Red Cliffs Post Acute

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility' s general characteristics. The survey was conducted on January 29, 2025, to ensure compliance with the fire safety requirements of NFPA 101, Life Safety Code (LSC), 2012 edition, Chapter 19 for Existing Health Care Occupanc.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Weekly/Monthly: Not Provided2) Annual: 5.30.24 Excel, missing UL testing requirements. 3) Quick response heads dated 1990 due for replacement/ testing4) 5 Year: 2022 Excel, report from 8.17.22 indicates that back-flow internal was not performed5) 200 hall linen closet fire.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Annual: 12.19.24 Excel fire report does not indicate they tested any devices marked N/A NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements o.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Not Done per NFPA 110 standardsNFPA 110 8.4.1* EPSSs, including all appurtenant components, shall beInspected weekly and exercised under load at least monthly.NFPA 110 8.3.3 A written schedule .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Emergency Lighting (Monthly & Annual)(101 7.9.3.1.1): Not done per NFPA standards, 30 Seconds a month, 90 minutes per yearNFPA 101 7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1) Functional testing shall be co.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) The Oxygen Trans-filling room needs mechanical ventilation within 12" of the floor that terminates outside of the building and is connected to essential electrical systems.NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 i.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by:1) remove excessive lent from dryers 2) The birdcage area needs to protect abandoned electrical wiring under the couch NFPA 101: 19.5.1.1 Utilities shall comply with the provisions of Section 9.1.NFPA 101: 9.1.1 Gas. Equipment using gas and related gas piping shall be in accord.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:1) Fire Doors (annually)(80 5.2): Not done per NFPA 80 standards2) activities door closure not working3) 200 hall double fire door not latching4) 200 hall linen closet closure not attached5) 100 halls soiled linen closet need closure adjusted, latch and hole in door repaired6) 100 hall ..

A recertification survey with complaint #CO38742, #CO38744 and Incident #38977 was completed on 1/13/25 to 1/16/25. Twelve deficiencies were cited. An Emergency Preparedness survey was conducted from 1/13/25 to 1/16/25. No deficiencies were cited. Based 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 ph.. Based 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.. Based 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 indivi.. Based 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 en.. Based 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 tran.. Based 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 .. Based 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 .. Based 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.. Based 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 s.. Based 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.Specificall.. Based 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.. Based 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..

A complaint survey, prompted by #CO37476 was conducted on 10/1/24 to 10/2/24. Two deficiencies were cited. Based 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.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation, Reporting and Investigating policy, dated 2001, was provided by the nursing home administrator (NHA) on 10/2/24 at 11:44 a.m. The policy read in pertinent part, "All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported."Staff conducting the investigation should as a minimum:-Review the documentation and evidence;-Review the resident' s medical record to determine the resident' s physical and cognitive status at the time of the incident and since the incident; -Observe th.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.