Mantey Heights Rehabilitation & Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure was kept free from physical abuse for one (#4) of five residents reviewed for abuse out of six sample residents. Specifically, the facility failed to protect Resident #4 from physical abuse by Resident #5.

Inspectors wroteBased on record review and interviews, the facility failed to timely report an allegation of abuse involving three (#2, #1 and #5) of five residents reviewed for abuse out of five sample residents. Specifically, the facility failed to throughly investigate and timely report two allegations of sexual abuse by Resident #1 toward Resident #2 and Resident #5.

Inspectors wroteBased on observations, record review and interviews, the facility failed to timely investigate an allegation of abuse involving three (#2, #1 and #5) of five residents reviewed for abuse out of five sample residents. Specifically, the facility failed to throughly investigate allegations of sexual abuse by Resident #1 towards Resident #2 and Resident #5.

Inspectors wroteBased on record review, and interview, the facility failed to provide choices for preference of bathing schedule for two (#4 and #1) of six residents reviewed for self-determination out of 10 sample residents. Specifically, the facility failed to ensure Residents #1 and Resident #4, who were dependent on staff for care, received regular bathing in accordance with preferences and plan of care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a copy of medical records were provided timely for two (#2 and #1) of three residents out of 10 sample residents. Specifically, the facility failed to ensure medical records were provided timely upon request to the representatives of Resident #2 and Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two (#4 and #1) of three residents out of 10 sample residents. Specifically, the facility failed to: -Provide timely restorative services, as was care planned and recommended, for Resident #4; and, -Offer and provide a restorative service program for Resident #1 to help maintain the resident's function after the resident was discharged from therapy services.

Inspectors wroteBased on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for three (#7, #8 and #3) of seven residents out of 13 sample residents. Specifically, the facility failed to: -Report an allegation of physical abuse towards Resident #7 by Resident #3 to the State Agency; -Report an allegation of sexual abuse towards Resident #8 by Resident #3 to the State Agency; and, -Report an allegation of sexual abuse towards Resident #3 by Resident #9 to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two (#7 and #8) of seven residents out of 13 sample residents. Specifically, the facility failed to complete a thorough investigation after: -An allegation of physical abuse towards Resident #7 by Resident #3; and, -An allegation of sexual abuse towards Resident #8 by Resident #3.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#7) of five residents reviewed were free from abuse out of 13 sample residents. Specifically, the facility failed to ensure Resident #7 was free from physical abuse by Resident #3.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for one (#2) of three residents reviewed for catheter care out of 13 sample residents. Specifically, the facility failed to: -Ensure staff provided appropriate catheter care for Resident #2, who had a history of recurring urinary tract infections (UTI); and, -Ensure Resident #2's baseline care plan included catheter care for his indwelling Foley catheter.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#1) of three residents reviewed for unnecessary medications out of 13 sample residents. Specifically, the facility failed to: -Document behaviors that justified the rationale for Resident #1's physician's order for the use of as needed (PRN) Lorazepam (an antianxiety medication) after 14 days; and, -Ensure the physician was notified of Resident #1's frequent refusals of scheduled Lorazepam and reassessed Resident #1 for the need to continue the medication.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure two (#9 and #65) of four residents reviewed for nutrition out of 46 sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being. Resident #9 was admitted to the facility for long-term care on 11/6/15 with diagnoses of unspecified disorder of psychological development, cerebral palsy, and cerebellar ataxia (difficulty with balance). On 8/20/24, Resident #9 weighed 167.2 pounds (lbs). On 9/24/24, Resident #9 weighed 160 lbs., a weight loss of 7.2 lbs (4.3%) in one month, which was not significant. However, the facility failed to implement nutritional interventions or closer monitoring of the resident's weight to prevent further weight loss for the resident. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.conditions in the kitchen. Specifically, the facility failed to: -Ensure the staff medications were not stored in the walk-in refrigerator with resident food; -Ensure the staff wore a beard net while preparing and serving meals; and, -Ensure the air vent above the food service line was free of dust and dirt.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control 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.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for five (#63, #9, #2, #57 and #23) of ten residents out of 46 sample residents. Specifically, the facility failed to: -Implement and update fall care plans in a timely manner for Resident #63; -Ensure neurological checks were completed appropriately for Resident #63 and Resident #9 following an unwitnessed fall; -Ensure Resident #2 was safely transferred using a slide board; -Ensure Resident #57 was appropriately monitored while smoking; and, -Ensure safe transfer pole use for Resident #23.

Inspectors wroteBased on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure 10 (#12, #64, #4, #15, #41, #55, #7, #44, #18 and #129) of 17 residents with an order for a mechanically altered diet texture out of 46 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders. Specifically, the facility failed to: -Provide Resident #12, #64, #4, #15, #41, #55, #7, #44 and #18 with the correct altered mechanical soft diet texture: and, -Provide Resident #129 with the correct altered pureed diet texture.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#63) of two residents out of 46 sample residents. Specifically, the facility failed to ensure Resident #63's proxy selected or refused life-saving treatments within the power of a proxy.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide necessary respiratory care consistent with professional standards of practice, the resident's care plan, goals and preferences for two (#32 and #70) of two residents reviewed for respiratory care out of 46 sample residents. Specifically, the facility failed to: -Implement a care plan focus with purpose, goals and interventions to document Resident #32 and Resident #70's goals for using a Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure (CPAP/BiPAP) machine; -Develop and implement effective interventions to maintain and clean Resident #32 and Resident #70's CPAP/BiPAP machines to ensure the non-invasive mechanical ventilators were maintained in a hygienic manner; and, -Develop and implement effective interventions for oxygen therapy for Resident #32 and Resident #70.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal and influenza vaccinations for two (#28 and #43) of five residents out of 46 sample residents. Specifically, the facility failed to offer pneumococcal vaccinations to Resident #28 or Resident #43.

Inspectors wroteBased on interviews and record review, the facility failed to take steps to protect one (#10) of six residents reviewed for abuse out of 24 sample residents. Resident #10, who had a diagnosis of anxiety disorder and was always incontinent of urine and occasionally incontinent of bowel, was dependent on staff assistance for all activities of daily living (ADL), including toileting hygiene, showering, upper and lower body dressing, personal hygiene and transfers. She required maximal assistance from staff to propel her wheelchair. She was able to use her call light to call staff when she needed assistance. On 5/3/24, certified nurse aide (CNA) #2 provided a shower to Resident #10. After the resident's shower, CNA #2 placed Resident #10 in her wheelchair near the bathroom in her room. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure three (#1, #6 and #7) of four residents reviewed for nutrition out of seven sample residents received the care and services necessary to meet their nutritional needs and maintain their highest level practicable physical well-being. Specifically, the facility failed to prevent a significant weight loss, implement interventions after a significant weight loss was identified, consistently monitor weights and ensure meal intake records were accurate. Resident #1 experienced a significant, unplanned weight loss of 10.88% in less than two months. Resident #1's weight record/log identified Resident #1 lost almost 20 pounds (lbs) between 11/6/23 and 12/27/23. Resident #1's weight on 11/6/23 was 180.2 lbs. On 12/27/23 the resident's weight was 160.6 lbs. [...]

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to promote resident dignity and respect for two (#1 and #2) of four residents reviewed for dignity out of 11 sample residents. Specifically, the facility failed to ensure Resident #1 and Resident #2 were treated and spoken to in a dignified manner.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide adequate supervision and/or safety devices to prevent falls and accidents for three (#35, #20 and #8) of eight residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure Resident #35 was not injured during a staff-assisted transfer out of her daughter's car on 4/2/23. The resident per facility assessments required two-plus person assist for transfers, but one staff person assisted Resident #35 to transfer out of the car into a wheelchair. The resident fell to the pavement and broke her foot causing her pain and discomfort and thereafter, reducing her mobility and contributing to a decline (cross-reference F692, weight loss/nutrition). [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#35) of nine residents reviewed for weight loss out of 37 sample residents maintained adequate nutritional parameters. Specifically, Resident #35 had a condition change when she experienced a fall with a fracture on 4/2/23 (cross-reference F689 falls/accidents). Resident #35's weights, taken on 3/30/23 and 5/11/23, more than one month apart, demonstrated a 10-pound weight loss from 201.6 to 191 pounds, which was not followed up with timely nutritional assessments and interventions. Resident #35 was observed needing extensive to total assistance with dining although her assessments and care plan identified she was independent with setup help only; staff who provided care for Resident #35 said she had needed an extensive level of assistance for about one month. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure cold food items were at appropriate temperatures; -Ensure expired food was discarded; and, -Ensure food items removed from its original packaging and opened had a dating system.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure remedial actions were followed and timely implemented after the identification of Legionella was detected in the facility's water.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure four (#4, #50, #125 and #36) of 11 residents reviewed out of 37 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #4 did not suffer from verbal abuse by Resident #66. The facility failed to ensure effective personalized care planned interventions were in place for Resident #4 to prevent verbal abuse, who had a history of dementia and was exhibiting constant loud vocalizations. On [DATE] Resident #66 shouted at Resident #4, while in Resident #4's room, to shut up and stop yelling as she was disturbing him and the entire hallway. Resident #4 was observed hunched over in a wheelchair with hands covering her face. The facility further failed to ensure: -Resident #50 did not suffer from verbal/mental abuse by registered nurse (RN) #1; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure adequate assistance with activities of daily living (ADLs) for four (#8, #63, #50 and #7) of nine residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure: -Resident #8 received adequate assistance with bathing, grooming and toilet use/incontinence; -Resident #63 received adequate assistance with bathing and grooming; -Resident #50 received adequate assistance with showers; and -Resident #7 received adequate assistance with showers. All the above residents needed physical assistance from staff with these ADLs. Residents #50 and #7 said the lack of showers affected their psychosocial well-being.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference F689 accident hazards and F677 activities of daily living (ADLs).

Inspectors wroteBased on interviews and record review, the facility failed to ensure four (#4, #36, #50 and #125) of 11 residents reviewed out of 37 sample residents had personalized behavioral interventions in place. Specifically, the failed to ensure: -Resident #4, who had a history of dementia, had effective personalized behavioral interventions care planned and in place who was exhibiting verbally disruptive behaviors and was at risk for abuse; and -Residents #36, #50 and #125 had personalized behavioral interventions care planned for dementia and trauma informed care for these residents that were difficult to redirect and had triggered behaviors.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance.

Inspectors wroteBased on interviews and record review, the facility failed to ensure its quality assurance and process improvement (QAPI) committee prioritized its improvement activities, developed and implemented action plans, measured the success of those actions, tracked performance, regularly reviewed and analyzed and acted on data collected. Specifically, the facility failed to identify and implement effective action plans to address repeat deficiencies and resident quality of life and quality of care issues related to abuse prevention, activities of daily living, dementia care, quality assurance and infection control.

Inspectors wroteBased on observations, interviews and record review, the facility failed to accommodate the needs of two (#63 and #16) of seven residents reviewed for environmental concerns out of 37 sample residents. Specifically, Residents #63 and #16, who used wheelchairs for ambulation, were unable to access their bathrooms, have privacy while in their bathrooms and/or fully utilize their toiletry items at the sink in shared rooms.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident room temperatures were comfortable and safe for residents in one of three neighborhoods. Specifically, the residents who lived in two of eight resident rooms on the west side of Grand Mesa Hall experienced uncomfortably hot room temperatures when outdoor temperatures were high. Residents said all the rooms in that area of the building were uncomfortably hot and the facility's evaporative cooling system was ineffective.

Inspectors wroteBased on record review and interviews the facility failed to report incidents of potential abuse to the State Survey and Certification agency in accordance with State law for three (#4, #66 and #50) of 11 residents reviewed for abuse out of 37 sample residents. Specifically, the facility failed to report: -An incident of verbal abuse involving Resident #4 and Resident #66; and, -Incidents involving verbal/mental abuse by registered nurse (RN) #1 toward Resident #50 to the State Survey and Certification Agency. Cross-reference F600, failure to ensure residents were free from abuse.

Inspectors wroteBased on record review and interviews, the facility failed to coordinate assessment with the preadmission screening resident review (PASRR) program for one (#50) of two residents reviewed for PASRR out of 37 sample residents. Specifically, the facility failed to submit another PASRR assessment when Resident #50's diagnosis changed in June 2023.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an individualized activity program to meet the psychosocial needs of one (#8) of six residents reviewed out of 37 sample residents. Specifically, Resident #8 had specialized activity needs due to diagnoses of autism and major depression. Resident #8 was deaf and did not speak. The facility failed to develop effective methods to communicate with the resident, family and interdisciplinary team to assess, develop and implement activities in keeping with his preferences and communication needs to ensure he reached his highest practicable psychosocial potential and well-being. The facility failed to meet Resident #8's specialized, person-centered activity needs which contributed to his isolation.

Inspectors wroteBased on record review and interviews, the facility failed to provide the necessary behavioral healthcare and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (#7) of four residents reviewed for behavioral services out of 37 sample residents. Specifically, the facility failed to document Resident #7's suicidal ideation and self-harm tendencies to ensure staff knew what behaviors or statements to watch for and how to help Resident #7 with her increased anxiety and depression.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the medication error rate was not greater than five percent. Specifically the facility's medication error rate was 7.41% with two errors out of 27 opportunities.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that residents were free from significant mediation errors for one (#3) of four residents reviewed for medication errors out of 37 sample residents. Specifically, the facility failed to ensure that Resident #3 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of three medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were timely removed from the medication storage area and refrigerator; and, -Ensure expired tuberculin purified protein derivative (PPD) was removed timely from the medication storage refrigerator.

Inspectors wroteBased on observation, record review and interviews the facility failed to maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for one (#47) of four residents reviewed for hospice care services out of 37 sample residents. Specifically, the facility failed to for Resident #47: -Demonstrate documentation of a collaboration of care between the facility and the hospice provider; -Delineate care responsibilities between facility care staff and hospice care staff and the frequency of the hospice staff visits; and, -Documentation of hospice staff visits and the hospice plan of care.

Inspectors wroteBased on observations and interviews, the facility failed to ensure mechanical equipment was in safe, operational condition. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in safe, working condition.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly and timely investigate an allegation of sexual abuse and protect one (#43) of two residents out of 30 sample residents during and after the investigation and, failed to investigate a subsequent allegation reported in resident council of staff's rough treatment. Resident #43 alleged sexual abuse by registered nurse (RN) #4 on 3/12/22. The facility failed to timely respond, thoroughly investigate and protect Resident #43, and allowed RN #4 to continue working with Resident #43. As a result, Resident #43 said she felt very upset and angry that she was not believed, and was fearful of RN #4. There was insufficient evidence the facility took measures to reassure Resident #43 and ensure she felt safe in her home. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide one (#8) of two residents reviewed out of 30 sample residents, the care and services necessary to prevent the development of a stage 4 pressure injury to the resident's left foot, third digit (toe) that became infected and painful and was amputated within two months of admission. Resident #8 was admitted to the facility on [DATE] with no documented pressure injuries but at risk for such injuries. He was a diabetic and had a history of toe amputations of both feet, and a hyperkeratotic lesion (thickening of skin) on the third digit on his left foot, one of his three remaining toes. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify concerns and or implement effective action plans to mitigate the repetition facility failures including quality of care and infection control.

Inspectors wroteBased on interviews and record review, the facility failed to take action on grievances of the resident group. Specifically, resident council members brought forward the following concerns: -Some certified nurse aides (CNAs) were being a little rough (cross-reference F610 to investigate allegations of abuse); -Call light response was too slow, and as a result residents did not receive timely assistance to the bathroom, and did not receive baths/showers; -Water cups were not being changed enough and the water got warm or their cups were empty; -Laundry service was slow and clothing items were missing and not returned; -Food orders were not being taken correctly, so residents were not receiving their food choices; and -Food and coffee needed to be hotter. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide necessary assistance with activities of daily living (ADLs) for four (#11, #14, #3 and #8) of six residents reviewed out of 30 sample residents. Specifically, the facility failed to provide timely: -Incontinence care, grooming and bathing for Resident #11; -Incontinence care, assistance with toilet use and bathing for Resident #14. -Baths/showers for Resident #3; and, -Incontinence care, grooming and showers for Resident #8.

Inspectors wroteBased on staff interviews, observations and record review, the facility failed to ensure four (#6, #8, #14 and #38) reviewed for accident hazards of six residents out of 30 sample residents, were provided adequate supervision and a safe environment to prevent accidents and the re-occurrence of accidents. Specifically, the facility failed to: -Comprehensively review, implement effective interventions and update the resident's care plans after multiple falls for Resident #6, #8 and #14; and, -Provide a safe environment with adequate supervision to avoid potential safety hazards for Resident #38.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#19, #20 and #43) of five residents reviewed for medications of 30 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Obtain an informed consent for Residents #19, #20 and #43 for the use of antipsychotic medication; and, -Create a care plan that addressed the use of an antipsychotic medication for Resident #20.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement an effective infection prevention and control program to prevent the potential spread of infection. Specifically, the facility failed to: -Provide wound care in a sanitary manner for Resident #8; -Provide hand hygiene for residents before meal service; -Maintain a clean and sanitary environment for residents in their rooms; and, -Ensure staff used appropriate personal protective equipment (PPE).

Inspectors wroteBased on observations, record review and interviews, the facility failed to allow residents to make choices about aspects of their life in the facility that were significant to them for two (#39 and #46) out of 30 sample residents. Specifically, the facility failed to provide routine bathing consistent with the residents' preferences for Resident #39 and #46.

Inspectors wroteBased on record review and interview, the facility failed to protect a resident's right to formulate advance directives for one (#43) of one resident reviewed out of 30 sample residents. Specifically, although Resident #43 was facility assessed as cognitively intact, her power of attorney (POA)/family signed her advance directives and designated her status as do not resuscitate (DNR).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#19) of five residents reviewed for dementia care of 30 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to comprehensively identify person-centered approaches for dementia care for Resident #19.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to provide routine and emergency dental services to meet the needs of each resident for one (#38) of one resident reviewed for dental out of 30 sample residents. Specifically, Resident #38 was not timely offered the opportunity to see a dentist, impacting his ability to safely chew all his food and receive food choices of his preference.