Deficiencies (last 4 years)
Deficiencies (over 4 years)
25.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
390% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
78% occupied
Based on a July 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 11, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide resident choice in bathing schedules and failure to provide timely medical records and appropriate restorative services for residents.
Complaint Details
The complaint investigation focused on bathing schedule preferences and refusals for Residents #1 and #4, timely provision of medical records for Residents #1 and #2, and provision of restorative services for Residents #1 and #4. The investigation found substantiated issues with bathing preferences not honored, delays in medical record provision, and lack of restorative services.
Findings
The facility failed to honor resident bathing preferences for Residents #1 and #4, failed to provide timely medical records to representatives of Residents #1 and #2, and failed to provide appropriate restorative services and equipment to Residents #1 and #4. Staff education was provided to address bathing refusals and documentation. The facility lacked a restorative program for several months but had recently hired a restorative nurse aide to restart the program.
Deficiencies (3)
Failed to provide choices for preference of bathing schedule for Residents #1 and #4, who were dependent on staff for care.
Failed to ensure medical records were provided timely upon request to representatives of Residents #1 and #2.
Failed to provide appropriate restorative services and equipment to Residents #1 and #4 to maintain or improve mobility.
Report Facts
Bathing opportunities for Resident #4 in April 2025: 16
Bathing opportunities for Resident #4 in May 2025: 31
Bathing opportunities for Resident #1 in January 2025: 31
Staff education attendance: 26
Restorative services program frequency recommendation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided facility policies, interviewed regarding bathing preferences, refusals, and restorative services. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided staff education on bathing refusals and documentation, interviewed regarding restorative services and OT evaluation. |
| CNA #1 | Certified Nurse Aide | Interviewed about bathing documentation and refusal procedures. |
| Former Medical Records Director | Former Medical Records Director (FMRD) | Interviewed about medical records release procedures and timelines. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 11, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide resident choice in bathing schedules and failure to provide timely medical records and restorative services.
Complaint Details
The complaint investigation substantiated that the facility did not honor bathing preferences for Residents #1 and #4, delayed provision of medical records to representatives of Residents #1 and #2, and failed to provide or offer restorative services to Residents #1 and #4 as required.
Findings
The facility failed to honor residents' rights to self-determination regarding bathing preferences for two residents, failed to provide timely medical records to representatives of two residents, and failed to provide appropriate restorative services to two residents with limited mobility.
Deficiencies (3)
F 0561: The facility failed to provide bathing choices and schedules according to resident preferences and care plans for Residents #1 and #4, who were dependent on staff for care.
F 0573: The facility failed to provide medical records timely upon request to the representatives of Residents #1 and #2.
F 0688: The facility failed to provide timely restorative services as planned for Resident #4 and failed to offer a restorative service program for Resident #1 after discharge from therapy services.
Report Facts
Bathing opportunities received: 3
Bathing opportunities received: 6
Bathing opportunities received: 6
Staff education attendance: 21
Staff education attendance: 5
Restorative services program frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Director of Nursing | Named in bathing preference and restorative services findings and interviews. |
| Jane Doe | Assistant Director of Nursing | Provided staff education on bathing documentation and restorative services program interviews. |
| CNA #1 | Interviewed regarding bathing documentation and refusal procedures. | |
| Former Medical Records Director | Interviewed regarding medical records release procedures and delays. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 2, 2025
Visit Reason
The inspection was conducted due to allegations of resident abuse, neglect, exploitation, and mistreatment involving multiple residents, including physical and sexual abuse incidents.
Complaint Details
The complaint investigation revealed multiple incidents of resident-to-resident physical and sexual abuse involving Residents #3, #7, #8, and #9. The facility failed to report these incidents timely to the State Agency and failed to conduct thorough investigations. Resident interviews and staff interviews confirmed ongoing aggressive and inappropriate behaviors. The facility also failed to provide adequate catheter care and proper medication management for other residents.
Findings
The facility failed to protect residents from abuse, failed to timely report abuse allegations to the State Agency, and failed to thoroughly investigate abuse allegations. Additionally, the facility failed to provide appropriate catheter care for one resident and failed to ensure proper documentation and reassessment of psychotropic medication use for another resident.
Deficiencies (5)
Failure to protect Resident #7 from physical abuse by Resident #3.
Failure to timely report allegations of physical and sexual abuse involving Residents #3, #7, #8, and #9 to the State Agency.
Failure to thoroughly investigate allegations of abuse for Residents #7 and #8.
Failure to consistently provide appropriate catheter care for Resident #2, including failure to include catheter care in baseline care plan and failure to assess catheter patency.
Failure to document behaviors justifying continued PRN Lorazepam use for Resident #1 beyond 14 days and failure to notify physician of frequent refusals and reassess medication need.
Report Facts
Days delayed reporting physical abuse: 22
Days delayed reporting sexual abuse: 16
Days delayed reporting sexual abuse: 1
PRN Lorazepam refusals: 17
PRN Lorazepam administration: 1
BIMS score: 7
BIMS score: 2
BIMS score: 13
BIMS score: 13
BIMS score: 9
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Responded to sexual abuse incident involving Resident #9 exposing himself to Resident #3. |
| NHA | Nursing Home Administrator | Interviewed multiple times regarding abuse prevention, reporting, and investigations. |
| DON | Director of Nursing | Provided facility policies, interviewed regarding abuse reporting and investigations. |
| NM | Nurse Manager | Investigated 3/16/25 incident between Resident #3 and Resident #8; oversaw incident documentation. |
| CNA #3 | Certified Nurse Aide | Interviewed about Resident #3's behaviors and witnessed abuse incidents. |
| CNA #4 | Certified Nurse Aide | Interviewed about Resident #3's sundowning behaviors and Resident #9's sexual behaviors. |
| RN #1 | Registered Nurse | Interviewed about catheter care practices. |
| LPN #1 | Licensed Practical Nurse | Interviewed about catheter care responsibilities. |
| HRN | Hospice Registered Nurse | Observed catheter site issues and provided care for Resident #2. |
| CP | Consulting Pharmacist | Reviewed PRN Lorazepam orders and communicated with physician. |
| PHY #1 | Physician | Provided medical oversight for Resident #3 and commented on behaviors and medication. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 2, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and improper care at the facility, including physical and sexual abuse incidents involving residents and concerns about catheter care and psychotropic medication use.
Complaint Details
The complaint investigation involved multiple allegations of resident-to-resident physical and sexual abuse, failure to report abuse timely, failure to investigate abuse allegations thoroughly, inadequate catheter care leading to urinary tract infections, and improper use of psychotropic medications without proper documentation or reassessment.
Findings
The facility failed to protect residents from abuse, failed to timely report abuse allegations to the State Agency, failed to thoroughly investigate abuse allegations, failed to provide appropriate catheter care, and failed to ensure residents were free from unnecessary psychotropic medications.
Deficiencies (5)
F600: The facility failed to protect Resident #7 from physical abuse by Resident #3 on 3/10/25, resulting in minimal harm with no injuries.
F609: The facility failed to timely report allegations of physical and sexual abuse involving Residents #3, #7, #8, and #9 to the State Agency, with delays ranging from 16 to 22 days.
F610: The facility failed to thoroughly investigate allegations of abuse for Residents #7 and #8, including incomplete interviews and lack of documentation.
F690: The facility failed to provide appropriate catheter care for Resident #2, including failure to clean the catheter after bowel incontinence and lack of a baseline care plan for catheter care.
F758: The facility failed to document behaviors justifying continued use of PRN Lorazepam for Resident #1 beyond 14 days and failed to notify the physician of frequent medication refusals or reassess the need for the medication.
Report Facts
Days delayed reporting physical abuse: 22
Days delayed reporting sexual abuse: 16
PRN Lorazepam refusals: 17
BIMS score: 7
BIMS score: 2
BIMS score: 13
BIMS score: 9
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Reported sexual abuse incident involving Resident #9 exposing himself to Resident #3 |
| NHA | Nursing Home Administrator | Provided multiple interviews regarding abuse prevention, reporting, and investigation |
| DON | Director of Nursing | Provided multiple interviews regarding abuse policies, investigations, and medication management |
| NM | Nurse Manager | Investigated 3/16/25 incident between Resident #3 and Resident #8 and reported to DON |
| CNA #3 | Certified Nurse Aide | Witnessed Resident #3's behaviors and provided information on resident aggression |
| LPN #3 | Licensed Practical Nurse | Reported witnessing Resident #3 touching Resident #8 and communicated with NM |
| PHY #1 | Physician | Provided medical oversight for Resident #3 and commented on behaviors and medication |
| CP | Consulting Pharmacist | Reviewed PRN Lorazepam orders and made recommendations to prescribing physician |
| HRN | Hospice Registered Nurse | Provided catheter care assessment and recommendations for Resident #2 |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, safety, nutrition, respiratory care, infection control, and other aspects of care in a nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, safe use of assistive devices, appropriate monitoring of residents while smoking, timely fall care plans and neurological assessments, adequate nutrition and weight monitoring, proper respiratory care and equipment maintenance, food palatability and temperature, correct preparation of mechanically altered diets, sanitary food storage and preparation, and implementation of infection control programs including water management and vaccination procedures.
Deficiencies (13)
Failed to ensure Resident #63's proxy selected or refused life-saving treatments within the power of a proxy without required physician documentation.
Failed to ensure safe transfer pole use for Resident #23, including proper placement and installation.
Failed to provide Resident #57 with appropriate monitoring while smoking, including consistent use of smoking aprons and staff supervision.
Failed to implement and update fall care plans timely and perform neurological assessments per protocol for Residents #63 and #9.
Failed to provide adequate nutrition and implement timely interventions for Residents #9 and #65 experiencing significant weight loss.
Failed to provide safe and appropriate respiratory care for Residents #32 and #70, including cleaning and maintenance of CPAP/BiPAP machines and oxygen therapy.
Failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures; multiple residents reported cold and unpalatable food.
Failed to provide mechanically altered diets prepared in a form designed to meet individual needs for 10 residents, including incorrect food textures and improper food preparation.
Failed to store staff medications separately from resident food in the walk-in refrigerator.
Failed to ensure kitchen staff wore appropriate hair restraints including beard nets during food preparation and serving.
Failed to maintain kitchen air vents free of dust and dirt, with black dust observed on vents above stove and food service line.
Failed to implement an effective water management plan to prevent Legionella growth, including inadequate flushing of low flow piping and unoccupied rooms.
Failed to offer pneumococcal vaccinations to Residents #28 and #43 prior to the survey date.
Report Facts
Weight loss: 15.2
Weight loss: 22.4
Weight loss: 19.6
Temperature: 115.5
Temperature: 121
BIMS score: 0
BIMS score: 9
BIMS score: 8
BIMS score: 1
BIMS score: 3
BIMS score: 12
BIMS score: 15
BIMS score: 0
BIMS score: 13
BIMS score: 0
BIMS score: 0
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food palatability, diet texture training, and kitchen sanitation issues. | |
| Cook | Interviewed regarding food preparation and diet texture compliance. | |
| Dietary Aide #1 | Observed and interviewed regarding food service and diet texture compliance. | |
| Maintenance Director | Interviewed regarding water management and legionella prevention. | |
| Registered Dietician | Interviewed regarding nutritional assessments and interventions. | |
| Director of Nursing | Interviewed regarding oversight of nutrition, respiratory care, and vaccination procedures. | |
| Nursing Home Administrator | Interviewed regarding facility operations and compliance with regulations. | |
| Licensed Practical Nurse #2 | Interviewed regarding fall protocols and nutrition monitoring. | |
| Certified Nurse Aide #7 | Interviewed regarding resident eating habits and weight loss. | |
| Registered Nurse #4 | Interviewed regarding respiratory equipment maintenance. | |
| Licensed Practical Nurse #3 | Interviewed regarding respiratory equipment maintenance. | |
| Dietary Manager | Interviewed regarding kitchen staff hair restraint compliance and sanitation. | |
| Housekeeper #1 | Interviewed regarding room cleaning and flushing procedures. | |
| Infection Preventionist | Interviewed regarding vaccination policies and procedures. |
Inspection Report
Routine
Deficiencies: 10
Date: Dec 19, 2024
Visit Reason
Routine inspection of Mantey Heights Rehabilitation & Care Center to assess compliance with healthcare regulations including resident rights, safety, nutrition, respiratory care, infection control, and vaccination policies.
Findings
The facility had multiple deficiencies including failure to ensure residents' rights regarding advance directives, safe use of assistive devices, appropriate monitoring during smoking, timely fall care and neurological assessments, adequate nutrition and food palatability, proper respiratory care and equipment maintenance, correct diet texture preparation, sanitary food storage and preparation, effective water management to prevent legionella, and proper vaccination procedures.
Deficiencies (10)
F 0578: The facility failed to ensure Resident #63's proxy legally selected or refused life-saving treatments, lacking required physician documentation for artificial nutrition decisions.
F 0689: The facility failed to ensure safe transfer pole use for Resident #23, including improper placement and installation, and failed to provide adequate supervision for Resident #57 while smoking.
F 0689: The facility failed to implement timely fall care plans and neurological assessments for Residents #63 and #9, and failed to ensure safe transfers for Resident #2.
F 0692: The facility failed to provide adequate nutrition and implement effective interventions for Residents #9 and #65 despite severe weight loss and malnourishment.
F 0695: The facility failed to maintain and clean CPAP/BiPAP machines for Residents #32 and #70 and failed to document care plans for respiratory therapy.
F 0804: The facility failed to serve food that was palatable and at appropriate temperatures, with multiple residents reporting cold and unappetizing meals.
F 0805: The facility failed to provide mechanically altered diets in correct textures for 10 residents, including improper cutting of meats, unsoaked rolls, and incorrect soup consistency.
F 0812: The facility failed to store staff medications separately from resident food, failed to ensure kitchen staff wore beard nets, and failed to keep kitchen air vents free of dust and dirt.
F 0880: The facility failed to implement an effective water management plan to prevent legionella growth, including inadequate flushing of low flow piping and unoccupied rooms.
F 0883: The facility failed to offer pneumococcal vaccinations to Residents #28 and #43 prior to the survey date, lacking documentation of vaccination or consent.
Report Facts
Weight loss: 15.2
Weight loss: 22.4
Weight loss: 19.6
Temperature: 115.5
Temperature: 121
BIMS score: 0
BIMS score: 9
BIMS score: 8
BIMS score: 1
BIMS score: 3
BIMS score: 12
BIMS score: 15
BIMS score: 0
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food palatability, diet texture training, kitchen sanitation, and air vent cleaning. | |
| Cook | Interviewed regarding food preparation, diet texture, and kitchen sanitation. | |
| Dietary Aide #1 | Observed and interviewed regarding diet textures and food service practices. | |
| Maintenance Director | Interviewed regarding water management and legionella prevention. | |
| Regional Maintenance Director | Interviewed regarding water management and legionella prevention. | |
| Housekeeper #1 | Observed and interviewed regarding room cleaning and flushing sinks. | |
| Licensed Practical Nurse #2 | Interviewed regarding nutrition and weight loss monitoring. | |
| Licensed Practical Nurse #3 | Interviewed regarding respiratory care and weight loss monitoring. | |
| Registered Nurse #4 | Interviewed regarding respiratory care responsibilities. | |
| Infection Preventionist | Interviewed regarding vaccination policies and practices. | |
| Director of Nursing | Interviewed regarding nutrition, respiratory care, vaccination, and infection control. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect and failure to protect a resident from abuse, specifically concerning Resident #10 who was left unattended without access to her call light for an extended period.
Complaint Details
The complaint investigation substantiated neglect of Resident #10 by staff, specifically CNA #2, who left the resident unattended without access to her call light and failed to complete care tasks. The resident reported feeling abandoned and afraid. The incident was reported to the State agency.
Findings
The facility failed to protect Resident #10 from neglect and abuse by leaving her unattended in her wheelchair without access to her call light for 20 minutes, causing her distress and fear. Multiple instances of delayed staff response to the resident's call light were documented, with response times exceeding 15 to 56 minutes on various occasions.
Deficiencies (2)
Failure to protect Resident #10 from neglect by leaving her unattended without access to her call light for 20 minutes after a shower.
Repeated delays in responding to Resident #10's call light, with response times greater than 15 minutes on 54 occasions and greater than 20 minutes on 16 occasions.
Report Facts
Call light response times greater than 15 minutes: 54
Call light response times greater than 20 minutes: 16
Call light response time: 30
Call light response time: 56
Duration left unattended: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in neglect incident for leaving Resident #10 unattended without call light access. |
| CNA #1 | Certified Nurse Aide | Provided assistance to Resident #10 after family member intervention and described resident care needs. |
| Social Services Director | Social Services Director | Conducted investigatory interview and follow-up regarding neglect incident. |
| Executive Director | Executive Director | Provided facility policies and interviewed regarding call light procedures and rounds. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect and failure to protect a resident from abuse, specifically related to Resident #10 being left unattended without access to her call light and delayed staff response times.
Complaint Details
The complaint investigation substantiated neglect of Resident #10 by CNA #2 who left the resident unattended without access to her call light for 20 minutes. The resident reported feeling abandoned and afraid. The investigation included interviews with staff and the resident, review of call light response logs showing multiple delayed responses, and documentation of the incident. CNA #2 was suspended pending the abuse investigation.
Findings
The facility failed to protect Resident #10 from neglect and abuse by leaving her unattended in her wheelchair without access to her call light for 20 minutes after a shower. The resident experienced fear and distress due to delayed assistance, with multiple documented instances of call light response times exceeding 15 minutes, including times over 30 and 56 minutes.
Deficiencies (1)
F 0600: The facility failed to protect Resident #10 from abuse and neglect by leaving her unattended without access to her call light for 20 minutes after a shower, causing fear and distress. Multiple instances showed call light response times exceeding 15 minutes, with some over 30 minutes.
Report Facts
Call light response times greater than 15 minutes: 54
Call light response times greater than 20 minutes: 16
Call light response time: 30
Call light response time: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in neglect incident for leaving Resident #10 unattended without call light access. |
| CNA #1 | Certified Nurse Aide | Provided assistance to Resident #10 after family member intervention and described resident care needs. |
| Social Services Director | Social Services Director | Conducted investigatory interview and reviewed incident involving Resident #10. |
| Executive Director | Executive Director | Provided facility policies and described staff rounds and call light procedures. |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nutritional care standards, specifically focusing on residents' weight monitoring, meal intake documentation, and interventions to prevent weight loss.
Findings
The facility failed to ensure adequate nutritional care for three of seven sampled residents, resulting in significant unplanned weight loss, inaccurate meal intake documentation, and failure to implement timely interventions or consistent weight monitoring as recommended by the registered dietitian.
Deficiencies (2)
Failure to prevent significant weight loss and implement interventions after identification of weight loss for Resident #1.
Inaccurate documentation of meal intake and nutritional supplement consumption for Residents #6 and #7, presenting a risk for weight loss.
Report Facts
Weight loss percentage: 10.88
Weight loss in pounds: 19.6
Nutritional supplement opportunities: 141
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD) | Recommended weekly weights for Resident #1 and expressed concerns about inaccurate meal intake documentation. | |
| Certified Nurse Aides (CNA) #1 and #2 | Responsible for meal intake documentation; interviews revealed challenges in accurately recording intake. | |
| Restorative Aide (RA) #1 | Primarily responsible for weighing residents and recording meal intakes; noted gaps in weekly weighing of Resident #1. | |
| Staff Development Coordinator (SDC) | Trained staff on meal intake documentation and weight recording; acknowledged errors in weight logging. | |
| Director of Nursing (DON) | Oversaw weight monitoring and interdisciplinary team meetings; acknowledged gaps in weight monitoring in December 2023. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 18, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to meet residents' nutritional needs and maintain their highest level of physical well-being, specifically focusing on significant weight loss and inaccurate meal intake documentation.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure in nutritional care, weight monitoring, and accurate meal intake documentation, affecting three residents out of seven reviewed.
Findings
The facility failed to prevent significant weight loss, implement timely interventions, consistently monitor weights, and accurately document meal intake for residents at nutritional risk. Resident #1 experienced a significant unplanned weight loss of 10.88% in less than two months, and documentation inaccuracies were noted for residents #6 and #7, both at nutritional risk with dementia.
Deficiencies (1)
F 0692: The facility failed to provide enough food/fluids to maintain residents' health, resulting in significant weight loss for Resident #1 and inaccurate meal intake documentation for Residents #6 and #7.
Report Facts
Weight loss percentage: 10.88
Weight loss in pounds: 19.6
Nutritional supplement opportunities: 141
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to complaints regarding the treatment of residents, specifically concerns about dignity and respect shown by staff towards residents #1 and #2.
Complaint Details
The complaint investigation was triggered by reports that RN #1 was rude, disrespectful, and unprofessional towards residents #1 and #2, including making inappropriate comments about PTSD and medication administration. The investigation included interviews with residents, staff, and review of witness statements. The complaint was substantiated with findings of disrespectful behavior.
Findings
The facility failed to ensure residents #1 and #2 were treated and spoken to in a dignified manner, with multiple witness statements and interviews indicating disrespectful and rude behavior by RN #1. The facility is investigating the incident and plans to implement a performance improvement plan and staff training on dignity and respect.
Deficiencies (1)
Failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Report Facts
Residents reviewed for dignity: 4
Residents affected: 2
BIMS score Resident #1: 10
BIMS score Resident #2: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in multiple findings related to disrespectful and rude behavior towards residents #1 and #2. |
| Director of Nurses | Director of Nursing | Interviewed regarding the incidents and investigation. |
| Social Service Director | Social Service Director | Provided witness statements and involved in investigation. |
| CNA #1 | Certified Nursing Assistant | Provided witness statement describing RN #1's behavior. |
| INHA | Interim Nursing Home Administrator | Interviewed about the investigation and facility response. |
| LPN #1 | Licensed Practical Nurse | Reported concerns about RN #1's behavior to SSD. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
The inspection was conducted in response to complaints regarding disrespectful and undignified treatment of residents by a registered nurse (RN #1) during medication administration and interactions.
Complaint Details
The complaint investigation was substantiated with findings that RN #1 was disrespectful and rude to residents, including making disparaging remarks about PTSD. Residents expressed fear and discomfort, and the facility is actively investigating and addressing the issue.
Findings
The facility failed to ensure residents were treated with dignity and respect. Two residents reported that RN #1 was rude, disrespectful, and made disparaging comments related to PTSD. The facility is investigating the incidents and plans to implement corrective actions including staff training on dignity and respect.
Deficiencies (1)
F 0550: The facility failed to honor residents' rights to a dignified existence and respect. Specifically, RN #1 was rude and disrespectful to Resident #1 and Resident #2, including making inappropriate comments about PTSD and interrupting residents' concerns.
Report Facts
Residents reviewed for dignity: 4
Residents affected: 2
BIMS score Resident #1: 10
BIMS score Resident #2: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in findings for disrespectful behavior and inappropriate comments to residents |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and investigation |
| Social Service Director | Social Service Director | Provided witness statements and involved in investigation |
| Interim Nursing Home Administrator | Interim Nursing Home Administrator | Provided witness statement and involved in investigation |
| LPN #1 | Licensed Practical Nurse | Reported concerns about RN #1's behavior |
| CNA #1 | Certified Nursing Assistant | Provided witness statement about RN #1's behavior |
| CNA #2 | Certified Nursing Assistant | Reported Resident #1's upset after RN #1 interaction |
| RN #2 | Registered Nurse | Interviewed about Resident #1's concerns with RN #1 |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 17
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident care related to activities of daily living, abuse prevention, behavioral health services, medication administration, infection control, food service, staffing adequacy, and water management. Several residents experienced inadequate assistance, delayed call light responses, medication errors, and environmental concerns. Legionella was detected in the water system with delayed remediation. The facility had repeat deficiencies from prior surveys.
Deficiencies (17)
Failed to accommodate the needs of residents #63 and #16 related to bathroom accessibility and privacy in shared rooms.
Failed to ensure resident room temperatures were comfortable and safe in one neighborhood, with ineffective evaporative cooling system.
Failed to protect residents #4, #50, #125, and #36 from verbal, mental, and physical abuse by staff and other residents.
Failed to timely report incidents of potential abuse to the State Survey and Certification agency for residents #4, #66, and #50.
Failed to coordinate PASRR assessment for Resident #50 after diagnosis change in June 2023.
Failed to ensure adequate assistance with activities of daily living for residents #8, #63, #50, and #7, including bathing and grooming.
Failed to provide an individualized activity program to meet the psychosocial needs of Resident #8 with autism and major depression.
Failed to provide adequate supervision and safety devices to prevent falls and accidents for residents #35, #20, and #8.
Failed to maintain adequate nutritional status for Resident #35 after a fall with fracture and significant weight loss, with insufficient monitoring and interventions.
Failed to provide sufficient nursing staff with appropriate competencies and skills to meet resident care needs, resulting in delayed call light responses and inconsistent care.
Failed to ensure medication error rate was not greater than five percent; insulin pen was not primed properly before administration to Resident #3; Resident #50 was not given correct inhaler dose.
Failed to ensure all drugs and biologicals were properly stored; expired medications including tuberculin PPD and lorazepam were found in medication storage refrigerator.
Failed to maintain communication and coordination with hospice provider for Resident #47, including documentation of hospice visits and delineation of care responsibilities.
Failed to provide necessary behavioral health care and services for residents #4, #36, #50, and #125, including lack of personalized behavioral interventions and failure to report abuse allegations.
Failed to ensure food was palatable, attractive, and served at safe temperatures; residents reported food was bland, dry, fatty, and served at room temperature; expired food and unlabeled opened food items were found.
Failed to maintain an infection prevention and control program; delayed and incomplete remediation after Legionella was detected in the facility's water system in February 2022; annual testing was overdue.
Failed to ensure mechanical kitchen equipment was maintained in safe, working condition; hand washing and food preparation sinks had low water pressure and were not warm until identified during survey.
Report Facts
Medication error rate: 7.41
Resident census: 69
Weight loss: 10
Call light response time: 44
Call light response time: 282
Fall risk score: 15
Fall risk score: 24
Fall risk score: 10
Weight: 189.6
Weight: 190.4
Weight: 198
Weight: 191
Weight: 201.6
Temperature: 60
Temperature: 62
Temperature: 61.8
Temperature: 64.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered insulin without priming pen; verbal/mental abuse allegation toward Resident #50 |
| CNA #14 | Certified Nurse Aide | Forcefully pushed Resident #125 into wheelchair; abuse investigation |
| CNA #15 | Certified Nurse Aide | Involved in abuse investigation of Resident #125 |
| CNA #1 | Certified Nurse Aide | Verbally abused Resident #36; abuse investigation |
| CNA #4 | Certified Nurse Aide | Reported staffing shortages and trauma-informed care training gaps |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies and staffing |
| NHA | Nursing Home Administrator | Interviewed regarding multiple deficiencies and staffing |
| MTD | Maintenance Director | Interviewed regarding Legionella water management and kitchen sink issues |
| RD | Registered Dietitian | Interviewed regarding nutritional care and food quality |
| SSD | Social Services Director | Interviewed regarding behavioral health and PASRR |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding staffing and resident care |
| RN #3 | Registered Nurse | Interviewed regarding behavioral health and medication storage |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Jul 13, 2023
Visit Reason
The inspection was the annual recertification survey to assess compliance with regulatory requirements for nursing home care, including resident rights, safety, quality of care, and infection control.
Findings
The facility was found deficient in multiple areas including resident rights and accommodations, environmental safety, abuse prevention, activities of daily living assistance, dementia care, nutritional care, staffing adequacy, medication administration, infection control, hospice care coordination, food service quality, and equipment maintenance. Several repeat deficiencies were noted from prior surveys.
Deficiencies (16)
F0558: The facility failed to accommodate the needs of residents #63 and #16 who used wheelchairs and had difficulty accessing and using their bathrooms with privacy in shared rooms.
F0584: Residents in two neighborhoods experienced uncomfortably hot room temperatures due to ineffective evaporative cooling system; temperatures measured up to 89 degrees Fahrenheit.
F0600: The facility failed to prevent verbal and physical abuse for residents #4, #50, #125, and #36, including verbal altercations between residents and staff verbal abuse; investigations and care plans were inadequate.
F0609: The facility failed to timely report incidents of potential abuse involving residents #4, #66, and #50 to the State Survey Agency as required by law.
F0644: The facility failed to coordinate PASRR assessments for Resident #50 after a diagnosis change, delaying recommended specialized services for trauma and PTSD.
F0677: The facility failed to provide adequate assistance with activities of daily living for residents #8, #63, #50, and #7, including bathing, grooming, toileting, and showers, affecting resident well-being.
F0689: The facility failed to provide an individualized activity program to meet the psychosocial needs of Resident #8, who had autism and major depression, resulting in social isolation.
F0692: The facility failed to provide adequate supervision and safety measures to prevent falls and accidents for residents #35, #20, and #8, resulting in injuries including a fractured foot and multiple falls.
F0692: Resident #35 experienced significant unplanned weight loss of more than 10 percent within six months due to inadequate nutritional monitoring and assistance.
F0725: The facility failed to provide sufficient nursing staff with appropriate competencies and skills to meet resident care needs, resulting in delayed call light responses, inadequate assistance, and staff burnout.
F0760: Resident #3 was administered insulin from a Levemir FlexPen without priming the pen as required, risking incorrect dosing.
F0812: The facility failed to ensure dietary food items were stored at proper temperatures, expired food was discarded, and opened food items were properly dated to prevent foodborne illness.
F0849: The facility failed to maintain communication and coordination with hospice provider for Resident #47, including documentation of hospice visits and delineation of care responsibilities.
F0867: The facility failed to implement effective quality assurance and process improvement plans to address repeat deficiencies and quality of care issues including abuse prevention, ADL assistance, dementia care, and infection control.
F0880: The facility failed to maintain an effective infection prevention and control program, including timely remedial actions after Legionella was detected in the water system and lack of annual testing.
F0908: The facility failed to ensure mechanical kitchen equipment was maintained in safe, working condition, including low water pressure and temperature in hand washing and food preparation sinks.
Report Facts
Medication error rate: 7.41
Resident weight loss: 10
Resident census: 69
Staffing minimum: 5
Staffing minimum: 3
Staffing minimum: 3
Staffing minimum: 2
Call light response time: 44
Call light unanswered: 26
Call light unanswered: 282
Expired medication: 3
Legionella level: 15.6
Resident weight: 189.6
Resident weight: 201.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered insulin without priming pen; verbal abuse allegation toward Resident #50 |
| CNA #14 | Certified Nurse Aide | Pushed Resident #125 into wheelchair causing injury; involved in abuse investigation |
| CNA #15 | Certified Nurse Aide | Involved in abuse investigation with Resident #125 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies and staffing |
| NHA | Nursing Home Administrator | Interviewed regarding multiple deficiencies and staffing |
| MTD | Maintenance Director | Interviewed regarding Legionella water management and kitchen sink issues |
| SSD | Social Services Director | Interviewed regarding behavioral health and abuse investigations |
| RD | Registered Dietitian | Interviewed regarding nutritional care and food quality |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding staffing and care concerns |
| CNA #4 | Certified Nurse Aide | Interviewed regarding staffing shortages and trauma-informed care |
| CNA #3 | Certified Nurse Aide | Interviewed regarding staffing and shower assistance |
| RN #3 | Registered Nurse | Interviewed regarding behavioral care and staffing |
| CNA #1 | Certified Nurse Aide | Observed verbally abusing Resident #36 |
| CNA #10 | Certified Nurse Aide | Interviewed regarding behavioral care for Resident #4 |
| CNA #8 | Certified Nurse Aide | Interviewed regarding food service and meal assistance |
| RN #4 | Registered Nurse | Interviewed regarding food service and meal assistance |
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 10
Date: May 19, 2022
Visit Reason
The inspection was conducted to investigate multiple complaints and concerns including resident rights, bathing and hygiene care, resident council grievances, abuse allegations, advance directives, medication management, falls, pressure ulcers, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, failure to investigate and respond to abuse allegations timely and thoroughly, inadequate assistance with activities of daily living, failure to prevent pressure ulcers and falls, inadequate dementia care, failure to obtain informed consent for psychotropic medications, failure to provide timely dental care, and failure to maintain an effective infection prevention and control program. The quality assurance program was also found ineffective in identifying and correcting repeated deficiencies.
Deficiencies (10)
Failure to provide routine bathing consistent with residents' preferences for Resident #39 and #46.
Failure to investigate and protect Resident #43 from sexual abuse allegation and failure to investigate resident council allegation of staff roughness.
Failure to provide timely assistance with activities of daily living including incontinence care, grooming, bathing and toileting for multiple residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #8, resulting in stage 4 pressure injury and amputation.
Failure to ensure adequate supervision and safe environment to prevent accidents and falls for multiple residents including Resident #6, #8, #14 and #38.
Failure to provide appropriate treatment and services to a resident with dementia, including person-centered care and meaningful engagement for Resident #19.
Failure to implement gradual dose reductions and obtain informed consent for psychotropic medications for Residents #19, #20 and #43.
Failure to provide routine and emergency dental services timely for Resident #38, impacting ability to safely chew food and receive preferred food choices.
Failure to implement an effective infection prevention and control program including wound care, hand hygiene before meals, maintaining clean resident environments, and appropriate PPE use by staff.
Failure to operate an effective quality assurance and performance improvement (QAPI) program to identify and address repeated deficiencies in care and compliance.
Report Facts
Resident census: 56
Number of falls: 13
Activities offered: 158
Activities not offered: 73
BIMS score: 4
BIMS score: 11
BIMS score: 0
BIMS score: 0
BIMS score: 2
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed routine work with Residents #19 and #20 and described medication consent process |
| CNA #1 | Certified Nurse Aide | Routinely worked with Resident #19 and Resident #38, described observations of resident care |
| SDC | Staff Development Coordinator / Infection Preventionist | Provided wound care for Resident #8 and interviewed about infection control practices |
| ADON | Assistant Director of Nursing | Interviewed about bathing, falls, dementia care, psychotropic medication consents, and QAPI |
| RRN | Regional Resource Nurse | Interviewed about falls, dementia care, psychotropic medication consents, and QAPI |
| NHA | Nursing Home Administrator | Interviewed about QAPI, psychotropic medication consents, falls, and infection control |
| DM | Dietary Manager | Interviewed about dietary staff mask use and resident #38 dental care |
| Resident #43's daughter / POA | Interviewed regarding abuse allegation and advance directives |
Inspection Report
Re-Inspection
Deficiencies: 12
Date: May 19, 2022
Visit Reason
Recertification inspection and complaint investigation of Mantey Heights Rehabilitation & Care Center to assess compliance with state and federal regulations.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights to self-determination, failure to investigate and address resident grievances, failure to protect residents from abuse, failure to provide adequate assistance with activities of daily living, failure to prevent pressure ulcers and falls, failure to provide appropriate dementia care, failure to ensure psychotropic medications were properly managed, failure to provide timely dental care, failure to maintain an effective quality assurance program, and failure to implement an effective infection prevention and control program.
Deficiencies (12)
F0561: The facility failed to honor residents' rights to make choices about their daily life, specifically bathing preferences for two residents, resulting in missed or delayed baths.
F0565: The facility failed to take action on grievances raised by the resident council, including allegations of rough treatment by staff, slow call light response, and issues with laundry and food service.
F0578: The facility failed to protect a cognitively intact resident's right to formulate advance directives, as the resident's power of attorney signed the advance directive without documented resident consent.
F0610: The facility failed to thoroughly and timely investigate an allegation of sexual abuse by a staff member and failed to protect the resident during and after the investigation.
F0677: The facility failed to provide timely and adequate assistance with activities of daily living, including bathing, grooming, and incontinence care for four residents.
F0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers, resulting in a stage 4 pressure injury with infection and amputation for one resident.
F0689: The facility failed to ensure residents were free from accident hazards by not comprehensively reviewing falls, implementing effective interventions, and updating care plans for residents with multiple falls.
F0744: The facility failed to provide appropriate dementia care, including person-centered approaches and meaningful engagement for one resident with severe cognitive impairment.
F0758: The facility failed to obtain informed consent for antipsychotic medications for three residents and failed to create a care plan addressing antipsychotic use for one resident.
F0791: The facility failed to provide routine and emergency dental services timely to one resident, impacting his ability to safely chew food and receive preferred food choices.
F0867: The facility failed to implement an effective quality assurance program to identify and address repeat deficiencies including advanced directives, ADL care, pressure ulcers, accident hazards, psychotropic medication use, and infection control.
F0880: The facility failed to implement an effective infection prevention and control program, including failure to provide sanitary wound care, hand hygiene before meals, clean resident environments, and appropriate use of personal protective equipment.
Report Facts
Resident falls: 13
Resident census: 56
Activities offered: 158
Activities not offered: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Responsible for obtaining psychotropic medication consents and confirmed routine work with Residents #19 and #20. |
| SDC | Staff Development Coordinator / Infection Preventionist | Performed wound care, infection control observations, and provided infection control education. |
| ADON | Assistant Director of Nursing | Provided facility policies, interviewed regarding multiple findings including dementia care, falls, and psychotropic medication management. |
| RRN | Regional Resource Nurse | Interviewed regarding falls, psychotropic medication management, and dementia care. |
| NHA | Nursing Home Administrator | Interviewed regarding QAPI program, psychotropic medication consents, and overall facility compliance. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident care and observations related to bathing, dementia care, and dental issues. |
| Dietary Manager | Dietary Manager | Interviewed regarding infection control mask use and nutrition care. |
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