Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mantey Heights Rehabilitation & Care Center during CMS and state inspections, most recent first.
The facility failed to timely report and adequately document two separate allegations of sexual abuse involving the same cognitively intact male resident and two cognitively intact female residents. In one case, a resident with multiple sclerosis and psychiatric diagnoses reported that another resident entered her room at night and kissed her on the mouth while she slept; the facility became aware the next morning but did not report the allegation to the State Agency until several days later, beyond required timeframes, and did not document the event in either resident’s progress notes. In a second case, another resident with heart failure and mood and anxiety disorders reported feeling uncomfortable and unsafe after the same male resident attempted to kiss her and engaged in increasingly invasive behavior, which was also witnessed by a CNA; although the ADON and DON acknowledged this met criteria for potential abuse, the NHA did not report the allegation to the State Agency, believing the interaction was consensual.
A male resident with dementia and wandering behaviors was repeatedly reported by cognitively intact female residents as entering their rooms, attempting or giving unwanted kisses, and invading their privacy, including listening at doors and looking through windows. One resident reported being kissed while asleep in bed, another reported an unwanted kiss on the smoking porch and feeling unsafe, and a third reported frequent uninvited room entry. Although staff and leadership were aware of these concerns and one CNA witnessed a kiss, the facility delayed required reporting to the State Agency for one allegation, failed to conduct or retain a thorough investigation for another, did not document key investigative interviews, and did not add or consistently implement care plan interventions to protect the residents or restrict the male resident’s behavior, including allowing him to push a female resident’s wheelchair despite a care plan directive against this.
Two residents who were dependent on staff for ADLs did not receive bathing opportunities in accordance with their documented preferences and care plans. One resident, who preferred showers twice a week, received significantly fewer showers than scheduled, with inadequate documentation of refusals or reasons for missed care. Another resident, who wanted showers every other day, also received far fewer showers than requested, and her care plan did not reflect her preferences or need for assistance. Staff interviews and records confirmed inconsistent documentation and failure to support resident choice regarding personal care.
The facility did not provide timely access to medical records for two residents' representatives, as required by its own policy, resulting in delays of about a week or more after requests were made. Staff interviews indicated confusion about the required timeframe, with records sometimes being provided up to two weeks after the request instead of within the 48-hour policy.
Two residents with limited mobility did not receive timely or appropriate restorative services as outlined in their care plans and recommended by the care team. One resident did not receive restorative ROM exercises despite requests and care plan directives, while another was not offered restorative nursing services after therapy discharge. Facility leadership confirmed that a lack of restorative staff led to these deficiencies.
The facility did not timely report multiple incidents of alleged physical and sexual abuse between residents to the State Agency, as required by policy. In each case, staff either delayed or failed to recognize the need for reporting, despite clear evidence of inappropriate or non-consensual contact. Documentation and follow-up with affected residents were also lacking, and staff interviews revealed inconsistent understanding of reporting requirements.
The facility did not thoroughly investigate two separate allegations of abuse involving two residents—one involving physical abuse and another involving sexual abuse—by another resident. In both cases, required steps such as interviewing staff and other residents, reviewing documentation, and following up with the victims were not completed, and there was no evidence of comprehensive investigation or documentation as required by facility policy.
A resident with a history of cognitive impairment and prior victimization was physically abused by another cognitively impaired resident known for aggressive behaviors. The incident occurred during routine care and was witnessed by a CNA, with the victim expressing pain but no injury found. Despite care plans outlining risks and interventions for both residents, the aggressive behavior was not prevented, and staff did not consistently intervene during episodes of aggression.
A resident with an indwelling Foley catheter and a history of recurrent UTIs did not consistently receive appropriate catheter care, particularly after episodes of bowel incontinence. Staff failed to clean the catheter and insertion site as required, and there was confusion among CNAs and nurses about care responsibilities. The resident's baseline care plan did not address catheter care in a timely manner, and documentation of care was lacking. Improper placement of the catheter securement device and signs of infection were also observed, ultimately resulting in a confirmed UTI.
Two residents in a LTC facility experienced significant weight loss due to the facility's failure to implement necessary nutritional interventions. One resident, with cerebral palsy and cerebellar ataxia, lost 22.4 lbs over six months without additional interventions despite being at risk for malnutrition. Another resident, with chronic kidney disease, lost 19.6 lbs, and the dietician was unaware due to a cleared weight loss trigger. Observations showed meals were often cold, and snacks were not offered as ordered. Staff interviews revealed a lack of awareness and appropriate action regarding the residents' nutritional needs.
The facility failed to maintain sanitary conditions in the kitchen, with staff medications improperly stored with resident food, and kitchen staff not wearing required beard nets. Additionally, the air vent above the food service line was covered in thick dust, which was being blown around during meal service. The dietary manager was unaware of the regulations and requirements, leading to these deficiencies.
The facility failed to implement an effective water management plan to prevent Legionella, as recommended by the CDC. The policy required biannual flushing of dead legs and low flow piping runs, contrary to the weekly flushing advised. Observations showed that sinks were not flushed during cleaning, and interviews revealed a misunderstanding of the required flushing frequency. The deficiency was due to inadequate documentation and lack of specific instructions for housekeeping staff.
The facility failed to ensure a safe environment for residents, leading to multiple deficiencies. A resident experienced several falls without timely updates to their care plan or proper neurological assessments. Another resident was involved in an unsafe transfer due to inadequate staff training. Additionally, a resident was not consistently monitored while smoking, despite requiring supervision. These failures highlight the facility's inability to adhere to its own safety protocols and policies.
The facility failed to serve food at appropriate temperatures, with residents reporting cold and bland meals. Observations confirmed that meals, including chicken cordon bleu and Italian wedding soup, were not served at the correct temperature. Staff interviews revealed management issues in the kitchen, contributing to the deficiency.
The facility failed to provide mechanically altered diets as ordered for 10 residents, serving inappropriate food textures such as regular rolls and improperly sized chicken pieces. Staff interviews revealed a lack of awareness of diet requirements, posing a risk of choking for residents with dysphagia and other conditions.
A facility failed to ensure a resident's advance directive was properly documented, as a proxy declined artificial nutrition without required physician documentation. The resident, with severe cognitive impairment, had a proxy appointed due to multiple strokes. Staff interviews revealed a lack of understanding of the proxy's legal limitations, leading to non-compliance with advance directive requirements.
The facility failed to provide necessary respiratory care for two residents using CPAP/BiPAP machines, as their care plans lacked documentation of goals and interventions. Observations showed inadequate maintenance and cleaning of the equipment, with residents lacking supplies to perform these tasks. Staff interviews revealed confusion over responsibility for equipment maintenance, contributing to the deficiency.
The facility failed to offer pneumococcal vaccinations to two residents over 65, as required by CDC guidelines. One resident, without cognitive impairments, was not offered the vaccine until the survey date, while another with severe cognitive impairment had no updated vaccination record or consent. Staff interviews confirmed the oversight, attributing it to a delay in accessing the state immunization system.
A resident with anxiety disorder and dependent on staff for daily activities was left unattended without access to a call light after a shower, leading to feelings of fear and abandonment. The facility's records showed multiple instances of delayed response to the resident's call light, highlighting a significant lapse in care.
Failure to Timely Report and Document Allegations of Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to timely report and thoroughly document allegations of sexual abuse to the State Agency and other required authorities, as required by its own abuse, neglect, exploitation, and misappropriation reporting policy. The policy, revised in September 2022, states that all reports of resident abuse, neglect, exploitation, or theft are to be reported to local, state, and federal agencies and thoroughly investigated, with findings documented and reported. It further specifies that suspicions of abuse or related concerns must be reported immediately to the administrator and other officials, and that allegations involving abuse or serious bodily injury must be reported within two hours, while other allegations must be reported within 24 hours. Despite this, the facility did not meet these timelines or fully implement the policy in at least two separate incidents involving three residents. In the first incident, an allegation of sexual abuse occurred when one resident entered another resident’s room at night and kissed her on the mouth while she was asleep in bed. The alleged victim was an older adult with progressive multiple sclerosis, generalized muscle weakness, major depressive disorder in remission, PTSD, generalized anxiety, and delusional behavioral symptoms, but was cognitively intact with a BIMS score of 15 and largely independent in ADLs. She reported that the same resident had previously kissed her on the forehead and that the mouth kiss made her fearful and angry at the time. The incident occurred on 10/13/25 at 2:30 a.m., but the facility first became aware of the allegation on 10/14/25 at 8:30 a.m., and did not submit the initial report to the State Agency until 10/16/25 at 4:59 p.m. The occurrence report itself identified that the report was submitted late. Additionally, progress notes for both the alleged victim and the alleged assailant on and around the date of the incident did not document the allegation. In the second incident, another cognitively intact resident, with heart failure, unspecified mood disorder, anxiety disorder, and nicotine dependence, reported that the same male resident leaned down to kiss her while they were on the outside smoking porch; she moved her head so the kiss landed on her cheek, but she felt very uncomfortable and did not view him as a romantic interest. She also reported that his behavior had become increasingly invasive, including standing outside her door and listening to her phone conversations, and she expressed feeling unsure what to do. A later nursing note documented that she came to the nurses’ station stating she felt unsafe with this resident, reporting that he had tried to kiss her on the porch and had come into her room; the ADON was informed. A behavior note for the alleged assailant documented that a CNA saw him kiss a female resident on the smoking porch, and that he became defensive, denied the incident, and refused to continue the conversation when approached by an RN. The NHA acknowledged that this was a second incident of potential sexual inappropriateness involving the same resident and stated he did not report it to the State Agency because he believed the kiss was mutually agreed upon, despite the ADON and DON indicating that a report of a resident feeling uncomfortable when kissed and any potential abuse should have been investigated and reported. This incident was not reported to the State Agency at all, constituting a failure to timely report an allegation of abuse.
Failure to Thoroughly Investigate and Care Plan Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to timely and thoroughly investigate multiple allegations of sexual abuse and boundary violations involving one male resident and several female residents, contrary to its abuse policy requiring immediate reporting and comprehensive investigations. The facility’s policy mandated that all allegations of abuse, neglect, or exploitation be reported within specified time frames and that investigations include review of documentation, medical records, interviews with residents, staff, and witnesses, and detailed documentation of findings. In the case of an allegation that a male resident kissed a female resident while she was asleep in bed, the incident allegedly occurred in the early morning hours, but the facility did not become aware until the following day and did not report the allegation to the State Agency until several days later, beyond the required reporting timeframe. The investigation that was completed did not document when the involved residents were interviewed, did not identify the events leading up to the alleged incident, did not specify where staff or the alleged perpetrator were at the time, and did not include documented interviews of staff or other residents, despite the policy’s requirements. The female resident who alleged being kissed in bed had progressive multiple sclerosis, was cognitively intact with a BIMS score of 15, used a wheelchair, and had documented delusional behavioral symptoms. She reported that the male resident had come into her room, closed the door, and kissed her on the mouth while she was asleep, and that he had previously kissed her on the forehead. She also reported that he would look into her room window from outside, prompting her to yell for staff, and that she kept her blinds down because she did not feel safe enough to keep them open. Her behavior care plan noted a history of making allegations about peers standing over her bed and a history of flirtation and conflict with caregivers, but it did not include interventions to ensure her privacy, address unwanted room entry, or guide staff response if another resident entered her room while she was sleeping. Observations on the smoking porch showed the same male resident pushing her wheelchair through the facility despite a care plan intervention stating it was not safe for him or any resident to push other residents, and staff were not observed intervening or offering assistance. A second female resident, who was cognitively intact with a BIMS score of 13 and independent with mobility, reported that the same male resident leaned down to kiss her, that she turned her head so the kiss landed on her cheek, and that the kiss made her feel very uncomfortable. She also reported that he had become increasingly invasive, including standing outside her door listening to her phone conversations, and later told nursing staff she felt unsafe with him, stating he had tried to kiss her on the porch and had come into her room. A CNA reported seeing the male resident kiss this female resident on the smoking porch, and an RN reported the incident to management. However, there was no investigation located or provided for this allegation, no evidence that it was reported to the State Agency, and no new care plan interventions were added for either resident following these events. Another female resident reported that the same male resident frequently entered her room without knocking to ask for soda and cigarettes, and that a stop sign banner intended to deter entry was not kept across her doorway. Staff interviews confirmed that the male resident could become too familiar with female residents, enter their rooms, and had kissed other female residents, yet one CNA stated she had not been informed of any specific behaviors or interventions to watch for with him. The NHA and DON acknowledged that documentation of interviews and investigations was lacking, that the report to the State Agency for one allegation was late, and that there were no new care plan interventions after the allegations involving the two female residents.
Failure to Honor Resident Bathing Preferences and Document Care
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not providing bathing opportunities in accordance with the preferences and care plans of two residents who were dependent on staff for their activities of daily living (ADLs). Both residents had documented preferences for bathing frequency and schedule, but records showed that these preferences were not consistently followed. For one resident, the care plan specified a preference for showers twice a week, but documentation revealed that she received significantly fewer showers than scheduled, with long gaps between bathing opportunities and insufficient documentation of refusals or reasons for missed showers. The care plan also lacked interventions to address any refusals of care. Another resident expressed a desire for showers every other day, a preference that was documented during admission. However, the care plan did not reflect this preference, nor did it indicate that the resident required staff assistance with ADLs. Bathing records showed that this resident received only a fraction of the expected bathing opportunities, and there was no documentation of refusals or changes in preference. The resident's representative reported that the resident often had to be taken home for bathing due to inadequate hygiene at the facility, and staff provided explanations that were not supported by the resident's documented wishes. Staff interviews confirmed that there were gaps in documentation and inconsistencies in offering and recording bathing opportunities. The DON acknowledged that residents were not always offered showers according to their preferences and that refusals were not properly documented or addressed in care plans. Staff education on proper documentation and procedures for addressing refusals had been provided, but the deficiencies persisted during the review period, resulting in a failure to support resident choice and autonomy regarding personal care.
Delayed Provision of Medical Records to Resident Representatives
Penalty
Summary
The facility failed to provide timely access to medical records for two residents when requested by their representatives. According to facility policy, residents or their representatives are entitled to obtain photocopies of records within 48 hours of a written request. However, interviews revealed that one representative waited about a week and had to call multiple times before receiving the records, while another representative also experienced a delay of over a week after making a request for records needed for social security requirements. Documentation did not consistently indicate when records were provided, and there was a lack of evidence for some requests mentioned by the representatives. Staff interviews confirmed that the process required a signed authorization and that the facility believed it had up to 30 days to fulfill such requests, despite the policy stating a 48-hour timeframe. The former medical records director acknowledged prioritizing one request but still provided the records within two weeks, exceeding the policy's stated timeline. The director of nursing confirmed the expectation that records should be provided within 48 hours, highlighting a disconnect between policy and practice that led to the deficiency.
Failure to Provide Restorative Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate restorative services and assistance to maintain or improve mobility for two residents with limited range of motion (ROM) and mobility needs. For one resident with a history of stroke and hemiplegia, the care plan directed staff to provide active and passive ROM exercises, but there was no documentation that these restorative services were actually provided. Despite requests from the resident's representative for therapy screening and restorative services, the facility informed them that such services were unavailable due to staffing issues. The interdisciplinary team recommended therapy evaluation after a fall, but the evaluation and initiation of restorative services were delayed. Another resident, also with a history of stroke and hemiplegia, experienced a decline in function prior to discharge. The resident's representative reported that restorative nursing services were not offered or discussed as an option to help maintain function after therapy services ended. The care plan encouraged participation in activities to promote mobility, but there was no evidence that a restorative program was recommended or implemented by the nursing department after therapy discharge. Interviews with the DON and ADON confirmed that the facility had not had a restorative program for several months and was only able to offer meal assistance during that period. The lack of a functioning restorative program resulted in residents not receiving the necessary services to maintain or improve their mobility, as outlined in their care plans and recommended by the interdisciplinary team.
Failure to Timely Report Alleged Abuse and Sexual Misconduct
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and sexual misconduct involving residents to the State Agency as required by policy and regulation. Specifically, three separate incidents involving physical and sexual abuse among residents were not reported within the mandated timeframe. In one case, a resident with severe cognitive impairment was pinched by another resident, and although the incident was witnessed and documented, it was not reported to the State Agency until 22 days later, during the survey. The facility's own policy requires all such incidents to be reported to local, state, and federal agencies and thoroughly investigated, but this was not followed. Another incident involved a cognitively intact resident who reported being touched inappropriately by another resident during an activity. The resident expressed discomfort and stated that the touching continued even after he asked for it to stop. Despite the resident's clear statement that the contact was unwelcome and made him uncomfortable, the incident was not documented in the progress notes nor was there evidence of follow-up with the resident. The allegation of sexual abuse was not reported to the State Agency until 16 days after the event, only after surveyors inquired about it. A third incident involved a resident exposing himself to another resident, which was witnessed by staff and reported internally. The incident report and staff interviews confirmed that the behavior was sexually inappropriate and that the involved residents had histories of behavioral issues. However, the event was not reported to the State Agency until more than 24 hours after it occurred. In all cases, staff and leadership interviews revealed a lack of clarity and consistency in recognizing and reporting abuse allegations, with some staff and administrators minimizing the incidents or failing to initiate investigations and timely reporting as required.
Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents. In one incident, a resident reported being pinched on the leg by another resident while being pushed in a wheelchair. Although the incident was witnessed by a CNA and reported to nursing management, the facility's investigation did not include interviews with other staff or residents, nor did it assess whether other residents had experienced similar altercations or felt unsafe. The documentation lacked evidence of a comprehensive review as required by facility policy, which mandates thorough investigation steps including interviews and documentation of findings. In a separate incident, another resident reported that a fellow resident engaged in sexually inappropriate behavior by placing her hand under his shirt and continuing to touch him after being told to stop. The facility was unable to provide documentation of an investigation into this allegation, despite the resident expressing discomfort and concern about future interactions. Progress notes and care plans indicated a history of sexually inappropriate behaviors by the alleged perpetrator, but there was no evidence that the specific incident was investigated or that follow-up with the victim occurred. Interviews with staff and leadership revealed inconsistencies in the understanding and execution of abuse investigation protocols. The DON and NHA acknowledged that required documentation and risk management reports were not completed for the incidents. Staff interviews also indicated a lack of awareness or involvement in the investigation process, and the facility did not document or implement new care plan interventions in response to the reported behaviors. These actions and omissions resulted in a failure to respond appropriately to alleged violations as required by facility policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, as required by its abuse prevention policies. On the evening of 3/10/25, a resident with severe cognitive impairment and a history of being a victim of aggression was pinched on the leg by another resident, who also had severe cognitive impairment and a documented pattern of physical and verbal aggression. The incident was witnessed by a CNA while the aggressor was being transported in a wheelchair. The victim verbally expressed pain at the time of the incident, though no physical injury was observed during assessment. Prior to the incident, the care plan for the victim identified him as at risk for abuse due to developmental delay and previous victimization, with interventions directing staff to closely observe his interactions and to separate him from others during incidents of aggression. The aggressor's care plans documented a history of physical and verbal aggression, particularly in the afternoons and evenings, and included interventions such as behavior tracking, redirection, and medication management. Despite these documented risks and interventions, the aggressor was able to physically harm another resident during routine movement through the facility. Interviews with staff and other residents confirmed that the aggressor frequently exhibited aggressive behaviors, including yelling, pinching, and hitting both residents and staff. Staff were aware of the aggressor's behavioral patterns, especially the increase in aggression later in the day, but did not consistently intervene during observed episodes of aggression. The facility's response to the incident did not initially recognize the event as abuse, and there was a lack of formal documentation of increased monitoring or safety checks following the incident.
Failure to Provide Consistent Catheter Care and UTI Prevention
Penalty
Summary
The facility failed to consistently provide appropriate catheter care and services to minimize the risk of urinary tract infections for a resident with an indwelling Foley catheter and a history of recurring UTIs. During an observed episode of bowel incontinence, staff did not clean the resident's catheter or the insertion site, despite facility policy requiring such care to prevent infection. Interviews with staff revealed confusion regarding responsibilities for catheter care, with CNAs and nurses providing inconsistent information about who should perform catheter care and when it should be done. Documentation also showed that there was no physician's order for catheter care until 12 days after the resident's admission, and no evidence that catheter care or assessment of catheter patency was performed prior to that time. The resident's baseline care plan did not address the care of the indwelling catheter within 48 hours of admission, as required. The comprehensive care plan, initiated later, included interventions for catheter care, but these were not consistently implemented, particularly after episodes of bowel incontinence. Additionally, a hospice nurse documented improper placement of the catheter securement device, which resulted in pulling and irritation at the insertion site, and observed signs of infection such as redness, swelling, and purulent drainage. Medical records indicated that the resident developed a UTI, confirmed by urinalysis, after staff observed purulent and foul-smelling urine and a clogged catheter. The resident and their representative both expressed concerns about inconsistent catheter care and hygiene assistance, with the representative specifically worried that inadequate care contributed to the resident's recurrent UTIs. Staff interviews further highlighted a lack of clear communication and documentation regarding catheter care responsibilities and practices.
Failure to Address Nutritional Needs Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that two residents received the necessary care and services to meet their nutritional needs, resulting in significant weight loss. Resident #9, who was admitted with diagnoses including cerebral palsy and cerebellar ataxia, experienced a severe weight loss of 22.4 lbs (13.4%) over a period of less than six months. Despite the resident's documented risk for malnutrition and severe weight loss, the facility did not implement additional nutritional interventions. Observations revealed that Resident #9 was not offered additional food after consuming 100% of his meals, and the facility failed to offer snacks three times per day as ordered by the physician. Resident #65, admitted with chronic kidney disease and adult failure to thrive, also experienced weight loss, losing 19.6 lbs (7.3%) over less than six months. The registered dietician was unaware of this weight loss due to a cleared weight loss trigger in the resident's electronic medical record. Despite being assessed as malnourished, the facility did not implement nutritional interventions to address the resident's malnourishment. Observations indicated that Resident #65 received meals that were often cold, affecting her ability to consume them. Interviews with staff revealed a lack of awareness regarding the residents' weight loss and the absence of appropriate interventions. The registered dietician acknowledged the failure to implement additional nutritional interventions for Resident #9 and was unaware of Resident #65's weight loss. The director of nursing expected the dietician to identify residents experiencing weight loss and implement interventions, but this did not occur effectively. The facility's failure to monitor and address the nutritional needs of these residents led to significant weight loss and malnutrition.
Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as evidenced by several observations and interviews. Staff medications, specifically an insulin pen and glucose test strips, were improperly stored in the walk-in refrigerator alongside resident food without proper labeling or containment. The dietary manager admitted to storing the medication there due to a lack of alternative storage options and was unaware of the regulations prohibiting such practice. This oversight indicates a lack of adherence to the Colorado Retail Food Establishment Rules and Regulations, which require employee medications to be stored in a separate, labeled, and leakproof container. Additionally, the facility did not ensure that kitchen staff wore appropriate hair restraints while preparing and serving food. Observations revealed multiple instances where staff, including dietary aides and maintenance workers, were not wearing beard nets despite having facial hair longer than the regulatory threshold. The dietary manager was under the misconception that beard nets were only necessary for facial hair longer than one-quarter inch and was unaware that maintenance staff also needed to comply with this requirement. Furthermore, the air vent above the food service line was found to be covered in thick, black dust, which was being blown around by the air conditioning system during meal service. The dietary manager acknowledged the oversight and stated that the air conditioning was not supposed to be on during meal service, and he had not realized the extent of the dust accumulation.
Inadequate Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in implementing a water management plan to prevent the growth and transmission of Legionella. According to the CDC guidelines, dead legs and low flow piping runs should be flushed at least weekly, but the facility's policy only required biannual flushing. The maintenance logs showed that while some areas were flushed weekly, there was no documentation for flushing empty resident rooms, which had been unoccupied for seven or more contiguous days. Observations revealed that during room cleaning, the sink faucets were not flushed, as seen with Housekeeper #1, who did not turn on the sink while cleaning a specific room. Interviews with the Maintenance Director (MTD) and the Regional Maintenance Director (RMD) indicated a misunderstanding of the frequency required for flushing, as they believed biannual flushing was sufficient. The MTD also mentioned that housekeepers were not specifically instructed to flush sinks as part of their cleaning routine. The facility's water management plan did not align with CDC recommendations, leading to a deficiency in preventing the growth of Legionella. The lack of documentation and adherence to recommended flushing frequencies contributed to the facility's failure to maintain a safe and sanitary environment. The deficiency was further highlighted by the absence of specific instructions for housekeeping staff to flush sinks during cleaning, which was not documented as part of their routine tasks.
Deficiencies in Fall Prevention, Transfer Safety, and Smoking Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents for several residents. Resident #63 experienced multiple falls, both witnessed and unwitnessed, without timely updates to their fall care plan. Neurological assessments were not consistently performed according to the facility's protocol after these falls, which is crucial to monitor for potential head injuries. The facility's failure to adhere to its own policies and protocols regarding fall prevention and post-fall assessments contributed to these deficiencies. Resident #2 was involved in an unsafe transfer incident using a slide board, which resulted in a fall. The staff members involved were not adequately trained in using the slide board, and the resident expressed fear of using it again. The facility lacked documentation of staff education on slide board transfers, and the resident's transfer orders were not updated to reflect the safest method of transfer until after the incident. Resident #57 was not consistently monitored while smoking, despite being identified as requiring supervision due to safety concerns. The resident was observed smoking without a smoking apron and without staff supervision on multiple occasions. The facility's failure to enforce its smoking policy and ensure proper supervision and safety measures for residents who smoke contributed to the risk of accidents. Additionally, Resident #23's use of a transfer pole was not adequately supervised, posing potential safety risks.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to consistently serve food that was palatable and at appropriate temperatures, as required by their Food and Nutrition Services policy. This policy mandates that each resident receives a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs, with food served at a safe and appetizing temperature. However, multiple resident interviews revealed that meals were often served cold and lacked flavor. Specific complaints included cold mashed potatoes and chicken cordon bleu, with one resident noting that even after reheating, the food remained cold. A group interview with five residents further confirmed that meals were consistently served cold, regardless of whether they were eaten in rooms or the dining room. Observations during dinner service on a specific date showed that the test tray, which included chicken cordon bleu and Italian wedding soup, was not served at the appropriate temperature. The soup was found to be salty with undercooked vegetables, and the chicken was lukewarm. Staff interviews revealed that the dietary manager had to leave during meal service and did not taste the food prepared by the cook. The dietary manager acknowledged the issues with the soup and the need for better management of meal preparation. The nursing home administrator admitted awareness of the complaints and attributed them to high turnover in the kitchen, although improvements were noted with the current dietary manager.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of 10 residents who had orders for mechanically altered diet textures. These residents were not served food and fluids in accordance with their physician's orders, which specified the need for mechanically altered diets such as mechanical soft or pureed textures. The deficiencies were observed during meal service, where residents were served food items that did not meet the required texture modifications, such as regular rolls instead of soaked rolls and chicken pieces that were larger than the prescribed size. The report highlights specific instances where residents with dysphagia and other conditions requiring texture-modified diets were served inappropriate food textures. For example, a resident with a history of oral cancer and dysphagia was served regular Italian wedding soup and a regular dinner roll, contrary to the order for thickened soup and a soaked roll. Another resident with Alzheimer's disease and severe cognitive impairment was served chicken cordon bleu cut into pieces larger than the prescribed half-inch size and a whole regular roll instead of a soaked one. Interviews with staff revealed a lack of awareness and understanding of the diet manual and the specific requirements for mechanically altered diets. The dietary manager and cook were unaware of the precise size requirements for food pieces, and a dietary aide admitted to serving whole rolls because residents preferred them that way, regardless of their diet orders. This lack of adherence to prescribed diet textures poses a risk of choking and highlights a significant deficiency in the facility's dietary services.
Failure to Ensure Proper Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored, specifically regarding the selection or refusal of life-saving treatments by a proxy. The deficiency involved a resident over the age of 65, who was admitted with diagnoses including vascular dementia, atrial fibrillation, stroke, and anxiety. The resident was severely cognitively impaired, with a BIMS score of zero, indicating a lack of decision-making capacity. A proxy was appointed to make decisions on behalf of the resident. However, the proxy declined artificial nutrition without the required supporting documentation from a physician and a neurologist, as stipulated by the Medical Orders for Scope of Treatment (MOST) form. Interviews with facility staff revealed a lack of understanding regarding the legal limitations of a proxy's authority. The Social Services Director (SSD) and the Director of Nursing (DON) were unaware that a proxy could not decline artificial nutrition without the necessary physician documentation. The Nursing Home Administrator (NHA) acknowledged that the MOST form needed to be updated to reflect only the decisions the proxy could legally make. This oversight resulted in the facility's failure to comply with the requirements for advance directives, as the proxy's decision to decline artificial nutrition was not supported by the required medical documentation.
Failure to Maintain and Document Respiratory Care for Residents
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for two residents who required the use of CPAP/BiPAP machines. The care plans for these residents did not include specific goals or interventions related to the use of these machines, nor did they document the residents' use of oxygen therapy. This lack of documentation and planning contributed to inadequate maintenance and cleaning of the respiratory equipment. Resident #32, who had diagnoses including COPD, obstructive sleep apnea, and respiratory failure, reported that the nursing staff did not clean her CPAP machine, leaving her to do it herself without proper supplies. Observations revealed that her CPAP machine and accessories were not maintained according to the manufacturer's recommendations, with visible dust and stains on the equipment. Similarly, Resident #70, who had COPD and heart failure, was unable to clean his BiPAP machine due to limited dexterity and lacked the necessary supplies to do so. His equipment was also found to be exposed to potential contaminants. Interviews with facility staff indicated a lack of clarity and responsibility regarding the maintenance of CPAP/BiPAP machines. The night shift nurses were believed to be responsible for cleaning the machines, but there was no consistent practice in place. The Director of Nursing stated that the respiratory provider was supposed to manage the equipment, but it was unclear if this was being done effectively. This lack of coordination and oversight resulted in the failure to maintain the residents' respiratory equipment in a hygienic manner.
Failure to Implement Pneumococcal Vaccination Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding pneumococcal vaccinations for two residents, leading to a deficiency. According to the CDC's recommended immunization schedule, individuals over the age of 65 should receive a pneumococcal vaccination if they lack documentation of prior vaccination or evidence of past infection. Resident #28, who was over 65 and had no cognitive impairments, was not offered a pneumococcal vaccination until the day of the survey, despite the absence of documentation indicating prior vaccination. Similarly, Resident #43, also over 65 and with severe cognitive impairment, was documented to have received a pneumococcal vaccination on a specific date, but there was no evidence in the electronic medical record to support this. The resident had previously received a different pneumococcal vaccine years earlier, but there was no updated vaccination record or consent obtained before the survey date. The facility's failure to offer the vaccination in a timely manner was confirmed during staff interviews. Interviews with the infection preventionist and the director of nursing revealed that the facility's process involved reviewing vaccination consents and declinations annually in October. However, due to the infection preventionist's recent access to the state immunization system, the process was not completed for Residents #28 and #43 before the survey. Both staff members acknowledged that the residents should have been offered the pneumococcal vaccination prior to the survey date, in accordance with CDC recommendations.
Neglect of Resident Due to Inadequate Call Light Access
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by an incident where a certified nurse aide (CNA) left the resident unattended without access to a call light. The resident, who had a diagnosis of anxiety disorder and was dependent on staff for all activities of daily living, was left in her wheelchair near the bathroom after a shower. The CNA did not inform the resident that she would be back or why she was leaving, and the call light was left approximately eight feet away, out of the resident's reach. The resident began to feel afraid and started yelling for help, and it took 20 minutes for a family member to arrive and find her crying and upset before seeking assistance from another staff member. Additionally, the facility's records revealed that the resident's call light had been on for 15 minutes or more on multiple occasions between March and May, with some instances exceeding 20 minutes. The care plan for the resident indicated that she required extensive assistance with various activities and was encouraged to use the call bell for help. However, the facility's failure to ensure timely response to the call light and to keep it within the resident's reach led to the resident feeling abandoned and neglected. Interviews with staff members confirmed the resident's account of the incident and highlighted the importance of having the call light within reach for residents, especially those who are not mobile. The facility's executive director acknowledged that residents should have their call lights within reach at all times and mentioned that management staff conducted rounds to check on this. Despite these measures, the incident on May 3rd and the repeated delays in responding to the call light demonstrated a significant lapse in the facility's duty to protect the resident from neglect.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grand Junction
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Larchwood Health And Rehab Llc | 1.1 mi | — | 5 | 0 |
| Red Cliffs Post Acute | 1.1 mi | — | 1 | 0 |
| Eagle Ridge Post Acute | 1.3 mi | — | 4 | 1 |
| La Villa Grande Care Center | 1.6 mi | — | 1 | 1 |
| Center At Foresight Llc, The | 3.2 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.