Red Cliffs Post Acute

F-F600 failure to prevent resident abuse.

Findings include:

I. Facility policy and procedure

The Dementia Clinical Protocol policy and procedure, revised November 2018 was provided by the nursing home administrator (NHA) on 1/16/25 at 3:29 p.m. The policy read in part, For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life.

The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT.

The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician.

The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.

II. Resident status

Resident #53, age greater than 65, was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the January 2025 computerized physician's orders (CPO), diagnoses included chronic obstructive pulmonary disease, alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, single episode, severe without psychotic features, and insomnia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 The 12/13/24 minimum data assessment (MDS) assessment identified Resident #23 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment Level of Harm - Minimal harm or indicated Resident #53 did not have physical or verbal behavioral symptoms other behaviors directed by potential for actual harm others. The resident's functional ability on admission identified the resident was independent or needed some supervision with his ADLs. According to the MDS assessment, he did not use a mobility device for Residents Affected - Few ambulation.

III. Incident of physical abuse of Resident #34 by Resident #53

The 12/31/24 investigation report for abuse was provided by the NHA on 1/15/25 at 3:15 p.m. p.m. The investigation report identified Resident #53 pushed Resident #34 on 12/28/24 because he did not shut the shared bedroom door and Resident #53 did not want his dog to get out of the room. The facility was not aware of the incident until Resident #34 reported the incident to a staff member on 12/30/24. The investigation for abuse determined physical abuse was substantiated because of the intentionality of the incident.

IV. Resident interviews

Resident #53 was interviewed on 1/13/25 at 2:45 p.m. Resident #53 said he had a lot of problems with his former roommate (Resident #34) and referred to him as a derogatory name. According to the resident, he and his roommate had a lot of verbal fights, cursing at each other.

Resident #34 was interviewed on 1/14/25 at 4:09 p.m. Resident #34 said his roommate yelled and cursed at him on two different occasions prior to the 12/28/24 incident of physical abuse. He said he reported yelling and cursing to the maintenance director when he worked on his television remote (12/24/24).

-The facility failed to document and observe potential triggers, outward frustration or verbal aggression toward other residents or roommates and intervene as necessary as identified by Resident #53's behavior care plan (see below).

V. Record review

The behavior care plan, revised 12/23/24, identified Resident #53 exhibited or was at risk for behavioral symptoms (for example) striking out, grabbing others, combative, verbally, or physically abusive, inappropriate disrobing, smears/throws food/feces/objects) due to:

anxiety, dementia, depression, history of alcohol abuse, history of substance abuse, insomnia and major depression. Interventions, dated 11/17/24, read in pertinent part, directed staff to anticipate Resident #53's needs and meet the needs promptly; encourage the resident to verbalize his feelings; maintain a calm, slow, and understandable approach; manage environmental factors to optimize comfort; observe and document changes in behavior, including frequency of occurrence and potential triggers with outward frustration or verbal aggression toward other residents

or roommates; observe the resident's mood and response to medication; observe whether the behavior endangers the resident and/or others and intervene if necessary, removing others from the surrounding area; and, reduce stimulation such as noise, crowding, other physically aggressive residents to the extent possible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 The psychosocial unsettled relationships care plan, initiated 1/13/25 (during survey), indicated

Level of Harm - Minimal harm or Resident #53 had an unsettled relationship with friends, other residents, and roommates. He could become potential for actual harm irritated and exhibited verbal or physical behaviors with increased confusion and frustration without processing the situation. Interventions, dated 1/13/25, directed staff to assess Resident #53 for mood and/or Residents Affected - Few behavioral problems; assist the resident with psychosocial needs, to include preferences with placement of roommates who had similar likes/interests; assist the resident in identifying the origin of the complaint or concern; monitor Resident #53's behavior and determine appropriate interventions for each situation; encourage the resident to verbalize feelings of anger, anxiety, or sadness in an acceptable manner; provide understanding and validation of his preference of routine; establish a therapeutic relationship; redirect and offer solutions with the resident when he was frustrated; encourage Resident #53 to share how staff could assist or correct a situation; praise efforts in the use of effective coping strategies and provide reassurance and active empathetic listening.

-The facility did not implement new interventions to address Resident #53's mood and behavior until 1/13/25, two weeks after physical abuse was reported and substantiated and provided a new roommate.

The December 2024 treatment administration record (TAR) directed staff to monitor Resident #53's targeted behaviors of aggression. According to the December 2024 TAR, the resident exhibited easily altered aggression on 12/29/24, 12/30/24, and 12/31/24.

The TAR did not identify behaviors on the 12/21/24 and 12/24/24 (see interview below) or behaviors on 12/28/24 when the physical altercation occurred.

Review of progress notes did not identify what the behavior was on 12/30/24 and 12/31/24 as a targeted aggressive behavior on the December 2024 TAR as directed by Resident #53's behavior care plan.

The 12/29/24 medication administration note identified Resident #53's roommate exited the bedroom without shutting the bedroom door behind him. Resident #53 was alone in his room and got up out of bed and said loud enough for the nurse to hear in the hallway that he was going to initiate a physically aggressive act towards his roommate because the roommate did not shut the bedroom door. The note documented a manager on call was notified of the Resident #53's behavior. According to the note, staff would make sure

the door was closed at all times to prevent an altercation.

-The facility failed to address the physically aggressive threat other than to document they would make sure

the door was shut.

-The staff did not approach the Resident #43 to understand Resident #53 feelings and concerns as identified

in his behavior care plan.

-Resident #53 was not provided another room to separate him from the situation that was triggering his aggression as identified in his behavior care plan.

The review of the December 2024 progress notes for Resident #53 revealed the 12/29/24 medication administration note was the only note in December 2024 that identify concerns or behaviors related to Resident #53's roommate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 VI. Staff interview

Level of Harm - Minimal harm or The maintenance director (MTD) was interviewed on 1/15/25 at 10:35 p.m. The MTD said when he was potential for actual harm looking at the televisions (12/24/24), Resident #34 told him there was tension between him and his roommate. He said Resident #34 said his roommate would curse and yell at him. The MTD said he was not Residents Affected - Few sure he mentioned Resident #34's concerns to someone else. The MTD said he thought the Resident #34's concerns were something that may have already been reported. The MTD said he probably should have made sure someone else knew about the report of cursing and tension towards Resident #34 from Resident #53.

The NHA was interviewed on 1/15/25 at 3:18 p.m. The NHA identified the resident had a pattern of altercations with a roommate. He said he was moved to Resident #34's room after an altercation with his former roommate in November 2024. He said there was argument between the two roommates and Resident #53 threatened his roommate at the time.

The NHA said he was not aware of the threatening words made by Resident #53 as documented on 12/29/24. He said the interdisciplinary team tried to review progress notes to identify potential concerns but

the note was not identified as a concern. The NHA said behavior tracking was documented in TARs and a note documented a behavior would usually just be completed when there was a significant change from a resident's baseline behavior.

The director of nursing (DON) was interviewed on 1/15/25 at 4:54 p.m. The DON said the threatening remarks on 12/29/24 were loud enough for the nurse in the hallway to hear him but Resident #34 was not in

the room at the time. The DON said Resident #53 was already on behavior tracking so his behaviors should have been monitored.

The social service director (SSD) was interviewed on 1/16/25 at 3:07 p.m. The SSD said she helped the facility with dementia care training with the certified nurse aides (CNA). She said she helped the CNAs understand and familiarize themselves with person centered care planned interventions.

The SSD said Resident #53 had vascular dementia which could contribute to aggressive behaviors. She said Resident #53 was reclusive. His personal space and visits with his dog was very important to him. The SSD said he could make his needs known and it was important for staff to meet him where he was at, meaning identifying his behavior needs. She said staff attempted to pair him with an appropriate roommate. She said his new roommate (after the 12/28/24 incident) spent most of his time on his side of the shared room in bed.

She said moving Resident #53 to another room was the safest option after the 12/28/24 physical aggression.

The SSD said to help prevent Resident #53's aggressive behaviors, staff should watch for restlessness and changes in his normal behavior. She said if they observe any concerns in his behavior, staff should ask him if there was something bothering him so the concern could be addressed.

The SSD said arguing with his roommate would be an opportunity to use dementia care inventions. She said staff should have watched Resident #53's watch body language and interactions. She said it would have been important to keep an eye on the interactions between Resident #53 and Resident #34.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 The SSD said she was not made aware of the augments between the roommates or Resident #53's threat of physical aggression until 1/15/25. She said it was important to involve social services when their behavioral Level of Harm - Minimal harm or concerns with residents because she focuses on residents' psychosocial wellness and could help deescalate potential for actual harm potential altercations and provide additional support needs. The SSD said additional dementia care resources could have been family support. She said she could have requested family involvement and Residents Affected - Few encouraged them to come to visit. The SSD said she would continue to provide dementia care education and remind staff to report any changes staff see with Resident #53.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 40467

Residents Affected - Many 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 conducted appropriately after touching potential contaminated surfaces; and,

-Ensure hand hygiene was conducted before and after glove use.

Findings include:

I. Professional reference

The Center for Disease Control and Prevention (CDC) About Hand Hygiene For Patients in Healthcare Settings (2/27/24), was retrieved on 1/23/25 from

https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, read in pertinent part, Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients.

According to the CDC, hand washing should occur before preparing or eating food, before touching the eyes, nose or mouth, and after touching potential contaminated surfaces.

II. Facility policy and procedure

The Food Preparation and Service policy, undated, was provided on nursing home administrator (NHA) on 1/16/25 at 3:22 p.m. The policy read in pertinent part, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.

Cross contamination can occur when harmful substances, (for example) chemical or disease-causing microorganisms are transferred to food by hands including gloved hands, food contact services, sponges, cloth towels, or utensils that are not adequately cleaned.

The Preventing Foodborne Illness policy, revised November 2022, was provided on nursing home administrator (NHA) on 1/16/25 at 3:22 p.m. The policy read in pertinent part, Food and nutrition services employees follow appropriate hygiene and sanitary practices to prevent the spread of foodborne illnesses.

All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illnesses. Employees will demonstrate knowledge and competency in these practices prior to working with food or servicing food to residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 According to the policy, employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks and/or after engaging Level of Harm - Minimal harm or in activities that contaminate the hands. potential for actual harm

The policy identified that gloves are considered single-use items. The gloves must be discarded after Residents Affected - Many completing the task. According to the policy, hands were to be washed after the gloves were removed and

before the new gloves were replaced.

B. Observations

During a continuous observation of the lunch meal service in the dining room on 1/13/25, beginning at 11:45 a.m and ending at 12:52 p.m., the following was observed:

At 12:03 p.m. dietary aide (DA) #4 began delivering meal trays to residents in the dining room. DA #4 did not perform hand hygiene before serving three meal trays to residents.

At 12:06 p.m. DA #4 touched the outer surface of his face mask with his hand. He did not perform hand hygiene after touching his mask. He proceeded to serve two more meal trays to residents before performing hand hygiene.

At 12:15 p.m DA #4 touched the outer surface of his face mask with his hand, delivered a meal tray to a resident in the dining room and placed five meal trays in a mobile food cart before he performed hand hygiene at 12:17 p.m.

During a continuous observation of the lunch meal service in the kitchen on 1/15/25, beginning at 11:40 a.m and ending at 12:55 p.m., the following was observed:

At 12:01 p.m. DA #1 touched the outer surface of her mask and proceeded to sort meal tickets. She did not change her gloves and wash her hands after she touched her mask.

Between 12:07 p.m. and 12:15 p.m DA #1 placed the meal tickets, desert bowls and napkin rolled utensils on each resident meal tray without changing her gloves and performing hand hygiene after touching her mask.

At 12:11 p.m. cook (CK) #1 removed her gloves and placed new gloves on her hands without performing hand hygiene. CK #1 separated a pot pie from the disposable cardboard shell with a cooking utensil but touched the rim of the pie crust with her gloved hand.

At 12:16 p.m. DA #2 placed gloves on his hands without washing his hands. DA #2 proceeded to place meal tickets, napkins, utensil and dessert bowls on each of the resident meal trays.

At 12:43 p.m. DA #2 touched the outer surface of his face mask with the back of his gloved hand, touched four resident meal bowls before removing his gloves and performing hand hygiene.

C. Record review

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The online hand hygiene education certificates for the dietary staff were provided by the NHA on 1/16/25 at 3:22 p.m. The certificates identified DA #1, DA #2, DA #3, DA #4 and DA #5 last completed basic hand Level of Harm - Minimal harm or hygiene training and handling food safely training in November 2023. The DM completed basic hand hygiene potential for actual harm training in November 2023 but evidence of handling food safety training was not provided by the facility.

Review of the provided educations did not identify CK #1 received the online basic hand hygiene training or Residents Affected - Many handling food safety training.

D. Staff interviews

DA #2 was interviewed on 1/16/25 at 2:05 p.m. He said hand hygiene should be completed anytime the hands touch something dirty and between glove changes.

CK #1 was interviewed on 1/16/25 at 2:07 p.m. She said hand hygiene should be completed when gloves were changed and after touching any potential surfaces.

DA #5 was interviewed on 1/16/25 at 2:07 p.m. He said hand hygiene was completed in between tasks, every time a task was changed and when serving trays.

DA #3 was interviewed on 1/16/25 at 2:09 p.m. He said staff should wash their hands after using the restroom, every time they enter the kitchen and before touching resident dishes. He said he was trained to perform hand hygiene with alcohol base hand rub (ABHR) after every third delivery of a meal tray.

The DM was interviewed on 1/16/25 at 2:11 p.m. She said her staff has had hand hygiene training but it had not been recent. She said the dietary staff also attended an all staff infection control training that demonstrated proper hand hygiene but the training was not food handling specific. The DM said staff should wash their hands anytime they touch something potentially contaminated and between glove changes. The DM said she trained her to use ABHR after every third tray delivered to the residents.

Registered nurse (RN) #2 was interviewed on 1/16/25 at 2:54 p.m. RN #2 identified herself and the facility ' s infection control nurse. She said hand hygiene should be performed before placing gloves on and after removing the gloves, anytime the hands touch potentially contaminated surfaces, or touch a resident. She said staff delivering meal trays should use ABHR between each meal delivery to avoid potential cross-contamination. RN #2 said staff should wash their hands after three uses of ABHR. RN #2 said she had not completed hand hygiene training with the dietary staff.

RN #2 was interviewed again on 1/16/25 at 3:45 p.m. RN #2 said she audited the hand hygiene practices in

the kitchen with the dietary staff on 1/16/25. She said she identified concerns with hand hygiene and re-educated the dietary on proper hand hygiene procedures.

D. Facility follow-up

The Clinical Competency Validation for Hand Hygiene audit checklist was provided by the clincal consulant (CC) on 1/16/25 at 4:58 p.m. The review of the competency audit identified hand hygiene practices of five (DM and DA #2, #3, #5 and #6) dietary staff were observed by RN #2 on 1/16/25. According to the audit, there were hand hygiene concerns identified during the observation. RN #2 addressed the identified concerns and provided hand hygiene education to the present dietary staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40467 potential for actual harm Based on record review and interviews, the facility failed to ensure residents or their representative were Residents Affected - Some aware of the nature and implications of the facility's arbitration agreement to inform their decision on whether or not to enter into such agreements for four (#15, #36, #58 and #74) of six residents out of 32 sample residents.

Specifically, the facility failed to:

-Thoroughly explain the arbitration agreement in a form and in a manner the residents and/or resident representatives understood the agreement before signing the arbitration agreement;

-Accurately inform residents the arbitration agreement was a binding agreement before the agreement was signed;

-Accurately inform residents the agreement waived residents' right to a trial before a judge or jury for all disputes between the resident and the facility.

-Accurately inform residents the agreement could be rescinded by written notice within 90 days of the signing of the agreement; and,

-Ensure staff reviewing the arbitration agreement with residents understood the components of the agreement.

Findings include:

I. The arbitration agreement

The Voluntary Agreement for Arbitration, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 1:27 p.m. The agreement read in part, Under Colorado law two or more parties may agree in writing for the settlement by binding arbitration of any dispute arising between them, including disputes relating to health care matters.

By signing this agreement, you will give up your constitutional right to a jury or court trial as you are agreeing that any dispute between you and the facility will be subject to binding and final arbitration.

You, as our resident, have the right to seek legal counsel concerning this agreement, and you have the absolute right to rescind this agreement by written notice within 90 days after the agreement has been signed and executed by both parties.

The resident and or legal representative understands, agrees to, and has received a fully executed copy of

the voluntary arbitration agreement, and acknowledges that terms have been explained to him/her, or his/her designee, in a manner that he/she understands by an agent of the facility and that he/she has had an opportunity to ask questions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Each party agrees to waive the right to a trial, before a judge or jury, for all disputes, including those at law or equity, subject to arbitration under this voluntary arbitration agreement.In the event that any portion of this Level of Harm - Minimal harm or voluntary arbitration agreement is determined to be invalid or enforceable, the remainder of this voluntary potential for actual harm arbitration agreement will be deemed to continue to be binding upon parties hereto in the same manner as if

the valid or enforceable provision were not part of the agreement. Residents Affected - Some

The undersigned acknowledged that each of them has read this voluntary arbitration agreement and understands that by signing each has waived his/her right to a trial before a judge or jury and that each of them voluntarily consents to all of the terms of the voluntary agreement.

By signing this agreement you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than by a jury or court trial.

You have the right to legal counsel and you have the right to rescind this agreement within 90 days from the date of signature by both parties unless the agreement was signed in contemplation of hospitalization in which case you have 90 days after discharge or release from the hospital to rescind the agreement.

II. Explanation of arbitration to the residents

The admissions coordinator (AC) was interviewed on 1/14/25 at 4:39 p.m. The AC said she completed most of the admissions paperwork with the new admissions to the facility. She said when she was not available,

the marketing director (MKD) was her back up and completed the admission paperwork process.

The AC said most of the admissions paperwork, including the arbitration agreement, was signed by the resident's power of attorney (POA) but she has had several residents that signed their own paperwork. The AC said she always checked with the facility's clinical team to determine if the resident was capable of signing their own paperwork when a POA was not present or in place.

The AC said she was trained to explain to the residents that if there were any challenges between the facility and the resident, the facility would try to settle the concern without involving lawyers. She said the arbitration agreement was optional and they did not have to sign it. She said the agreement was not binding and would assume it was a resident right to change their mind if they signed the agreement but still wanted to go to court. She said she was not aware of a timeline/deadline a resident had to rescind the agreement once it was signed.

The AC said she would always offer the residents a copy of the arbitration agreement but usually the residents did not want a copy.

III. Resident interview

Resident #15 was interviewed on 1/15/25 at 1:11 p.m. Resident #15 said he signed all of his admission paperwork but no one told him about the details of the arbitration agreement. He said he had some forgetfulness but would remember something like that. He said he would want to address any legal concerns

he had with the facility with the option to sue if warranted. He said if he signed the agreement, he would want to know the deadline to change his mind.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Resident #36 was interviewed on 1/15/25 at approximately 1:20 p.m. Resident #36 said she was not familiar with an arbitration agreement. She said was not aware of signing the agreement or anything regarding Level of Harm - Minimal harm or settling facility disputes with a third party. potential for actual harm Resident #58 was interviewed on 1/15/25 at 1:49 p.m. Resident #58 said he signed all of his own paperwork. Residents Affected - Some He said he was not told what an arbitration agreement was or that signing the agreement would waive his right to go to court. He said he had a lawyer and that would be something we would have wanted to review with his lawyer before signing.

Resident #74 was interviewed on 1/16/25 at 9:12 a.m. Resident #74 said she did not know what arbitration was and was not aware that she signed an arbitration agreement. She said she would have wanted someone to explain the agreement to her before signing anything.

Resident #54 was interviewed on 1/16/25 at 9:18 a.m. He said he knew what an arbitration agreement was and he had signed the agreement with the facility. He said he probably would not ever feel the need to rescind the agreement but he was not told of a timeline when he could change his mind if he wanted to.

IV. Record review

Arbitration agreements were reviewed for Resident #15, Resident #36, Resident #58, Resident #74 and Resident #54. Each resident signed their own arbitration agreement. The arbitration agreements were signed by either the AC or the marketing director (MKD) as the facility representatives.

Resident #15 was admitted on [DATE REDACTED]. The arbitration agreement was signed by AC on 11/27/24. The arbitration agreement was signed by Resident #15 on 11/27/24.

Resident #36 was admitted on [DATE REDACTED]. The arbitration agreement was signed by the AC on 10/28/24. The arbitration agreement was signed by Resident #36 on 10/28/24.

Resident #58 was admitted on [DATE REDACTED]. The arbitration agreement was signed by the MKD on 10/25/24. The arbitration agreement was signed by Resident #58 on 10/25/24.

Resident #74 was admitted on [DATE REDACTED]. The arbitration agreement was signed by the AC on 12/17/24. The arbitration agreement was signed by Resident #74 on 12/17/24.

Resident #54 was admitted on [DATE REDACTED]. The arbitration agreement was signed by the MKD on 12/27/24. The arbitration agreement was signed by Resident #54 on 12/27/24.

IV. Staff interviews

The MKD was interviewed on 1/16/25 at 9:23 a.m. The MKD said he would occasionally review the admissions paperwork including the arbitration agreement with the residents and or their POA's when the AC was not available. He said he would look at the arbitration agreement together with the resident and make sure they understand and were comfortable with signing before signing it was comfortable. He said the arbitration agreement was voluntary and not binding. He said he was not sure of a deadline to rescind the agreement, he would have to read it with them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 The NHA was interviewed on 1/16/25 at 9:38 a.m. The NHA said the intent of the agreement was to solve disputes but it did not limit the resident from going to court. He said if a resident signed the agreement, they Level of Harm - Minimal harm or had 30 days to rescind the agreement but if they did not rescind the agreement, they could still go to court. potential for actual harm He said the facility wanted to make sure the residents knew that if they had any concerns, the facility wanted to help resolve the concern. He said the residents can request a copy of the agreement and have it read to Residents Affected - Some them.

V. Facility follow-up

A plan of improvement, dated 1/16/25, was provided by the NHA on 1/16/25 at 12:12 p.m. According to the plan, arbitration agreement education was provided to the AC and the MKD on 1/16/25. The documented education identified the AC and the MKD were trained to ensure the signing party understood they had 30 days to take back their arbitration. According to the provided education, the residents signed away their right to go to court and will use an unbiased party as the arbitrator.

The plan of improvement identified the facility would add documentation in the residents' charts that the resident/POA had the right to revise the agreement within 30 days of signing it.

-However, the arbitration agreement the facility had in place, documented the residents had 90 days to rescind the agreement.

According to the plan of improvement, an audit was conducted to ensure residents/POA who signed the arbitration agreement in the last 30 days understood the agreement. The plan identified the notification to six of the facility's residents or their representatives who signed the arbitration agreement.

-The plan of improvement did not include Resident#15, Resident #36, Resident #58, and Resident #74

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50314 potential for actual harm Based on observations, record review and interviews, the facility failed to maintain an infection control Residents Affected - Many program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.

Specifically, the facility failed to implement an effective water management plan.

Findings include:

I. Professional reference

According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, last reviewed 1/3/25, was retrieved on 1/21/25 from https://www.cdc. gov/control-legionella/php/toolkit/potable-water-systems-module.html

It read in pertinent part,

Operation, maintenance, and control limits guidance:

Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability.

Hot water: Store hot water at temperatures above 140 F (degrees Fahrenheit) or 60 C (degrees Celsius). Ensure hot water in circulation does not fall below 120 F (49 C). Recirculate hot water continuously, if possible.

Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 F, 25-45 C). Legionella may grow at temperatures as low as 68 F (20 C).

Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits.

Ensure disinfectant residual is detectable throughout the potable water system.

Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly.

Consider testing for Legionella in accordance with the routine testing module of this toolkit.

B. Facility policy and procedure

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 43 065110 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065110 B. Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Red Cliffs Post Acute 2901 N 12th St Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The Legionella Water Management Program policy and procedure, dated July 2024, was provided by the nursing home administrator (NHA) on 1/13/25 at 2:17 p.m. Level of Harm - Minimal harm or potential for actual harm The program did not include documentation of when dead legs and low-flow piping runs were appropriately flushed to prevent the growth and spread of legionella. Residents Affected - Many -However, the CDC recommended that all dead legs and low flow piping runs should be flushed at least weekly to prevent the growth and spread of legionella (see professional reference above).

III. Record review

The water management maintenance logs were provided by the NHA on 1/13/25 at 2:17 p.m.

The maintenance logs documented the facility had obtained water temperature readings in the building on a weekly basis.

-There was no documentation available to verify that dead legs and low flow piping runs had been flushed in

the last calendar year.

On 1/14/25 at 12:52 p.m., the NHA documented that two resident rooms had been unoccupied for seven contiguous days or more in the last 60 days.

-The water management plan failed to document when empty resident rooms had low flow piping runs and lead legs flushed.

IV. Staff interviews

The maintenance director (MTD) was interviewed on 1/15/25 at 10:23 a.m. The MTD said he had recently assumed the MTD role in the past few months. The MTD said the facility tested for legionella annually, which was negative in August 2024. The MTD said he did not know where all the water piping and dead legs in the building were. The MTD said he did not know how often dead legs and low flow piping runs such as sink and toilet p-traps (back drainage) should be flushed to prevent the growth and spread of waterborne bacteria such as legionella. The MTD said the facility did not have documentation to show when resident rooms or infrequently used water fixtures were flushed.

The NHA was interviewed on 1/15/25 at 10:44 a.m. The NHA said he was not sure how often dead legs and low flow piping runs should be flushed to prevent the growth of legionella. The NHA said the facility did not have documentation to verify that flushing of dead legs and low-flow piping runs had occurred in the last calendar year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 43 065110