Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Red Cliffs Post Acute during CMS and state inspections, most recent first.
Two residents with cognitive impairment and high fall risk did not receive adequate supervision or effective, individualized fall prevention interventions. Despite care plans outlining measures such as non-skid footwear, anti-rollback wheelchair brakes, and frequent safety checks, observations and staff interviews revealed that these interventions were not consistently implemented or tailored to the residents' needs. Audits and documentation failed to confirm the effectiveness or appropriateness of the interventions, resulting in repeated falls.
The facility failed to ensure proper hand hygiene during meal service, as dietary staff did not wash hands after touching potentially contaminated surfaces, such as face masks, and before serving meal trays. This was contrary to facility policies and CDC guidelines, leading to unsanitary conditions in the kitchen and dining room.
The facility failed to implement an effective water management plan to prevent Legionella, lacking documentation of flushing dead legs and low-flow piping runs. Interviews revealed that both the maintenance director and nursing home administrator were unaware of the necessary procedures and documentation was missing for the past year.
The facility failed to honor resident bathing preferences, affecting three residents who did not receive showers according to their preferred frequency and timing. One resident, with moderate cognitive impairment, was not offered morning baths as preferred, while another resident, with mild cognitive impairments, did not receive the preferred number of showers. A third resident, also with mild cognitive impairments, preferred morning showers but mostly received them in the afternoon or evening. Staff interviews revealed a lack of awareness of these preferences.
The facility failed to ensure residents or their representatives were informed about the arbitration agreement's implications before signing. Staff interviews revealed a lack of understanding and communication regarding the agreement, leading to residents signing without full awareness of their rights and the binding nature of the agreement.
The facility failed to maintain the dignity of two residents. A blind resident felt unsafe when staff entered her room without announcing themselves, despite her care plan requiring it. Another resident, needing urgent restroom assistance, was told to return to her room and wait, causing distress. Staff interviews confirmed these actions were against facility standards.
A facility failed to notify a Medicaid-funded resident or their legal representative when the resident's personal funds account approached the Medicaid eligibility resource limit. The account balance was $39.14 away from exceeding the limit, and there was no documentation of notification until the survey. Interviews revealed that the business office manager claimed to have notified the resident, but lacked documentation to support this prior to the survey.
A resident's enteric-coated omeprazole was improperly crushed before administration, despite staff awareness that such medications should not be crushed. The resident, with cognitive impairments and multiple diagnoses, was unable to participate in decision-making. Interviews confirmed staff knowledge of proper medication handling, yet the error occurred, indicating a lapse in adherence to professional standards.
A resident with dementia and other health issues experienced an unwitnessed fall in the facility. The fall care plan was not updated promptly, and neurological assessments were missed on two days, contrary to the facility's protocol. Staff interviews confirmed the delay in implementing fall prevention interventions and the failure to perform required assessments.
Two residents in a LTC facility experienced inadequate catheter care, leading to potential health risks. One resident's suprapubic catheter was not cleaned daily, resulting in visible matter on the tubing, while another resident's indwelling catheter bag was improperly placed on the floor, creating a dependent loop. Despite completing antibiotics for a UTI, there was no documented follow-up assessment for the second resident. These deficiencies highlight a failure to adhere to catheter care policies and monitor residents' conditions effectively.
A resident with dementia was involved in a physical altercation with a roommate due to the facility's failure to implement person-centered care. Despite having a behavior care plan, the facility did not document or observe potential triggers or outward frustration, leading to the incident. Staff interviews revealed a lack of communication and awareness regarding the resident's behavior, contributing to the deficiency in care.
A resident was physically abused by a roommate in an LTC facility after ongoing verbal altercations. The facility failed to act on warning signs, such as previous aggressive behavior and verbal threats, leading to the incident. The residents were eventually separated, but the facility did not adequately monitor or address the behaviors prior to the altercation.
The facility failed to ensure residents and their families had access to survey results, as the binder was not easily accessible or labeled, and residents were unaware of its existence. The NHA acknowledged the issue and planned to address it.
A resident was subjected to verbal abuse by another resident on two occasions, but the facility failed to report the incidents, conduct thorough investigations, or implement interventions to prevent future occurrences. The affected resident, with severe cognitive deficits, was not monitored for changes in behavior or emotional distress, and the facility did not update care plans to address the situation.
A resident with a history of excessive alcohol consumption and multiple health issues was not adequately supervised in a LTC facility. Despite a care plan identifying fall risks due to alcohol use, the resident frequently left the facility unsupervised and returned with alcohol. The facility failed to implement effective measures to monitor the resident's behavior, leading to ongoing safety concerns.
Failure to Implement Effective Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls received adequate supervision and effective, person-centered interventions to prevent repeated falls. For one resident with a history of stroke, dementia, anxiety, and unsteadiness, the care plan included multiple interventions such as reminders to use the call light, non-skid footwear, and keeping personal items within reach. However, observations revealed that the resident's glasses and hearing aids were out of reach, the call light signage was difficult to read due to poor contrast, and the resident's wheelchair lacked proper identification. Documentation did not confirm whether the resident understood how to use the call light or if interventions were tailored to her cognitive abilities. Additionally, there was no evidence of pharmacy review specific to fall prevention, and the responsible party was not consistently involved in developing or updating fall prevention strategies. Another resident with severe cognitive impairment, muscle weakness, and a history of falls was also not provided with all required safety interventions. Although the care plan called for anti-rollback brakes on the wheelchair and other fall prevention measures, observations showed that the anti-rollback brakes were not installed as required. Staff interviews indicated a lack of awareness regarding the need for these safety devices, and progress notes documented multiple falls after the intervention was recommended but not implemented. The care plan included frequent checks and reminders, but these were not always carried out or documented as effective. Audits and performance improvement plans were in place to monitor fall prevention interventions, but these did not consistently assess the residents' specific needs or the effectiveness of interventions. For example, audits failed to evaluate whether residents could read reminder signs, reach their call lights, or use them effectively. There was also a lack of follow-through on therapy recommendations and incomplete documentation of resident preferences and abilities. As a result, the facility did not consistently implement or monitor person-centered, effective fall prevention interventions for the affected residents.
Failure in Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to maintain proper hand hygiene practices in the kitchen and dining room, leading to unsanitary conditions during food service. Observations revealed that dietary aides and a cook did not perform hand hygiene after touching potentially contaminated surfaces, such as the outer surface of their face masks, and before serving meal trays to residents. Specifically, dietary aide #4 did not wash hands before serving meal trays and touched his face mask without subsequent hand hygiene. Similarly, dietary aide #1 and cook #1 failed to change gloves and wash hands after touching their masks, and dietary aide #2 placed meal items on trays without washing hands after touching his mask. The facility's policies on food preparation and preventing foodborne illnesses require employees to wash hands during food preparation and after touching potentially contaminated surfaces. However, the dietary staff did not adhere to these policies, as evidenced by their actions during meal service. The staff's failure to perform hand hygiene between tasks and glove changes was contrary to the facility's guidelines and the CDC's recommendations for preventing the spread of infections in healthcare settings. Interviews with dietary staff and the infection control nurse confirmed that hand hygiene practices were not consistently followed. The dietary manager acknowledged that hand hygiene training had not been recent, and the infection control nurse admitted to not having completed hand hygiene training with the dietary staff. The lack of adherence to hand hygiene protocols and insufficient training contributed to the unsanitary conditions observed during the meal service.
Inadequate Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in implementing a water management plan to prevent the growth and transmission of Legionella. The facility's Legionella Water Management Program policy, dated July 2024, lacked documentation of when dead legs and low-flow piping runs were flushed, as recommended by the CDC. The maintenance logs showed that while water temperature readings were taken weekly, there was no documentation verifying that dead legs and low-flow piping runs had been flushed in the past year. Additionally, two resident rooms had been unoccupied for over seven days in the last 60 days, but the water management plan did not document flushing of these areas. Interviews with the maintenance director (MTD) and the nursing home administrator (NHA) revealed a lack of knowledge and documentation regarding the flushing of dead legs and low-flow piping runs. The MTD, who had recently assumed the role, was unaware of the location of all water piping and dead legs in the building and did not know the recommended frequency for flushing these areas. The NHA also expressed uncertainty about the flushing frequency and confirmed the absence of documentation for such activities in the last calendar year.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not offering choices to residents regarding their bathing preferences. Specifically, three residents were not provided with showers according to their preferred frequency and timing. Resident #8, who was moderately cognitively impaired, expressed a preference for two baths per week in the morning, but was only offered six baths over a 30-day period, all in the afternoon, and refused one bath because it was too late in the day. Resident #11, with mild cognitive impairments and physical limitations, preferred three showers a week due to excessive sweating. However, the resident received only nine showers out of 11 opportunities, not meeting the preferred frequency. Staff interviews revealed a lack of awareness of the resident's specific preferences, indicating a failure to adhere to the care plan. Resident #47, also with mild cognitive impairments, preferred morning showers to relax in the evenings but received only one morning shower out of five. Staff interviews confirmed a lack of awareness of the resident's preference for morning showers. The Director of Nursing acknowledged the discrepancies in meeting the residents' bathing preferences, highlighting a systemic issue in honoring resident choices.
Failure to Inform Residents of Arbitration Agreement Details
Penalty
Summary
The facility failed to ensure that residents or their representatives were adequately informed about the nature and implications of the arbitration agreement before signing. This deficiency was identified for four out of six residents sampled. The arbitration agreement, which was undated, stated that by signing, residents waived their right to a jury or court trial, agreeing instead to binding arbitration for disputes with the facility. However, the facility did not thoroughly explain this agreement in a manner that the residents or their representatives could understand, nor did they accurately inform them that the agreement was binding and that it waived their right to a trial. Interviews with the admissions coordinator (AC) and the marketing director (MKD) revealed a lack of understanding and communication regarding the arbitration agreement. The AC believed the agreement was not binding and was unaware of the timeline for rescinding it. Similarly, the MKD was unsure of the deadline to rescind the agreement and incorrectly stated that the agreement was not binding. This misinformation was reflected in the interviews with residents, who were either unaware of the arbitration agreement or did not understand its implications. Some residents expressed a desire to have had the opportunity to review the agreement with legal counsel before signing. The record review showed that the arbitration agreements were signed by the residents and either the AC or MKD as facility representatives. Despite the facility's intent to resolve disputes amicably, the lack of proper explanation and understanding of the arbitration agreement led to residents signing without full awareness of their rights and the binding nature of the agreement. This oversight in communication and documentation contributed to the deficiency identified by the surveyors.
Failure to Maintain Resident Dignity and Provide Timely Assistance
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, leading to deficiencies in their care. Resident #3, who is blind and has a history of anxiety and mistrust, experienced fear and discomfort when staff entered her room without announcing themselves. Despite her care plan specifying that staff should announce their name and title upon entering, observations showed that staff members, including a laundry aide and a CNA, failed to do so, causing the resident to feel unsafe and anxious. Resident #44, who is moderately cognitively impaired and requires assistance with toileting, was not provided with timely help when she urgently needed to use the restroom. Despite her call light being on and her vocal request for assistance, she was instructed to return to her room and wait for help, which was not provided promptly. This lack of immediate assistance forced the resident to self-propel in her wheelchair to seek help, causing distress and discomfort. Interviews with staff, including an RN, LPN, and the DON, confirmed that the actions taken were not in line with the facility's standards for resident care. Staff acknowledged that residents should be assisted immediately when requesting help and that it was essential to announce themselves when entering Resident #3's room. The DON emphasized that the care plans for both residents should have been followed to ensure their dignity and respect.
Failure to Notify Resident of Personal Funds Account Limit
Penalty
Summary
The facility failed to manage the personal funds account of a Medicaid-funded resident accurately. Specifically, the facility did not notify the resident or their legal representative when the personal funds account reached $200 less than the eligibility resource limit for Medicaid. A review of the resident's trust account balance showed that the account had $1,960.86, which was $39.14 away from exceeding the Medicaid resource limit. There was no documentation indicating that the facility had notified the resident or their legal representative about the account balance reaching the threshold until the survey was conducted. Interviews with the nursing home administrator (NHA) and the business office manager (BOM) revealed that the BOM claimed to have notified the resident about the account being close to the Medicaid limit, but there was no documentation to support this claim prior to the survey. The BOM acknowledged that residents with funds over the limit were at risk of losing their Medicaid eligibility. The lack of documentation and notification led to the deficiency being identified during the survey.
Improper Crushing of Enteric-Coated Medication
Penalty
Summary
The facility failed to ensure that the administration of medications met professional standards of quality for one resident. Specifically, the deficiency involved the improper handling of enteric-coated omeprazole, which was crushed prior to administration. This action was observed when an LPN was preparing the resident's morning medications, including the omeprazole capsule, which should not have been crushed according to professional guidelines. The resident, who was over 65 years old and had diagnoses including gastro-esophageal reflux disease and chronic obstructive pulmonary disease, was unable to participate in decision-making due to cognitive impairments. Interviews with multiple nursing staff, including LPNs, an RN, and the Director of Nursing, revealed a general understanding that enteric-coated, extended-release, or delayed-release medications should not be crushed. Despite this knowledge, the medication was still crushed, indicating a lapse in adherence to professional standards. The physician's order for the omeprazole had been in place since 2021, yet the error occurred, highlighting a failure in the medication administration process for this resident.
Failure to Implement Timely Fall Prevention and Neurological Assessments
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents for one resident. Specifically, the facility did not implement and update fall care plans in a timely manner and failed to ensure neurological checks were completed appropriately following an unwitnessed fall. The facility's policy required a resident-centered fall prevention plan and neurological assessments after a fall, but these were not adequately followed for the resident in question. The resident, who was over 65 years old and had diagnoses including dementia, congestive heart failure, and rheumatoid arthritis, experienced an unwitnessed fall while attempting to self-transfer from a wheelchair to a bed. The fall plan of care was not updated promptly, and the intervention for physical therapy evaluation was delayed by three days. Additionally, the facility did not perform neurological assessments according to the protocol, missing assessments on two consecutive days. Interviews with staff, including the physical therapist, registered nurse, licensed practical nurse, and director of nursing, revealed that the facility's protocol for neurological assessments was not followed, and the fall prevention intervention was not implemented in a timely manner. The director of nursing acknowledged the failure to document neurological assessments and vital signs for the resident on the specified days, highlighting a lapse in adherence to the facility's procedures.
Inadequate Catheter Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential health risks. Resident #50, who had a suprapubic catheter due to multiple traumatic urinary diagnoses, reported discomfort and inadequate cleaning of his catheter. Observations revealed black and brown matter adhered to the catheter tubing, indicating that daily cleaning was not performed as documented. Despite the facility's records showing catheter care was provided, the physical state of the catheter suggested otherwise. Interviews with staff confirmed that the catheter needed cleaning, and there was a lack of awareness regarding the resident's concerns. Resident #58, who used an indwelling catheter, was observed with his catheter bag placed on the floor, creating a dependent loop in the tubing. This practice could impede urine flow and increase the risk of infection. The resident reported a burning sensation when urinating, a potential sign of a urinary tract infection (UTI). Despite completing a course of antibiotics for a UTI, there was no documented follow-up assessment to ensure the infection had resolved. The facility's failure to monitor the resident's condition post-antibiotic treatment and the improper handling of the catheter bag contributed to the deficiency. The facility's policies and procedures for catheter care were not adequately followed, as evidenced by the observations and interviews. The lack of proper catheter maintenance and monitoring for signs of infection posed a risk to the residents' health. The staff's failure to adhere to established guidelines and the absence of thorough assessments after antibiotic treatment were significant factors in the identified deficiencies.
Failure to Implement Person-Centered Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, leading to a deficiency in care. Resident #53, who had a history of alcohol-induced persisting dementia, major depressive disorder, and insomnia, was involved in a physical altercation with his roommate, Resident #34. The incident occurred because Resident #53 pushed Resident #34 for not shutting the shared bedroom door, which he feared would allow his dog to escape. The facility was unaware of the incident until it was reported two days later, and the investigation substantiated the physical abuse due to the intentionality of the act. The facility's failure to implement person-centered approaches for dementia care contributed to the altercation. Despite having a behavior care plan in place, the facility did not document or observe potential triggers or outward frustration exhibited by Resident #53. The care plan directed staff to anticipate the resident's needs, manage environmental factors, and document changes in behavior, but these interventions were not effectively implemented. The facility also failed to address the resident's aggressive threat on 12/29/24, other than ensuring the door was shut, and did not separate the resident from the triggering situation by providing another room. Interviews with staff revealed a lack of communication and awareness regarding the resident's behavior and the altercation. The maintenance director did not report the tension between the roommates, and the NHA was unaware of the threatening words made by Resident #53. The social service director emphasized the importance of monitoring the resident's behavior and involving social services in addressing behavioral concerns, but she was not informed of the issues until after the incident. The facility's inaction and lack of timely intervention contributed to the deficiency in providing appropriate care for Resident #53.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved a resident who was pushed by his roommate after a disagreement over a door being left open. The facility's investigation confirmed the physical abuse, noting the intentional nature of the incident. The residents were assessed without injury, and the facility eventually separated them by moving one to a different room. Prior to the physical altercation, there were signs of tension between the two residents. The victim had reported verbal altercations and cursing from his roommate to the maintenance director, who did not escalate the concerns to management. Additionally, the facility's records did not document any behavior monitoring or interventions for the victim following the incident, despite his history of depression and emotional distress. The assailant had a history of behavioral issues, including aggression and verbal altercations with previous roommates. Despite this, the facility did not adequately monitor or address these behaviors. A threatening remark made by the assailant was documented but not reported to the appropriate authorities, and no investigation was initiated. The facility's failure to act on these warning signs contributed to the escalation of the situation into physical abuse.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that residents, family members, and legal representatives had full access to review the results of the facility's most recent survey findings, including survey results, certifications, complaint investigations, and plans of correction for the preceding three years. The facility's policy stated that the survey binder should be located in the main lobby and be readily accessible without needing to ask staff members for the information. However, during a group interview with eight alert and oriented residents, it was revealed that they were unaware of the availability of the survey results and did not know where to find them. Observations confirmed that the binder containing past survey results was not easily accessible, as it was located on the lowest shelf underneath another binder near the receptionist's desk and was unlabeled. There was no sign posted in the facility indicating the binder's location. The Nursing Home Administrator (NHA) acknowledged that residents would not know where the binder was located without asking a staff member and stated an intention to label the binder and ensure it was more accessible.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident on two separate occasions. The incidents occurred when one resident, who had a history of alcohol dependence and verbal behavioral symptoms, called another resident derogatory names. Despite these occurrences, the facility did not report the allegations to the appropriate authorities, nor did they conduct a thorough investigation to determine if the allegations were substantiated. The facility's investigation into the first incident was limited to interviews with the involved residents and one other resident, without obtaining written witness statements or interviewing additional staff or residents. The facility did not document any monitoring of the affected resident for changes in behavior or emotional distress following the incidents. Furthermore, there were no person-centered interventions or care plan updates implemented to prevent future altercations between the residents. The second incident was documented in a progress note, but no investigation was conducted, and the facility did not report the incident to the state agency. The staff failed to follow the facility's policy and procedure for reporting and investigating abuse allegations, which required a comprehensive review of documentation, interviews with witnesses, and monitoring of the affected resident's condition. The facility's inaction left the resident vulnerable to further verbal abuse without appropriate interventions or support.
Inadequate Supervision and Care Plan for Resident with Alcohol Use
Penalty
Summary
The facility failed to provide adequate supervision and implement an effective plan of care for a resident with a history of excessive alcohol consumption. The resident, who had multiple diagnoses including major depressive disorder, a history of falling, and moderate cognitive impairment, was not adequately supervised both inside and outside the facility. Despite having a physician's order for supervised outings, the resident frequently left the facility unsupervised, often returning with alcohol, which was against the facility's policy. The resident's care plan identified her as at risk for falls due to her alcohol use and other medications, yet the facility did not effectively monitor or restrict her access to alcohol. The resident was observed multiple times with alcohol in her room and was known to share alcohol with other residents, raising safety concerns. Staff interviews revealed that the resident used the back door to leave the facility and that the facility's management was aware of the issue but had not taken effective measures to prevent it. The facility's management team failed to follow up on multiple incidents where the resident was found intoxicated or in possession of alcohol. Despite discussions in quality assurance meetings, there was no documented plan to address the resident's alcohol use or to ensure her safety and the safety of other residents. The facility's inaction and lack of a specific monitoring plan contributed to the ongoing safety risks associated with the resident's behavior.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grand Junction
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Larchwood Health And Rehab Llc | 0.1 mi | — | 5 | 0 |
| La Villa Grande Care Center | 0.6 mi | — | 1 | 1 |
| Mantey Heights Rehabilitation & Care Center | 1.1 mi | — | 2 | 0 |
| Eagle Ridge Post Acute | 1.4 mi | — | 4 | 1 |
| Center At Foresight Llc, The | 2.1 mi | — | 7 | 0 |
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