Mantey Heights Rehabilitation & Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

A complaint survey, prompted by #CO39809 and #CO40187 was conducted on 6/10/25 to 6/11/25. Three deficiencies were cited. Based 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. Findings include:I. Facility policy and procedure The Release of Information policy, revised November 2009, was provided by the director of nursing (DON) on 6/11/25 at 6:05 p.m. The policy read in pertinent part, "The resident may initiate a request to release such information contained in his or her records and charts to anyone he or she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative. "A resident may obtain photocopies of his or her records by providing the facility with at least a 48 hour advance notice of such request." II. Residents' representative interviewsResident #2' s representative was interviewed on 6/10/25 at 4:13 p.m. The representative said she requested Resident #2 medical records at the end 2024 and it took a week for the facility to provide them to her. She said she felt the medical records should have been provided to her within a couple days. She said she called the former social service director (SSD) a couple times to remind the facility of the request befor.. Based 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. Findings include:I. Facility policy and procedureThe Functional Impairment policy, revised September 2012, was provided by the director of nursing (DON) on 6/11/25 at 6:05 p.m. The policy read in pertinent part, "Upon admission to the facility, at any time a significant change of condition occurs, and periodically during the resident' s stay, the physician and staff will assess the resident' s physical condition and functional status."A physician, nurse or therapist may initiate screening for the potential to benefit from rehabilitation services such as physical and occupational therapy. "Following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation from unskilled therapy, as for example restorative nursing services that can be provided by caregivers or exercises with w..

A complaint survey, prompted by #CO39555, #CO39589, and #CO39686 was conducted on 4/1/25 to 4/2/25. Five deficiencies were cited. Based 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. Findings include:I. Facility policy and procedureThe Catheter Care policy, revised August 2022, was provided by the director of nursing (DON) on 4/2/25 at.. Based 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.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 4/2/25 at 3:34 p.m. The policy read in pertinent part, "All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly inves.. Based 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. Findings include:I. Facility policy and procedure The Antipsychotic Medicatio.. Based 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. Findings include:I. Facility policy and procedureThe Abuse, Ne.. Based 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.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation-Investigating and Reporting policy, revised September 2022, was provided by the director of nursing (DON) on 4/2/25 at 3:34 p.m. The policy read in pertinent part, "All reports of resident abuse, ne..

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This facility, licensed for eighty-eight (88) beds and having 43 resident rooms, is a single-story, 28,066 sq ft type V(000) structure with a partial basement and partial crawl space. The basement contains storage, multi-us.. Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Weekly/Monthly: Done in-house; need to add control valves to checklist2) Annual: 2.20.24 Pye-Barker+Report shows a green tag even though it has impairments+Report not showing accurate device count summary; FACP report shows possible 15 supervisory d.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by: 1) Fire alarm system upgraded communications without a permit; a permit is required for system upgrades that are not defined as maintenance. NFPA 101 19.3.4.1 General. Healthcare occupancies shall be provided with a fire alarm system in accordance with Se.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 80. This was evidenced by: 1) Fire Doors (annually)(80 5.2): A report from 11.27.24 indicates that the kitchen rolling door has a battery failure and needs to be replaced. Parts on order.2) Room 46 door not latching3) The bio laundry door needs to have closure speed up in order to latch properlyNFPA 101.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:1) The fire damper in monument dining is wired tied open2) fire dampers have been missed during inspection; need newly updated damper report to reflect 100% of all dampersNFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipmen.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Generator fuel quality (annually) (110 8.3.8): Not Provided2) Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Not done per NFPA 110 StandardsNFPA 110 8.3.8 A fuel quality test shall be performed at least annuallyUsing tests approved by ASTM sta.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) kitchen appliance missing gas cableNFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installation.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) The oxygen trans-filling room needs mechanical ventilation 0-12" from the floor and signage on the door.NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.NFPA 99 11.5.2.3.1Transfilling to liquid oxy..