Mantey Heights Rehabilitation & Care Center

F-F600 failure to protect Resident #7 from physical abuse.

B. Resident #7 (victim)

1. Resident status

Resident #7, age greater than 65, was admitted on [DATE REDACTED]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified disorder of psychological development, lack of coordination, difficulty in walking, unqualified vision loss in the left eye, cerebral palsy, cerebellar ataxia (movement disorder, reduced mobility, dependence on a wheelchair, weakness and contracture of the right and left lower leg muscles.

The 2/4/25 minimum data set (MDS) assessment documented Resident #7 had severe cognitive impairments with a brief interview of mental status (BIMS) score of seven out 15. The resident presented with inattention and disorganized thinking. The MDS assessment indicated Resident #7 did not exhibit verbal, physical or other behavioral symptoms directed towards others. He had upper extremity impairment to one side and lower extremity impairment to both sides. He used a manual wheelchair for mobility.

2. Record review

The 3/10/25 alert note documented Resident #7 reported that another resident (Resident #3) pinched his leg.

The note indicated the resident's left thigh was assessed and there was no redness, bruising or open areas identified. According to the note, Resident #7 said his leg no longer hurt but it did at the time of the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The 3/17/25 IDT (interdisciplinary team) note documented the IDT met and reviewed the physical aggression incident involving Resident #7. The note identified Resident #7 often sat in his wheelchair in his room Level of Harm - Minimal harm or doorway or in the hall near his room. He had some difficulty communicating with other residents which may potential for actual harm have led to intermittent tension. Resident #7 was reminded to ask staff for help when needed and to keep the halls clear when possible. The note indicated the resident often blocked the hallway with his wheelchair while Residents Affected - Some visiting with others. The IDT note indicated his care plan was updated.

C. Resident #3 (assailant)

1. Resident status

Resident #3, age greater than 65, was admitted on [DATE REDACTED]. According to the April 2025 CPO, diagnoses included unspecified dementia, and specified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.

The 2/27/25 MDS assessment documented Resident #3 had severe cognitive impairments with a BIMS score of two out 15. The resident presented with inattention and disorganized thinking. According to the MDS assessment, she did not have an upper extremity impairment and was able to propel her manual wheelchair for short and long distances.

The MDS assessment indicated Resident #3 had physical and verbal behavioral symptoms directed at others. The MDS assessment identified her behaviors impacted others and put them at risk for physical injury.

2. Record review

The behavior care plan, initiated 3/17/25, revealed Resident #3 may become physically

and/or verbally aggressive towards staff and others due to poor impulse control, dementia and history of harm to others. The care plan identified Resident #3 could be physically aggressive towards others, usually due to sundowning (increased confusion later in day and or evening). According to the care plan, staff should attempt to redirect the behavior.

The 3/10/25 alert note for Resident #3 documented there was a witnessed physical altercation between Resident #3 and Resident #7 on 3/10/25. According to the note, the CNA asked the resident to apologize

after Resident #3 pinched Resident #7 on the leg. Resident #3 apologized and then Resident #3 was assisted to her room.

The 3/20/25 interdisciplinary note (IDT) note documented Resident #3 lacked impulse control, experienced cognitive decline related to disease process and required frequent redirection during episodes of verbal and physical aggression.

D. Additional resident interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Resident #11 was interviewed on 4/1/25 at 11:12 a.m. She said there was a resident who yelled all the time

in the dining room. She said recently the resident entered her room and started yelling at her. Resident #11 Level of Harm - Minimal harm or identified the resident as Resident #3. Resident #11 said staff were aware that Resident #3 was yelling at her potential for actual harm in her room.

Residents Affected - Some III. Allegation of sexual abuse between Resident #8 and Resident #3 on 3/16/25

A. Facility investigation

A request was made for the facility's investigation after an allegation of sexual abuse was documented in Resident #3 progress notes on 3/16/25 (see record review below).

-The facility was unable to provide documentation indicating the sexual abuse allegation documented in Resident #3's electronic medical record (EMR) was investigated.

B. Resident #8 (victim)

1. Resident status

Resident #8, age greater than 65, was admitted on [DATE REDACTED]. According to the April 2025 CPO, diagnoses included Parkinson's disease without dyskinesia, anxiety disorder, major depressive disorder, abnormalities of the gate and mobility, weakness and unsteadiness on his feet.

The 2/12/25 MDS assessment documented Resident #8 was cognitively intact with a BIMS score of 13 out of 15. He required partial to moderate staff assistance with transfers from surface to surface and bed mobility.

He used a manual wheelchair for mobility. Resident #8 did not exhibit behaviors directed at others.

2. Resident #8 interview

Resident #8 was interviewed on 4/2/25 at 1:58 p.m. Resident #8 said Resident #3 was sitting next to him in

an activity on 3/16/25 when she put her hand under his shirt. Resident #8 said Resident #3 put her hand in

the sleeve of his t-shirt and proceeded to move her hand down his shirt and up against his side by his ribs. Resident #8 said Resident #3 started to move her fingers in a tapping fashion. He said he told her to stop but

she continued even after he told her to stop. He said Resident #3 continued to touch him in this manner for a couple minutes until the staff came over and stopped it. Resident #8 said the incident made him very uncomfortable. He said he felt Resident #3 was inappropriate towards him. He said he did not want to be around her and it would be uncomfortable if he was near her again. Resident #8 said Resident #3 came into his room last night (4/1/25) and was sitting by his bathroom until the staff removed her. He said he was very wary of doing anything because she had touched him before. He said he had also seen that she had very aggressive behaviors and hit and pounded on things with her fists.

3. Record review

The trauma care plan, initiated 5/6/24, identified Resident #8 was at risk for side effects of trauma. The 5/22/24 intervention directed staff to draw connections among the resident's history of trauma and subsequent consequences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 -Review of Resident #8's progress notes did not identify documentation of the 3/16/25 incident or facility follow-up with Resident #8 after the incident. Level of Harm - Minimal harm or potential for actual harm C. Resident #3 (assailant)

Residents Affected - Some 1. Record review

The depression care plan intervention for Resident #3, initiated 1/28/25, directed staff to track her sexually inappropriate behaviors.

The psycho-social care plan, revised 1/20/25, identified Resident #3 was semi-dependent on staff for meeting her emotional, intellectual, physical, spiritual and social needs. According to the care plan, Resident #3 could be very sexually inappropriate. The 1/31/25 care plan invention directed staff to draw boundaries, redirect her hands, offer her a task to help and redirect her to a conversation so she could have safe interactions with others.

The review of Resident #3's progress notes identified the resident had multiple incidents of sexually inappropriate behaviors, including touching staff inappropriately, between 1/29/25 and 3/15/25.

The 3/16/25 behavior note documented Resident #3 was observed touching another resident inappropriately. According to the note, the other resident (Resident #8) reported that Resident #3 stroked his arm and side. When Resident #8 asked her to stop, she responded with you know you like it. The note indicated Resident #3 was then redirected with an activity.

-However, the facility did not investigate Resident #3's sexually inappropriate behavior towards Resident #8

on 3/16/25.

D. Other resident interviews

Resident #12 and Resident #13 were interviewed together on 4/1/25 at 11:25 a.m. Resident #12 said there was a resident that was always yelling. Resident #12 said resident would pinch other residents.

Both Resident #12 and Resident #13 denied being touched by Resident #3 but said they had seen it happen to other people. They said the other resident inappropriately touched staff and other residents.

IV. Staff interviews

Registered nurse (RN) #2 was interviewed on 4/1/25 at 4:40 p.m. RN #2 said Resident #3 had a history of inappropriate sexual behaviors but it was usually directed at staff. She said she was not aware of incidents involving other residents. She said Resident #3 was difficult to redirect after her inappropriate sexual behaviors because Resident #3 did not think her behavior was wrong. RN #2 said Resident #3's representative said she had inappropriate sexual behaviors since she was diagnosed with dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 CNA #3 was interviewed on 4/2/25 at 9:30 a.m. CNA #3 said Resident #3 was pretty calm and was easier to redirect and more cognizant in the mornings. She said her behaviors usually increased after 2:00 p.m. and Level of Harm - Minimal harm or she was harder to redirect. She said Resident #3 had physical and sexual behaviors. CNA #3 said Resident potential for actual harm #3 had sexual behaviors directed toward staff and residents. She said she had not seen the sexual behavior towards residents herself but had been told it was a behavior. She said Resident #3 did not target one Residents Affected - Some particular resident. She said when Resident #3 had inappropriate behaviors, staff would separate them and would try to redirect Resident #3 to an activity.

The nursing home administrator (NHA) was interviewed on 4/2/25 at 10:25 a.m. The NHA said abuse prevention started with making sure staff was appropriately trained to help prevent abuse occurrences. He said all potential abuse allegations should be investigated and reported.

The NHA was interviewed again on 4/2/25 at 12:02 p.m. The NHA said the 3/16/25 incident between Resident #3 and Resident #8 was investigated by the nurse manager (NM). The NHA said the incident did not rise to the level of abuse because Resident #8 said Resident #3 just touched his arm.

-However, Resident #8 said Resident #3 put her hand under Resident #8's shirt (see Resident #8's interview above).

The NM was interviewed on 4/2/25 at 12:20 p.m. The NM said she was the nurse manager a few days a week. She said if an incident occurred on her weekend shift, she would make sure the floor nurse documented the incident in a note and would look at the risk management process.

The NM said on 3/16/25 the floor nurse, licensed practical nurse (LPN) #3 reported to her that another staff member told LPN #3 they either witnessed or heard that Resident #3 touched Resident #8 and Resident #3 was told to stop. The NM said LPN #3 spoke to Resident #8 after the incident. She said LPN #3 told her Resident #8 said Resident #3 was touching his arm, he told her to stop and Resident #3 asked him if he liked it.

The NM said her role related to the investigation was to talk to LPN #3, direct her to write a progress note and report the incident to the DON. The NM said she completed no documentation and was not involved in any other part of the investigation. The NM said she did not usually do anymore in an investigation other than just oversight of the situation when she was the nurse manager on duty. She said the DON or the NHA did

the full investigation.

The social services designee (SSD) was interviewed on 4/2/25 at 10:30 a.m. The SSD said she had not been part of any investigations but was aware of Resident #3's inappropriate sexual behaviors toward staff.

She said she was not aware of any incidents involving residents. She said Resident #3 tended to reach out and grab staff inappropriately. The SSD said she had displayed as many sexual behaviors in the past month since she was admitted to hospice services. She said the staff had been instructed to hold her hand when

she tried to reach for them. She said she felt Resident #3 just needed a human touch. She said Resident #3's family decided they were going to move her closer to other family members to help with her behaviors, but the family and the facility had had difficulty finding another facility because of Resident #3's behaviors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The DON was interviewed on 4/2/25 at 12:51 p.m. She said allegations of abuse should be reported to the nurse, nurse leadership, including the DON, and the NHA should be alerted. She said the facility talked with Level of Harm - Minimal harm or staff and to find out what happened. The DON said if the incident was an abuse allegation, it should be potential for actual harm reported to the State Agency within 24 hours. She said a reportable sexual abuse allegation would be reported if it was determined that there was a inappropriate touch to a resident and if the resident who was Residents Affected - Some touch did not consent. The DON said non-consentual touch could be considered sexual abuse. She said if a resident touched another resident and indicated it was not welcomed by words, such as no or do not touch me, it could be considered sexual abuse.

The DON said she did not have the investigation for the 3/16/25 investigation involving Resident #3 and Resident #8 but the NHA might have it. She said the NM spoke to LPN #3, Resident #3 and Resident #8

after the incident. The DON said a risk management report should have been completed after the 3/16/25 incident but she could not find one.

The DON said, based on what Resident #8 reported the NM, she felt that the 3/16/25 incident was not an allegation of sexual abuse because there was not a concern of sexual contact. She said she could assume that was why a risk management report was not done.

The DON said when there was a allegation of sexual abuse, the staff would review the resident's chart to look for similar behaviors. She said Resident #3 had a history of sexual behaviors towards staff. The DON said the physician was aware of the behaviors. She said the behaviors were tracked and reviewed in IDT and the medication review meeting.

Physician (PHY) #1 was interviewed on 4/2/25 at 2:55 p.m. PHY #1 said she was the physician for Resident #3. She said during her rounds at the facility, she was told Resident #3 was inappropriate with another resident (Resident #8). She said the incident was reported to her one to two days after the incident occurred.

She said she was not told what happened so she reviewed the chart and learned Resident #3 touched a male resident's arm and chest in his room and staff had to remove her.

PHY #1 said she was told Resident #3 pinched the leg of another resident. She said anytime there was a new behavior, she and the facility would assess the behavior and the facility would update the care plan. PHY #1 said she would make recommendations. She said it was determined to continue Resident #3 with her current medications because hypersexual behavior was a normal behavior and could be expected with Alzheimer's dementia.

The DON was interviewed again on 4/2/25 at 3:47 p.m. The DON said she reviewed the available documentation and the facility did not have an investigation for the 3/16/25 incident between Resident #3 and Resident #8.

The NHA was interviewed again on 4/2/25 at 4:25 p.m. The NHA said after Resident #3 pinched Resident #7, the facility did a risk management review and felt the incident did not rise to the level of abuse. He said

the pinching did occur but there was no potential for harm. The NHA said Resident #7 said ouch when he was pinched. He said the resident may have said ouch out of a response to the pinching but it might not have indicated he was in pain.

The NHA said an investigation was not documented for the 3/16/25 incident between Resident #3 and Resident #8.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 The NHA said he would write out an investigation today (4/2/25).

Level of Harm - Minimal harm or The NHA said the facility needed to continue to train the staff on abuse. He said the facility would work on potential for actual harm notifying

Residents Affected - Some PHY #1 after an incident. The NHA said the facility needed to do a better job with investigating alleged abuse.

The DON was interviewed a third time on 4/2/25 at 5:08 p.m. The DON said Resident #3 pinched Resident #8 on the leg and he said ouch. She said the incident was a resident-to-resident altercation. She said the IDT reviewed the incident and determined the pinching was intentional. The DON said after the 3/10/25 incident,

the facility implemented increased rounding and safety checks on Resident #3. She said the checks were not formal or documented. She said prior to the 3/10/25 resident-to-resident altercation, staff were not concerned about Resident #3's behaviors as a safety risk to other residents. The DON said since 3/10/25, Resident #3's behaviors had continued to progress. She said the staff were now more aware and observant.

The DON said Resident #3 did not have any new care plan interventions for sexual behaviors towards residents after the 3/16/25 incident because she and the NM did not think the incident was sexually inappropriate. The DON said now that she had dug more into the situation, she now felt the incident was a concern. She said that was why it was important to do a thorough investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52513

Residents Affected - Few 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 procedure

The Catheter Care policy, revised August 2022, was provided by the director of nursing (DON) on 4/2/25 at 5:40 p.m. It read in pertinent part,

The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.

Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from

the insertion site to approximately four inches outward.

Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site.

II. Resident #2

A. Resident status

Resident #2, age less than 65, was admitted on [DATE REDACTED]. According to the April 2025 computerized physician orders (CPO), diagnoses included stroke affecting the right dominant side, neuromuscular dysfunction of the bladder, sepsis and type 2 diabetes.

The 2/25/25 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) score of nine out of 15. He was dependent with toileting, bathing, dressing, and personal hygiene. He required assistance with setup to eat and complete oral hygiene.

B. Observation

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 On 4/1/25 at 11:34 a.m. Resident #2's incontinence care was observed. Certified nurse aides (CNA) #1 and CNA #2 entered the resident's room to provide care. CNA #2 assisted the resident onto his side while CNA Level of Harm - Minimal harm or #1 cleaned the resident following an episode of bowel incontinence. potential for actual harm -During the incontinence care, CNA #1 did not clean the resident's indwelling catheter or the catheter's Residents Affected - Few insertion site, despite the fact that Resident #2 had been incontinent of bowel.

C. Resident and resident representative interviews

Resident #2 was interviewed on 4/1/25 at 10:02 a.m. Resident #2 said staff cleaned his catheter sometimes, but he said staff did not clean his catheter daily.

Resident #2's representative was interviewed on 4/1/25 at 2:46 p.m. The resident's representative said she attended a care conference with the facility and the hospice agency on 3/18/25. She said they discussed the provision of hygiene assistance because she was concerned that the facility was not providing Resident #2 sufficient hygiene assistance and she was concerned that he had another UTI due to lack of consistent catheter care. The representative said Resident #2 had occasionally refused care, so she was not sure how

they ensured proper catheter care was being completed for the resident.

D. Record review

The history and physical exam, completed 2/20/25, indicated the clinical justification for Resident #2's indwelling catheter was for neurogenic bladder dysfunction after suffering a stroke and failed voiding trials in

the hospital prior to his admission to the facility. The exam indicated the resident had an indwelling catheter

on admission to the facility that had clear yellow urine without discharge. The physician recommended continued management of the indwelling catheter in the admission assessment.

-However, Resident #2's baseline care plan failed to document a care plan focus to address the care of the resident's indwelling catheter within 48 hours after the resident's admission to the facility.

Review of Resident #2's comprehensive care plan, initiated 3/2/25, revealed the resident had an impaired urinary elimination pattern due to a neurogenic bladder diagnosis. Interventions included providing indwelling catheter care each shift and as needed and securing the catheter with a securement device without pulling

on the catheter.

-However, the facility did not provide catheter care as needed appropriately after bowel incontinence (see

observation above).

-Additionally, per the hospice registered nurse's (HRN) 3/9/25, nursing note, the securement device for the catheter was placed incorrectly (see note below).

-Review of Resident #2's March 2025 treatment administration record (TAR) did not document a physician's order for catheter care until 3/2/25, 12 days after the resident's admission to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -Additionally, there was no documentation that nursing staff were assessing the catheter's patency (flow) or performing indwelling catheter care prior to 3/2/25. Level of Harm - Minimal harm or potential for actual harm The progress note, dated 3/9/25 at 7:18 a.m. documented an observation of purulent drainage thick, cloudy drainage) from Resident #2's indwelling catheter. Residents Affected - Few

The HRN note, dated 3/9/25, documented an observation of redness, swelling, and discharge around the resident's catheter insertion site. The note documented a concern that Resident #2's catheter was pulled to

the side due to inappropriate placement of the securement device that held the catheter in place in line with

the resident's anatomy (body). The HRN cleaned the area and readjusted the placement of the catheter tubing and securement device, so that it was not pulling on Resident #2's genitals at the insertion site.

The facility progress note, dated 3/10/25, documented the HRN changed the indwelling catheter because the catheter was clogged.

The HRN's progress note, dated 3/10/25, documented an observation of blood-tinged and foul smelling urine from Resident #2's indwelling catheter. The HRN requested the facility complete a urinalysis (UA) to assess for a possible infection.

The UA results, dated 3/11/25, documented that Resident #2's urine tested positive for bacteria, indicating

the resident had acquired a UTI.

-The facility obtained new physician's orders for antibiotics to treat a UTI on 3/12/25.

The March 2025 CPO documented the resident was prescribed Ciprofloxacin 250 milligrams (mg) twice a day, starting 3/12/25 with an end date of 3/15/25.

III. Staff interviews

Licensed practical nNurse (LPN) #1 was interviewed on 4/1/25 at 11:11 a.m. LPN #1 said the nurse on the unit was assigned to do daily catheter care. He said the CNAs should also clean the catheter if it was leaking or the resident was incontinent.

CNA #1 was interviewed on 4/1/25 at 12:02 p.m. CNA #1 said the CNAs provided incontinence care and that

the nurse provided Foley catheter care. She said she thought the nurses provided catheter care once a shift but she was not sure. She said she would ask the nurse for help if she found the catheter was leaking or looked infected.

Registered nurse (RN) #1 was interviewed on 4/1/25 at 12:58 p.m. RN #1 said the CNAs were supposed to provide catheter care when they changed the resident or provided incontinence care, but said he also provided catheter care whenever a catheter appeared soiled. He said the CNAs did not always tell him if they did the catheter care and that there was no place for them to chart if they did or did not provide the care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 065307 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065307 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mantey Heights Rehabilitation & Care Center 2825 Patterson Rd Grand Junction, CO 81506

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 The HRN was interviewed on 4/2/25 at 9:12 a.m. The HRN said she went to the facility on [DATE REDACTED] to assess Resident #2 after the facility reported the resident's catheter had purulent drainage and foul smelling urine. Level of Harm - Minimal harm or The HRN said she observed that the resident's skin around the urethra was red, irritated and had discharge. potential for actual harm She said she changed the catheter at that time and implemented new orders with the facility to keep the catheter flowing and test for a UTI. The HRN said she reminded the facility staff to provide catheter care Residents Affected - Few following each episode of fecal incontinence and to bathe Resident #2 per the bathing agreement between hospice and facility staff.

The DON was interviewed on 4/2/25 at 1:50 p.m. The DON said she attended a care conference for Resident #2 on 3/18/25. She said she remembered they discussed Resident #2 refusing care and how to reapproach him for care. She said they also discussed ways to communicate more effectively with hospice as to who was providing what type of care and on what day the care was to be provided.

The DON was interviewed a second time on 4/2/25 at 5:15 p.m. The DON said she expected her staff to provide catheter care when completing incontinence care for bowel movements in order to reduce the risk for infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 065307