Mantey Heights Rehabilitation & Care Center

In the surveyor’s words

From the most serious findings on record at Mantey Heights Rehabilitation & Care Center, in the surveyor’s own words.

• Actual harm, isolatedF692Dec 19, 2024

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

• Actual harm, isolatedF600May 10, 2024

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

• Actual harm, isolatedF692Mar 18, 2024

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

• Actual harm, isolatedF689Jul 13, 2023

  Based on record review, observations and interviews, the facility failed to provide adequate supervision and/or safety devices to prevent falls and accidents for three (#35, #20 and #8) of eight residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure Resident #35 was not injured during a staff-assisted transfer out of her daughter's car on 4/2/23. The resident per facility assessments required two-plus person assist for transfers, but one staff person assisted Resident #35 to transfer out of the car into a wheelchair. […]

• Actual harm, isolatedF692Jul 13, 2023

  Based on observations, record review, and interviews, the facility failed to ensure one (#35) of nine residents reviewed for weight loss out of 37 sample residents maintained adequate nutritional parameters. Specifically, Resident #35 had a condition change when she experienced a fall with a fracture on 4/2/23 (cross-reference F689 falls/accidents). Resident #35's weights, taken on 3/30/23 and 5/11/23, more than one month apart, demonstrated a 10-pound weight loss from 201.6 to 191 pounds, which was not followed up with timely nutritional assessments and interventions. […]