety |
| Wound Nurse | WN | Interviewed regarding nutritional monitoring |
| Dietary Aide #1 | DA | Observed during meal service with poor hand hygiene |
| Cook | Cook | Observed during meal service with poor hand hygiene |
| Activity Director | AD | Interviewed regarding activity program deficiencies |
Inspection Report
Routine
Deficiencies: 12
Date: Oct 26, 2023
Visit Reason
Routine state inspection survey of Red Cliffs Post Acute nursing home to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, grievance follow-up, abuse prevention, PASRR screening, care for changes in condition, smoking safety, fall prevention, pain management, trauma-informed care, dementia care, nutrition, and food safety.
Deficiencies (12)
F550: Facility failed to treat Resident #13 with respect and dignity by not honoring her preference for no male caregivers and failing to communicate this preference.
F565: Facility failed to promptly act on resident council grievances regarding call lights, staff friendliness, and bathing, affecting multiple residents including the resident council vice president.
F600: Facility failed to ensure Resident #30 was free from abuse by staff; investigation found emotional distress due to rough care and refusal of care, but physical abuse was unsubstantiated.
F644: Facility failed to obtain required PASRR level II screening for Resident #20 to determine appropriateness of care for mental health conditions.
F645: Facility failed to complete timely PASARR level I screenings for Residents #41 and #44 as required by state guidelines.
F684: Facility failed to assess and obtain physician orders for treatment of Resident #40's arm rashes, which were treated without orders and without timely change of condition documentation.
F689: Facility failed to provide adequate supervision for Resident #21 during smoking breaks as required by his smoking assessment and failed to conduct thorough fall investigations and implement effective interventions for Resident #44.
F692: Facility failed to maintain accurate and consistent weight measurements for Resident #52, resulting in unaddressed significant weight fluctuations and lack of appropriate nutritional monitoring.
F697: Facility failed to adequately manage Resident #27's chronic pain, including delayed administration of PRN pain medication and lack of non-pharmacological interventions.
F699: Facility failed to provide trauma informed care for Residents #20 and #23 by not including PTSD in care plans, not identifying and controlling individual triggers, and not involving residents in care planning.
F744: Facility failed to provide appropriate dementia care for Residents #44, #13, and #40, including lack of meaningful activities for Resident #44, inadequate person-centered interventions for Resident #13's behaviors, and insufficient care planning for Resident #40's cognitive and discharge needs.
F812: Facility failed to ensure safe food preparation and service in the kitchen, including poor hand hygiene by staff, unsafe food storage, unclean equipment, and inadequate temperature monitoring.
Report Facts
Weight gain: 22.7
Weight increase percentage: 17.1
Weight loss percentage: 12.37
Weight gain percentage: 22.19
Fall risk score: 22
Fall risk score: 30
Pain scale: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in delayed pain medication administration and terminated for performance issues |
| CNA #5 | Certified Nurse Aide | Named in abuse investigation involving rough care of Resident #30 and terminated |
| DON | Director of Nursing | Interviewed regarding multiple findings including abuse, falls, pain management, and trauma care |
| ADON | Assistant Director of Nursing | Interviewed regarding multiple findings including abuse, falls, pain management, and trauma care |
| DM | Dietary Manager | Interviewed regarding kitchen sanitation and food safety deficiencies |
| RD | Registered Dietitian | Interviewed regarding nutritional monitoring and weight discrepancies |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding pain management and trauma informed care |
| CNA #1 | Certified Nurse Aide | Interviewed regarding trauma informed care and dementia care |
| UM | Unit Manager | Interviewed regarding smoking supervision and fall prevention |
| MSD | Maintenance Service Director | Interviewed regarding call light maintenance and monitoring |
| WN | Wound Nurse | Interviewed regarding weight monitoring and nutritional care |
| AD | Activity Director | Interviewed regarding activity programming for residents with dementia |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 17, 2023
Visit Reason
The inspection was conducted due to multiple allegations of abuse and inappropriate behavior by a certified nurse aide (CNA #1) reported by several residents between 12/31/2022 and 3/15/2023.
Complaint Details
The complaint investigation involved five residents alleging inappropriate touching, unwanted care, and intrusive behavior by CNA #1. The facility failed to fully investigate these allegations, including failure to interview key staff and family members, and failed to implement adequate corrective actions. CNA #1 was suspended and ultimately not allowed to return to work due to repeated abuse allegations.
Findings
The facility failed to thoroughly investigate five separate allegations of inappropriate touching and behavior by CNA #1. Investigative failures included not interviewing key staff and family members, lack of clear corrective actions, and failure to protect residents. CNA #1 was suspended and ultimately not allowed to return to work due to repeated abuse allegations and staffing challenges.
Deficiencies (7)
F 0610: The facility failed to conduct thorough investigations on five separate complaints of inappropriate touching and behavior by CNA #1 between 12/31/22 and 3/15/23. The facility also failed to provide clear corrective actions and monitoring plans to protect residents.
The facility failed to interview LPN #1 who was the staff nurse to whom Resident #1 reported the allegation on 12/31/22.
The facility failed to interview family members or representatives for Resident #1 and failed to provide clear care limitations and monitoring instructions for CNA #1.
The facility failed to conduct and document an interview with CNA #1 regarding allegations from Resident #2 and failed to protect Resident #2 from further distress.
The facility failed to show evidence of an interview with the medical records manager who witnessed CNA #1 continuing care after Resident #3 told him to stop, and failed to interview CNA #1 or protect Resident #3.
The facility failed to show evidence of an interview with the business office manager who witnessed CNA #1 tickling Resident #4 and failed to interview other staff or witnesses or protect Resident #4.
The facility failed to initiate interviews with staff present when Resident #5 reported feeling uncomfortable with CNA #1, failed to contact the resident's representative, and failed to provide evidence of corrective action.
Report Facts
Residents in sample: 20
Residents affected: 5
BIMS scores: 15
BIMS scores: 11
BIMS scores: 14
BIMS scores: 5
BIMS scores: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Subject of multiple abuse allegations and investigations |
| NHA | Nursing Home Administrator | Interviewed regarding investigations and facility actions |
| DON | Director of Nursing | Provided facility policies and interviewed regarding investigations |
| LPN #1 | Licensed Practical Nurse | Staff nurse to whom Resident #1 reported abuse; not interviewed by facility |
| ADON | Assistant Director of Nursing | Provided statements and involved in investigations |
| DSS | Director of Social Services | Conducted interviews and documented investigations |
| MRM | Medical Records Manager | Witnessed incident involving Resident #3 and CNA #1 |
| BOM | Business Office Manager | Witnessed incident involving Resident #4 and CNA #1 |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: May 17, 2023
Visit Reason
The inspection was conducted due to multiple allegations of abuse and inappropriate behavior by a certified nurse aide (CNA #1) reported by five residents between 12/31/2022 and 3/15/2023.
Complaint Details
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.
Findings
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.
Deficiencies (9)
Failed to conduct thorough investigations on five separate complaints/allegations of inappropriate touching, kissing, hugging, tickling, verbal gestures, unwanted care and intrusive behavior by CNA #1.
Failed to provide a clear corrective action and monitoring/supervision plan to protect all residents.
Failed to interview LPN #1 who was the staff nurse to whom Resident #1 reported the allegation.
Failed to interview family members or representatives for Resident #1.
Failed to interview CNA #1 regarding allegations from Resident #2 and Resident #3.
Failed to show evidence of interviews with witnesses such as the medical records manager (MRM) and business office manager (BOM).
Failed to provide evidence that corrective actions were taken to protect residents from further distress.
Failed to contact Resident #5's representative for an interview.
Failed to provide clear instructions on care limitations to CNA #1 and how care would be monitored.
Report Facts
Residents in sample: 20
Residents affected: 5
BIMS scores: 15
BIMS scores: 11
BIMS scores: 14
BIMS scores: 5
BIMS scores: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Subject of multiple abuse allegations and investigations |
| NHA | Nursing Home Administrator | Interviewed regarding investigations and facility response |
| DON | Director of Nursing | Provided facility policies, interviewed staff, and discussed corrective actions |
| DSS | Director of Social Services | Conducted resident interviews and internal investigations |
| LPN #1 | Licensed Practical Nurse | Staff nurse to whom Resident #1 reported abuse; not interviewed by facility |
| ADON | Assistant Director of Nursing | Provided statements and education to CNA #1 |
| MRM | Medical Records Manager | Witnessed incident involving Resident #3; not interviewed by facility |
| BOM | Business Office Manager | Witnessed incident involving Resident #4; not interviewed by facility |
| UM #2 | Unit Manager | Received complaint from Resident #5 |
| Student Nurse | Student Nurse | Provided care in pairs with CNA #1 for Resident #5 |
Inspection Report
Deficiencies: 15
Date: Jul 28, 2022
Visit Reason
The inspection was conducted to investigate multiple areas of regulatory compliance including resident abuse, activities, treatment and care, pressure ulcers, range of motion, falls, medication administration, infection control, COVID-19 testing and vaccination, nutrition, respiratory care, and medication storage.
Findings
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.
Deficiencies (15)
Failure to protect Resident #19 from physical abuse by Resident #43 on 7/8/22.
Failure to provide ongoing personalized activity programs for Residents #43, #28, and #24.
Failure to provide appropriate treatment and care for Residents #8 and #51 including monitoring edema and following physician orders for pain medication.
Failure to continuously monitor and assess wound measurements for Residents #56, #18, and #24.
Failure to provide appropriate care to maintain or improve range of motion for Residents #51 and #36.
Failure to provide adequate supervision and monitoring to prevent falls and injuries for Residents #16 and #316.
Failure to timely address significant weight loss for Resident #34.
Failure to ensure oxygen was administered according to physician orders for Resident #43.
Failure to prime insulin pens prior to medication administration on two occasions.
Failure to maintain proper refrigerator temperatures for medication storage.
Failure to ensure food was palatable, attractive, and served at appropriate temperatures.
Failure to maintain an infection control program including disinfecting equipment between resident uses, offering hand hygiene before meals, proper PPE use, and proper disposal of medication syringes.
Failure to have a qualified infection preventionist on staff.
Failure to perform required COVID-19 testing on staff and individuals providing services under arrangement.
Failure to develop and implement a COVID-19 staff vaccination process to address all facility staff including agency and outside providers.
Report Facts
Weight loss: 15.8
Temperature: 26.2
Falls: 6
Pain level: 8
Pain level: 6
Oxygen liter flow: 3
Oxygen liter flow: 1
Insulin dose: 12
Insulin dose: 15
Refrigerator temperature: 33.1
Refrigerator temperature: 34.8
Refrigerator temperature: 31.8
Refrigerator temperature: 34.5
Refrigerator temperature: 33.9
Refrigerator temperature: 30.8
Refrigerator temperature: 31.7
Refrigerator temperature: 22.1
Refrigerator temperature: 21.3
Refrigerator temperature: 34.26
Refrigerator temperature: 32.36
Refrigerator temperature: 34.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed failing to place oxygen on Resident #43 and adjusting oxygen flow without checking pulse oximetry. |
| LPN #3 | Licensed Practical Nurse | Observed administering insulin pens without priming the needle. |
| RN #1 | Registered Nurse | Resident #16's regular nurse, interviewed about resident's injury and x-ray scheduling. |
| UM #1 | Unit Manager | Communicated with physician about Resident #16's arm pain and x-ray. |
| DON | Director of Nursing | Interviewed about multiple deficiencies including oxygen administration, infection control, medication errors, and COVID-19 testing. |
| NHA | Nursing Home Administrator | Interviewed about multiple deficiencies including infection control, medication administration, and COVID-19 vaccination. |
| RD | Registered Dietitian | Interviewed about Resident #34's weight loss and nutrition concerns. |
| CNA #2 | Certified Nurse Aide | Observed failing to clean equipment between residents and failing to offer hand hygiene before meals. |
| AA | Activity Assistant | Observed failing to disinfect beach ball between residents. |
| LPN #4 | Licensed Practical Nurse | Interviewed about insulin pen priming and COVID-19 testing. |
Inspection Report
Complaint Investigation
Deficiencies: 15
Date: Jul 28, 2022
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident abuse, failure to provide appropriate activities, treatment and care, pressure injury monitoring, falls, medication errors, infection control, COVID-19 testing and vaccination compliance.
Complaint Details
Complaint investigation revealed multiple deficiencies including resident abuse, inadequate care and supervision, medication errors, infection control lapses, and COVID-19 testing and vaccination failures.
Findings
The facility failed to protect a resident from physical abuse by another resident, failed to provide personalized activity programs, failed to provide appropriate treatment and care for edema and pain management, failed to monitor and assess pressure injuries, failed to provide restorative nursing programs, failed to prevent falls and provide adequate supervision, failed to ensure oxygen was administered per orders, failed to implement gradual dose reductions for psychotropic medications, failed to prime insulin pens prior to administration, failed to maintain proper medication refrigerator temperatures, failed to serve palatable and appropriately tempered food, failed to maintain infection control practices including equipment disinfection and hand hygiene, failed to perform required COVID-19 testing for staff, and failed to ensure staff vaccination compliance.
Deficiencies (15)
F0600: The facility failed to protect Resident #19 from physical abuse by Resident #43 on 7/8/22, resulting in visible scratches and police involvement.
F0679: The facility failed to provide personalized activity programs for Residents #43, #28, and #24, resulting in residents spending excessive time inactive or without preferred activities.
F0684: The facility failed to provide appropriate treatment and care for Resident #8's edema, including failure to elevate legs and delayed interventions, and failed to follow physician orders for Resident #51's pain medication.
F0686: The facility failed to continuously monitor and assess wound measurements for Residents #56, #18, and #24, resulting in incomplete wound care documentation and monitoring.
F0688: The facility failed to provide restorative nursing programs for Residents #51 and #36 with limited range of motion, risking decline in activities of daily living.
F0689: The facility failed to provide adequate supervision and fall prevention for Residents #16 and #316, resulting in multiple falls with injuries including fractures and head wounds.
F0692: The facility failed to timely address significant weight loss for Resident #34, including failure to reweigh and implement interventions after a 7.14% weight loss in less than a month.
F0695: The facility failed to ensure oxygen was administered according to physician orders for Resident #43, with frequent observations of oxygen cannula not in use and improper adjustments by staff.
F0758: The facility failed to ensure gradual dose reduction was attempted for Resident #30 who was administered psychotropic medications without documented attempts at dose reduction.
F0761: The facility failed to maintain proper temperatures for refrigerated pharmaceuticals, with multiple days of temperatures below the acceptable range of 36-46 degrees Fahrenheit.
F0804: The facility failed to consistently serve food that was palatable, attractive, and at appropriate temperatures, with residents reporting bland taste, mushy texture, and cold food.
F0880: The facility failed to maintain an infection control program, including failure to disinfect equipment between resident uses, failure to offer hand hygiene before meals, improper mask use by staff and visitors, and improper disposal of medication syringes.
F0882: The facility failed to have a qualified infection preventionist on staff, with the interim assistant director of nursing newly assigned and not yet certified.
F0886: The facility failed to complete required COVID-19 testing for staff and individuals providing services under arrangement, with inconsistent testing of non-up-to-date vaccinated staff.
F0888: The facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff and outside providers, with incomplete vaccination status records for contracted providers.
Report Facts
Residents sample size: 29
Resident #19 sample size: 29
Resident #43 age: 86
Resident #28 age: 70
Resident #24 age: 89
Resident #8 weight increase: 12.2
Resident #34 weight loss: 15.8
Resident #34 weight loss percent: 7.14
Medication refrigerator temperature: 26.2
Medication refrigerator temperature out of range days: 15
Oxygen liter per minute: 3
Insulin dose: 12
Insulin dose: 15
Falls Resident #316: 6
Falls Resident #16: 6
Pain scale Resident #16: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to place oxygen on Resident #43 and improperly adjusted oxygen flow |
| LPN #3 | Licensed Practical Nurse | Administered insulin pens without priming needle |
| CNA #2 | Certified Nurse Aide | Failed to disinfect blood pressure cuff and pulse oximeter between residents |
| Activity Assistant | Activity Assistant | Failed to disinfect beach ball between residents |
| Unit Manager #1 | Unit Manager | Communicated with physician about Resident #16's arm injury and pain |
| RN #1 | Registered Nurse | Resident #16's regular nurse, aware of injury and x-ray scheduling |
| Director of Nursing | Director of Nursing | Interviewed about multiple deficiencies including oxygen administration and infection control |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about multiple deficiencies including infection prevention and medication administration |
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