Red Cliffs Post Acute

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents received treatment and care in accordance with professional standards or practice out of eight sample residents. Specifically, the facility failed to complete a timely assessment after Resident #1 experienced symptoms of a urinary tract infection (UTI) and an acute kidney injury.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#5 and #7) of four residents reviewed for accident hazards received adequate supervision out of 11 sample residents. Specifically, the facility failed to put effective person centered interventions in place to prevent repeated falls for Residents #5 and Resident #7.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen and dining room. Specifically, the facility failed to: -Ensure hand hygiene was conducted appropriately after touching potential contaminated surfaces; and, -Ensure hand hygiene was conducted before and after glove use.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to implement an effective water management plan.

Inspectors wroteBased on record review and interviews, the facility failed to offer choices to residents for three (#8, #11, and #23) of five residents reviewed for activities of daily living (ADL) out of 32 sample residents. Specifically, the facility failed to ensure Resident #8, Resident #1 and Resident #23 received showers consistently according to their choice of frequency.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents or their representative were aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for four (#15, #36, #58 and #74) of six residents out of 32 sample residents. Specifically, the facility failed to: -Thoroughly explain the arbitration agreement in a form and in a manner the residents and/or resident representatives understood the agreement before signing the arbitration agreement; -Accurately inform residents the arbitration agreement was a binding agreement before the agreement was signed; -Accurately inform residents the agreement waived residents' right to a trial before a judge or jury for all disputes between the resident and the facility. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for two (#3 and #44) residents of 32 sample residents. Specifically, the facility failed to: -Have staff members identify themselves when entering Resident #3's room, who was blind; and, -Assist Resident #44 to use the restroom in a dignified manner.

Inspectors wroteBased on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for one (#39) of five residents reviewed for personal funds accounts out of 32 sample residents. Specifically, the facility failed to notify Resident #39, who was Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#34) of three residents reviewed were free from abuse out of 32 sample residents. Specifically, the facility failed to ensure Resident #34 was free from physical abuse by Resident #53.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure services provided to one (#10) of seven residents met professional standards of quality out of 32 sample residents. Specifically, the facility failed to ensure Resident #10's enteric-coated omeprazole was not crushed prior to administration.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for one (#8) of five residents out of 32 sample residents. Specifically, the facility failed to: -Implement and update fall care plans in a timely manner for Resident #8; and, -Ensure neurological checks were completed appropriately for Resident #8 following an unwitnessed fall.

Inspectors wroteBased on record review and interviews, the facility failed to ensure catheter care in accordance with professional standards of care for two (#50 and #58) of three residents reviewed for appropriate catheter use and care out of 32 sample residents. Specifically, the facility failed to: -Provide suprapubic catheter care to Resident #50; -Conduct a thorough assessment after Resident #58 completed antibiotics for a urinary tract infection (UTI) to ensure the resident did not display further signs or symptoms of an UTI.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#53) of four residents reviewed for mood and behavior out of 32 sample residents. Specifically, the facility failed to effectively implement person-centered approaches for dementia care to prevent resident-to-resident altercations. Cross-reference: F600 failure to prevent resident abuse.

Inspectors wroteBased on observations, record review and interviews,, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings including the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to: -Ensure the residents knew where the state survey results were located; and, -Ensure the binder was accessible for review by residents and visitors.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (#2) of four residents reviewed for abuse out of 13 sample residents was kept free from abuse. Specifically, the facility failed to: -Protect Resident #2 from verbal abuse from Resident #3 on two separate occasions (9/1/24 and 9/16/24); -Report an allegation of verbal abuse on 9/1/24 and 9/16/24; -Thoroughly investigate an allegation of verbal abuse of Resident #2 from Resident #3; and, -Initiate and implement interventions to prevent future resident to resident verbal altercations between Resident #2 and Resident #3.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of 13 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards. Specifically the facility failed to: -Implement an effective plan of care that adequately addressed the risks posed to Resident #1 and other residents in the facility due to Resident #1's excessive alcohol consumption; -Provide adequate supervision for Resident #1, inside and outside the facility, due to the resident's excessive alcohol consumption; and, -Follow physician's orders for Resident #1 to have supervision when the resident was out of the facility.

Inspectors wroteBased on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchens during meal services. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; -Ensure safe storage of food for resident use; and, -Ensure a clean environment and equipment where food was prepared.

Inspectors wroteBased on resident, family, and staff interviews; and record review, the facility failed to act promptly upon the grievances of the resident council concerning issues of resident care and lift in the facility that were important to the residents. These failures affected the resident council vice president and other residents who participated in the resident council over the past three months, regarding call lights, staff not being friendly and providing follow-up on grievances.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#44, #13 and #40) of three residents reviewed for dementia care out of 30 sample residents. Specifically, the facility failed to: -Effectively implement a meaningful activity program for Resident #44; -Implement person centered interventions for Resident #13's behaviors; and, -Implement person centered interventions and care plan for Resident #40.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#13) of two residents reviewed for respect and dignity out of 30 sample residents. Specifically, the facility failed to: -Treat Resident #13 with respect and dignity when she requested pain medication after identifying her preferences of no males in her room; and -Communicate Resident #13's preference for no male caregivers.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#30) of four residents were free from abuse from staff members out of 30 sample residents. Specifically, the facility failed to ensure Resident #30 was free from abuse from a staff member.

Inspectors wroteBased on record review, and interviews, the facility failed to coordinate and obtain the Preadmission screening and resident screening review (PASRR) screening for one (#20) of two residents reviewed for PASRR out of 30 sample residents. Specifically, the facility failed to obtain a PASRR level II screening, which was used to determine whether or not the facility could adequately care for certain medical or mental health conditions for Resident #20.

Inspectors wroteBased on record review and interviews, the facility failed to ensure level I preadmission screening and resident review (PASARR) were completed for two (#41 and #44) residents of five residents reviewed for PASARR to gain and maintain their highest practical medical, emotional and psychosocial well-being out of 30 sample residents. Specifically, the facility failed to ensure Resident #41 and #44 had a level I PASARR screening completed timely.

Inspectors wroteBased on observations, record review and interviews facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#40) of three resident reviewed for change of condition out of 30 sample residents. Specifically, the facility failed to assess Resident #40's rashes on both of her arms and have a physician order for treatment provided.

Inspectors wroteII. Smoking A. Facility policy and procedure The Smoking policy, revised August 2022, was provided by the DON on 10/25/23 at 2:30 p.m. which read in pertinent: Policy statement: This facility has established and maintains safe resident smoking practices. Policy interpretation and implementation: 1. Prior to, and upon admission, residents are informed of the facility's smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are permitted in designated areas only. Smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure nutritional parameters were maintained for one resident (#52) of two residents reviewed for nutrition out of 30 sample residents. Specifically, the facility failed to: -Consistently respond to an identification of a significant weight loss or gain even though the resident had health conditions that could affect his body fluid levels for Resident #52; and, -Ensure the accuracy of the weight of Resident #52.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure pain was adequately managed for one (#27) of five residents reviewed for pain out of 30 sample residents. Specifically, the facility failed to: -Manage Resident #27's chronic back pain; -Provide Resident #27 with her as-needed (PRN) pain medication timely; and, -Provide non-pharmacological interventions to help Resident #27's pain.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide trauma informed care in order to eliminate or mitigate triggers that caused re-traumatization for two of three (#20 and #23) residents reviewed trauma informed care out of 30 sample residents. Specifically, Residents #20 and #23 admitted with post traumatic stress disorder (PTSD) and the facility failed to: -Include PTSD in the resident's comprehensive care plans; -Identify and control individual traumatic triggers; and, -Involve the residents with the development of their plan of care including plans for medication adjustments.

Inspectors wroteIII. Resident #316 A. Resident status Resident #316, age [AGE], was admitted on [DATE]. The July 2022 computerized physicians orders (CPO) included diagnoses of dementia with behavioral disturbance, major depressive disorder, and weakness, and lack of coordination. A minimum data set (MDS) with brief interview for mental status (BIMS) was not performed as the resident was a new admission. B. Record review Resident #316's care plan for falls, initiated 7/8/22, the date of admission, focused on cognitive loss, lack of safety awareness, impaired mobility, and seizures. Interventions implemented to prevent falls included: [...]

Inspectors wroteBased on interviews and record review, the facility failed to have a qualified infection preventionist on staff. Specifically, the facility failed to have a qualified infection preventionist on staff.

Inspectors wroteBased on interviews and record review, the facility failed to test facility staff, and individuals providing services under arrangement and volunteers for COVID-19 which had the potential to affect all 69 residents residing in the facility at the time of the survey. Specifically, the facility failed to complete weekly lab based PCR (polymerase chain reaction) testing for COVID-19, and rapid molecular or antigen test consistently prior to the start of their shift, based on the facility's county positivity rate.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including agency staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to obtain the vaccination status of other outside providers. The facility did not have the vaccination status for all of the outside providers. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. Cross-reference F886 (COVID-19 testing)

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide an ongoing program to support residents in their chosen activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#43, #28, #24) of five out of 29 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #43, #28, and #24.

Inspectors wroteBased on record review, interviews and observations the facility failed to ensure proper monitoring and assessments of pressure injuries for three (#56, #18, and #24) of five residents reviewed for pressure injuries of 29 sample residents. Specifically, the facility failed to continuously monitor and assess wound measurements for residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of pharmaceuticals for one of one medication storage rooms. Specifically, the facility failed to ensure proper temperatures for refrigerated pharmaceuticals.

Inspectors wroteBased on observations,interviews and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure that residents' food was papatable in taste, texture, appearance and temperature.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 for three of four units. Specifically, the facility failed to: -Ensure equipment and supplies were disinfected between resident uses; -Ensure residents were offered hand hygiene before meals in both the dining rooms and room trays; -Ensure personal protective equipment were worn properly; and, -Ensure proper disposal of medication syringes.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to take steps to protect one (#19) from resident to resident abuse out of 29 sample residents Specifically, the facility failed to ensure Resident #19 was free from physical abuse from Resident #43 that occured on 7/8/22.

Inspectors wroteBased on observations, record review, interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#8 and #51) of two residents out of 29 sample residents. Specifically, the facility failed to: -Ensure the Resident #8's edema was routinely monitored and documented; -Ensure Resident #8 had interventions in place and timely to prevent the worsening of edema; -Ensure Resident #8 had opportunities and assistance to elevate her legs to prevent the worsening of the edema that were based on her preferences of daily routine; and, -Ensure physician's orders were followed for Tylenol administration for Reident #51.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#51 and #36) of seven residents with limited range of motion received appropriate treatment and services out of 29 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #51 and #36 did not have a potential decline in activities of daily living (ADL).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#34) of two residents observed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 29 sample residents. Specifically, the facility failed to timely address Resident #34's weight loss.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#43) of one out of 29 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #43.

Inspectors wroteBased on interview, and record review, the facility failed to ensure for one (#30) of five residents reviewed for the use of unnecessary medications out of 29 residents were free from unnecessary drugs. Specifically, the facility failed to ensure gradual dose reduction (GDR) was attempted for Resident #30 who was administered psychotropic medications.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure residents were kept free from significant medication errors for two out of 29 sample residents. Specifically, the facility failed to ensure insulin pens were primed prior to medication administration on two occasions.