GRAND JUNCTION, CO - Federal inspectors documented serious lapses in resident protection and food safety at Red Cliffs Post Acute during a January 16, 2025 inspection that revealed the facility failed to prevent physical abuse between residents.
Physical Abuse Incident Exposes Systemic Failures
The most serious violation involved a December 28, 2024 incident where a resident with dementia pushed his roommate because "he did not shut the shared bedroom door and did not want his dog to get out of the room." The facility remained unaware of the assault for two days until the victim reported it to staff on December 30.
Investigation records show the aggressor, identified as Resident #53, had alcohol-induced dementia and a documented history of behavioral issues including verbal aggression toward roommates. Despite having a comprehensive behavior care plan in place, staff failed to implement critical interventions that could have prevented the attack.
The behavior care plan specifically directed staff to "observe and document changes in behavior, including frequency of occurrence and potential triggers with outward frustration or verbal aggression toward other residents or roommates" and to "intervene if necessary, removing others from the surrounding area."
Warning Signs Went Unheeded
Documentation reveals multiple red flags that staff either ignored or failed to properly address. On December 29, just one day after the physical assault, a nurse heard Resident #53 threatening violence against his roommate loud enough to be heard in the hallway. The resident was upset because his roommate had left their shared bedroom door open.
According to facility records, staff documented they would "make sure the door was closed at all times to prevent an altercation" but took no other action to address the underlying behavioral issues or separate the residents.
The maintenance director reported that on December 24, Resident #34 had complained about "tension between him and his roommate" and said "his roommate would curse and yell at him." The maintenance director acknowledged he was unsure whether he reported these concerns to nursing staff and admitted he "probably should have made sure someone else knew about the report of cursing and tension."
Dementia Care Protocols Not Followed
Facility policies required the interdisciplinary team to identify and document residents' conditions and support needs, with particular attention to those with dementia. The policies specified that staff should monitor individuals with dementia for changes in condition and report findings to physicians.
However, the facility's own administrator acknowledged that Resident #53 "had a pattern of altercations with a roommate" and had been moved to Resident #34's room after an altercation with his previous roommate in November 2024. Despite this documented pattern, no additional safeguards were implemented.
The social service director, who specializes in dementia care, was not informed about the roommate conflicts or threats until January 15, 2025 - nearly three weeks after the incident. She told inspectors that involving social services earlier could have helped "deescalate potential altercations and provide additional support needs."
Medical Implications of Behavioral Interventions
Residents with alcohol-induced dementia face heightened risks for aggressive behaviors due to brain changes that affect impulse control and emotional regulation. The condition can cause increased irritability, confusion, and difficulty processing social situations appropriately.
Proper dementia care protocols require staff to recognize environmental triggers that may precipitate aggressive episodes. In this case, the resident's attachment to his dog and need for personal space were known factors that should have informed care planning decisions.
When residents with dementia exhibit threatening behavior, immediate intervention is critical to prevent escalation. Standard protocols include redirecting the resident, removing potential victims from the area, and implementing calming techniques. The facility's failure to act on the December 29 threats represents a significant breakdown in protective protocols.
Food Safety Violations Compound Concerns
Inspectors also documented widespread food safety violations that put residents at risk for foodborne illnesses. Multiple dietary staff members were observed failing to follow basic hand hygiene protocols during food preparation and service.
On January 13, a dietary aide touched his face mask multiple times without washing hands, then continued serving meal trays to residents. Another aide placed food items on resident trays after touching his mask without changing gloves or performing hand hygiene.
Kitchen observations on January 15 revealed similar patterns, with cooks changing gloves without washing hands and touching food surfaces after potential contamination. One cook was observed touching pie crust with her gloved hand after removing it from packaging.
The facility's own policies required staff to "wash their hands during food preparation, as often as necessary to remove soil and contamination and prevent cross contamination." The policies specifically stated that hands must be washed after glove removal and before new gloves are applied.
Training Deficiencies Identified
Record review revealed that dietary staff had not received updated hand hygiene training since November 2023, more than a year before the inspection. Some staff members could not provide evidence of completing required food safety training.
The infection control nurse acknowledged she had not provided hand hygiene education specifically to dietary staff and conducted an emergency audit during the inspection after violations were identified. The audit confirmed "hand hygiene concerns" and led to immediate re-education of present staff.
Additional Safety Concerns
The inspection also revealed failures in the facility's water management program designed to prevent Legionella bacteria growth. The facility lacked documentation showing that dead-end water lines and low-flow fixtures had been properly flushed, despite CDC recommendations for weekly flushing to prevent bacterial growth.
Two resident rooms had been unoccupied for seven or more consecutive days, but the facility could not demonstrate that water fixtures in these rooms had been flushed to maintain water quality. The maintenance director admitted he did not know the locations of all water piping and dead legs in the building or understand flushing requirements for bacterial prevention.
Arbitration Agreement Issues
Inspectors found the facility failed to properly explain arbitration agreements to residents, with four residents reporting they were not informed about the binding nature of the agreements or their right to rescind within 90 days. Some staff members providing explanations demonstrated incomplete understanding of the agreement terms.
Facility Response and Implications
Following the inspection, the facility provided immediate staff re-education on hand hygiene practices and behavior monitoring protocols. However, the violations reveal systemic issues in staff training, policy implementation, and resident protection that extend beyond isolated incidents.
The physical abuse case highlights the critical importance of comprehensive dementia care approaches that address both resident safety and environmental management. When facilities fail to implement their own care plans or ignore warning signs of escalating behavioral issues, vulnerable residents face increased risks of harm.
For families considering nursing home placement, these violations underscore the importance of reviewing facilities' abuse prevention policies, staff training records, and incident response procedures. Effective dementia care requires specialized training, adequate staffing, and proactive intervention protocols that many facilities struggle to maintain consistently.
The inspection findings demonstrate that regulatory oversight remains essential for identifying and correcting deficiencies that could compromise resident safety and health in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Red Cliffs Post Acute from 2025-01-16 including all violations, facility responses, and corrective action plans.
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