The state Department of Human Services has cleared two nurses at a Grand Junction nursing home of suspected caretaker neglect, reversing previous findings by Mesa County in connection with the death of an 83-year-old resident from fatal sepsis, according to a letter from the state shared with the Denver Gazette on Thursday.  

Ernest Griffiths Jr., a U.S. Air Force veteran with dementia, died February 25 after infection from an untreated leg wound spread through his body, shutting down his organs. His death certificate said the cause of death was complications of sepsis. 

Griffiths, a resident of Mantey Heights Rehabilitation and Care Center, was sent to Community Hospital in Grand Junction on Feb. 15 due to an open sore on his left leg. A nurse in the emergency room called Adult Protective Services to report suspected neglect. A caseworker for that agency in turn called the Grand Junction Police Department. Both investigated as did the state’s Department of Regulatory Agencies.

All three agencies have now dropped their investigations. 

In its Oct. 5 letters, the state’s Department of Human Services wrote it had reached a settlement with two nurses that resolves “each and every issue in the matter such that there is no need for further proceedings in this case.” The letters further state that the resolution “shall not be construed in any manner as an admission of wrongdoing by either party.”

This latest action overturns a Mesa County adult protective services conclusion that there was evidence of caretaker neglect. Adult Protective Services is a division of Colorado Department of Human Services.

Copies of correspondence from the state, with the names of the nurses redacted, were given to The Gazette by Trent Maxwell, a lawyer for Stellar Senior Living, the Utah-based company that manages Mantey Heights.

Adult Protective Services did not respond to a request for comment. Previously the agency has said its cases are confidential and cannot be discussed.

It remains unclear when Mr. Griffiths’ leg wound first developed. Staff at Mantey Heights told investigators it appeared quickly and worsened overnight on Feb. 14. A doctor at the hospital disputed that, telling Griffiths’ wife that such a serious wound and subsequent infection could not happen so quickly, according to internal investigative reports obtained by The Gazette.

In July, five months after Griffiths’ death, the Department of Regulatory Agencies dismissed its complaint due to insufficient grounds, according to a letter also obtained by The Gazette. Two weeks later police closed the case after the Colorado attorney general’s office declined to file charges for lack of evidence. 

 “I suppose I shouldn’t be surprised, but I have to say that I am appalled at the lack of oversight and accountability,” Ona Griffiths said on Thursday about the aftermath of her husband’s death.  

Parker Seibold, the denver Gazette Parker Seibold, the denver Gazette Ona Griffiths poses for a portrait next to the headstone of her husband, Air Force veteran Ernest Griffiths Jr., at the Veterans Memorial Cemetery of Western Colorado in Grand Junction.

Parker Seibold, the denver Gazette

The death of Ernest Griffiths, Jr. was highlighted as part of an Oct. 5 investigation by The Gazette. The story included excerpts from the police investigation along with the original Adult Protective Services internal caseworker report that found a “preponderance of evidence to support the allegation of caretaker neglect” that was “substantiated at a severe level.” 

Evrett Benton, CEO of Stellar Senior Living, told The Gazette for that story that it appealed the original findings by Mesa County and was confident Mantey Heights staff would be cleared. 

The Gazette investigation also highlighted how the Veterans Health Administration contracts with some troubled private sector nursing homes to care for the growing number of aging veterans. Griffiths was a disabled veteran who was referred to Mantey Heights by the VA which also paid for his care.

The VA has said it scrutinizes facilities for overall quality and care based on a star rating system developed by the Centers for Medicare and Medicaid Services. It also said it strives to only contract with the highest rated facilities and monitors performance after a veteran enters a nursing home. The Gazette found, however, that of the 28 nursing homes in Colorado with VA contracts, 13 were rated substandard by CMS. Mantey Heights had a rating of two out of five stars as of earlier this month.

Benton said problems at Mantey Heights predated his company taking over management in September 2021 and conditions have been improving since. 

Still, U.S. Rep. Jason Crow, a Democrat representing Colorado’s 6th District, was troubled by The Gazette’s findings. “Our nation makes a sacred promise to care for veterans long after service, including senior veterans in long-term residential facilities,” his office said in an emailed statement, “I’m fighting to increase federal oversight and provide the quality care our veterans and their loved ones were promised.”