GRAND JUNCTION, CO - Federal health inspectors found that Mantey Heights Rehabilitation & Care Center failed to adequately protect vulnerable residents from physical and sexual abuse by a fellow resident with dementia, according to a complaint inspection conducted in April 2025.
Pattern of Aggressive Behavior Goes Uninvestigated
The most serious violations centered around a resident with severe dementia who engaged in multiple incidents of physical aggression and inappropriate sexual contact with other residents. Despite documented care plans acknowledging this resident's history of "physical and verbal behavioral symptoms directed at others" that "put them at risk for physical injury," the facility failed to conduct proper investigations when incidents occurred.
On March 10, 2025, the aggressive resident pinched another resident's leg during a witnessed altercation. The victim, who uses a wheelchair due to cerebral palsy and has severe cognitive impairments, reported the incident to staff. While nursing assistants asked the aggressor to apologize, no formal investigation was conducted despite facility policies requiring thorough review of potential abuse allegations.
Six days later, on March 16, 2025, the same aggressive resident engaged in unwanted sexual contact with another resident during an activity. The victim, who was cognitively intact, reported that the aggressor "put her hand under his shirt" and moved it "down his shirt and up against his side by his ribs" in a tapping motion. When he told her to stop, she reportedly responded "you know you like it" and continued the contact for several minutes until staff intervened.
The facility's own documentation noted this resident had a care plan specifically tracking "sexually inappropriate behaviors" and requiring staff to "draw boundaries, redirect her hands" and provide "safe interactions with others." Records showed multiple incidents of inappropriate touching of staff members between January and March 2025.
Investigation Failures Create Safety Risks
Despite clear documentation of the March 16 incident in the resident's medical record, facility administrators failed to conduct any formal investigation. When questioned by federal inspectors, the nursing home administrator initially claimed the incident "did not rise to the level of abuse because the resident just touched his arm." However, the victim's detailed account described contact under clothing that continued despite verbal objections.
The facility's Director of Nursing acknowledged that "non-consensual touch could be considered sexual abuse" and that incidents where residents indicate unwelcome contact "by words, such as no or do not touch me, could be considered sexual abuse." She admitted no risk management report was completed and stated "now that she had dug more into the situation, she now felt the incident was a concern."
This investigative failure violated federal regulations requiring nursing homes to thoroughly investigate all allegations of abuse and report confirmed cases to state authorities within 24 hours. The lack of proper investigation left other residents at continued risk from a resident with documented aggressive behaviors.
Medical Consequences of Inadequate Protection
The failure to properly address aggressive behaviors in dementia care creates significant medical and psychological risks for vulnerable residents. Residents with cognitive impairments, physical disabilities, or trauma histories are particularly susceptible to harm from untreated aggressive behaviors.
Physical aggression between residents can result in injuries, falls, and psychological trauma that may worsen existing medical conditions. For residents with conditions like cerebral palsy or Parkinson's disease, even minor physical contact can cause pain or mobility issues. The facility's records showed the pinching victim had "contracture of the right and left lower leg muscles" and used a wheelchair for mobility, making him particularly vulnerable to physical aggression.
Sexual abuse creates additional trauma risks, especially for residents with intact cognition who understand the inappropriate nature of unwanted contact. The March 16 victim reported feeling "very uncomfortable" and "very wary" around the aggressor, indicating lasting psychological impact. He specifically stated he "did not want to be around her" and expressed concern about future encounters.
Proper dementia care requires comprehensive behavioral management plans that protect both the resident with dementia and others in the facility. When facilities fail to implement adequate supervision and intervention strategies, aggressive behaviors typically escalate rather than improve. The facility's own staff noted the aggressive resident's behaviors had "continued to progress" after the initial incidents.
Catheter Care Deficiencies Risk Serious Infections
Inspectors also identified significant failures in infection control related to catheter care for a resident with neurological bladder dysfunction following a stroke. The resident had an indwelling urinary catheter due to his inability to urinate normally, requiring daily cleaning to prevent life-threatening infections.
Direct observation revealed that nursing assistants failed to clean the resident's catheter or insertion site after he experienced bowel incontinence, despite facility policies requiring cleaning "from the insertion site to approximately four inches outward" to prevent complications. The resident confirmed that staff "cleaned his catheter sometimes, but did not clean his catheter daily."
This inadequate care contributed to a urinary tract infection requiring antibiotic treatment in March 2025. Hospital records from the hospice registered nurse documented "purulent drainage," "redness, swelling, and discharge around the catheter insertion site," and "blood-tinged and foul smelling urine" - all indicators of serious infection.
Catheter-associated urinary tract infections represent one of the most common healthcare-associated infections and can lead to sepsis, kidney damage, and death if untreated. Proper catheter care requires cleaning after each episode of incontinence and daily assessment for signs of infection. The facility's failure to maintain these basic infection control measures placed the resident at unnecessary medical risk.
Staff Training and Communication Gaps
The violations revealed systemic issues with staff training and communication about abuse prevention and medical care protocols. Multiple staff members provided conflicting information about their roles and responsibilities for catheter care, with some believing nurses were solely responsible while others understood it was a shared duty.
Regarding abuse investigations, staff demonstrated unclear understanding of reporting requirements and investigation procedures. The facility's physician was only notified "one to two days after the incident occurred" rather than immediately, and received incomplete information about what actually happened.
The nursing home administrator acknowledged these gaps, telling inspectors "the facility needed to continue to train the staff on abuse" and "needed to do a better job with investigating alleged abuse." He committed to implementing better notification procedures and investigation protocols.
Additional Issues Identified
Federal inspectors noted several other concerns during the complaint investigation:
Care Plan Deficiencies: The catheter-dependent resident's initial care plan failed to include catheter care instructions within the required 48-hour timeframe after admission, and no physician orders for catheter care were documented until 12 days post-admission.
Documentation Gaps: The facility lacked proper documentation systems for tracking catheter care completion by nursing assistants, making it impossible to verify whether required care was provided.
Supervision Concerns: Despite implementing "increased rounding and safety checks" on the aggressive resident after the first incident, these measures were neither formal nor documented, limiting their effectiveness.
Family Communication: The aggressive resident's family reportedly struggled to find alternative placement due to her behavioral issues, indicating the need for specialized dementia care resources.
The inspection findings highlight critical gaps in resident protection and medical care that federal regulations require nursing homes to address through comprehensive corrective action plans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mantey Heights Rehabilitation & Care Center from 2025-04-02 including all violations, facility responses, and corrective action plans.
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