Red Cliffs Post Acute

In the surveyor’s words

From the most serious findings on record at Red Cliffs Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 10, 2022

  Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of three sample residents. On 10/19/22 Resident #1's insulin orders were discontinued by licensed practical nurse nurse (LPN) #1. The facility failed to have a system in place to confirm and verify the accuracy of the discontinuation of resident medications. Resident #1's insulin orders were discontinued on 10/19/22 by the LPN #1 who thought the orders were a duplicate. This caused the resident to miss (one dose) of 16 units of her Basaglar (long acting insulin) and three units (one dose) of her Novolog (short acting insulin). The resident's blood sugar on 10/21/22 at 7:30 a.m. […]

• Actual harm, isolatedF689Jul 28, 2022

  Based on record review and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for two (#16 and #316) residents out of three residents reviewed for falls and accidents out of 29 sample residents. Systematic facility failures were identified for Resident #16 and Resident #316. The failures resulted in repeat falls resulting in injury and pain. Resident #16 had a history of falls with injury. On 7/14/22 staff identified the resident had a four inch long, deep purple bruise on his left arm. His left arm was swollen and he expressed a worsening of pain. Documentation identified the resident requested to have an x-ray to his arm. The resident did not have the x-ray until 7/26/22, 12 days after his request. […]

• Actual harm, isolatedF550May 12, 2022

  Based on resident and staff interviews and record review, the facility failed to promote resident dignity and respect. The facility failed to ensure residents were provided timely bathing, meals and call light response. Due to the facility's failure to follow-up with resident concerns for those that required staff assistance with care, it created feelings of frustration, embarrassment, worry, imprisonment, and lack of worth. In addition, the facility failed to ensure residents were treated and spoken to in a dignified manner. Cross-reference F565 grievances of a group Findings include: I. Facility policy The Resident Rights policy, revised 3/1/22, was provided by the nursing home administrator (NHA) on 5/16/22 at 4:38 p.m. via email. […]

• Actual harm, isolatedF600Apr 27, 2021

  Based on resident, staff interviews and record review, the facility failed to ensure two (#36 and #6) of five residents reviewed for abuse out of 30 sample residents, were free from physical and verbal abuse. Resident #36 said in an interview on 4/21/21 that he was verbally abused by certified nurse aide (CNA) #4 about a month and a half ago. He said it made him feel not respected and he was shocked and angry. He said that nursing staff were aware but no one had come to talk to him about the issue. […]

• Actual harm, isolatedF686Apr 27, 2021

  Based on observations, record review and interviews, the facility failed to prevent pressure ulcers from developing for two (#10 and #106) of three residents reviewed for pressure ulcers out of 30 sample residents. The facility failed to ensure Resident #10 did not develop an unstageable (stage 3 or above-see reference below) pressure ulcer to the trunk area on her back, which was acquired in-house. This resident was chair-fast with [CONDITION(S)]. The development of the pressure ulcer caused pain to the resident. The facility failed to consistently monitor and provide adequate and timely wound cares, including routine measurements of the wound. No documentation was found for this wound (which was first observed on 2/22/21) from 2/22/21 through 3/27/21. […]