Red Cliffs Health and Rehab

In the surveyor’s words

From the most serious findings on record at Red Cliffs Health and Rehab, in the surveyor’s own words.

• Actual harm, patternF689Jun 6, 2024

  Based on interview and record review it was determined, for 4 of 53 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls with one resulting in a fracture, a resident transported in the facility vehicle was not properly secured and sustained a fall with injury. These findings were cited at a harm. In addition, a resident with wandering behaviors, eloped from the facility and a resident was not secured in their wheelchair and sustained a fall. Resident identifiers: 5, 18, 367, and 374. Findings Included: 1. […]

• Actual harm, isolatedF580Jun 6, 2024

  Based on interview and record review, it was determined the facility did not immediately consult with the 2 of 53 sample residents' physicians after there was a need to alter treatment significantly. Specifically, one resident had symptoms of a change in condition and the facility physician instructed the facility nurses to contact the surgeon, but no evidence could be located that this occurred. This resulted in the finding of a harm for this resident. In addition, a resident experienced elevated blood glucose levels without timely notification of the physician. […]

• Actual harm, isolatedF600Jun 6, 2024

  Based on interview and record review it was determined, for 5 out of 53 sampled residents, that the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a staff member recorded a video in the shower room while a resident was in the bathtub naked, a cognitively impaired resident kissed two different cognitively impaired residents on two different occasions and another resident who was cognitively impaired was involved in a sexual relationship. Resident Identifiers: 5, 12, 17, 36, 42, and 374. Findings Included: 1. […]

• Actual harm, isolatedF684Jun 6, 2024

  Based on interview and record review, the facility did not ensure that 3 of 53 sample residents received treatment and care in accordance with professional standards of practice. Specifically, one resident experienced a change in condition, and the facility did not act in a timely manner to treat the condition. This resulted in a finding of harm for this resident. In addition, one resident was not monitored for a change in condition after a dental procedure, and a resident who was incontinent developed Moisture Associated Skin Damage (MASD). Resident identifiers: 5, 7, and 365. Findings include: 1. […]

• Actual harm, isolatedF690Jun 6, 2024

  Based on interview and record review it was determined that for 2 out 53 sampled residents, that the facility did not ensure that the resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to extent possible. Specifically, a resident developed a UTI after facility staff were not instructed and trained on the proper changing, frequency, and monitoring of the resident's PureWick urinary system device and a resident had a delay in starting antibiotic therapy for a UTI. Resident identifiers: 36, 54. Findings Included: 1. […]