Lowry Hills Care and Rehabilitation

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary and comfortable homelike environment for seven out of 10 rooms. Specifically, the facility failed to ensure resident room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were in good repair.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and personalized care for six (#9, #83, #104, #41, #2 and #29) of 10 residents out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #9's and Resident #83's care plans were updated with catheter care interventions;-Ensure Resident #104's care plan was updated with skin integrity/pressure wound interventions and feeding precaution interventions; -Ensure Resident #41's dementia and behavioral care plan was updated with all appropriate non-pharmacological interventions for psychotropic medications;-Ensure Resident #2's care plan was updated with specific target behaviors and interventions for the resident's use of psychotropic medications; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of six medication storage carts. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened;-Ensure medications were labeled with medication identification and resident identification; and,-Ensure expired medication were removed and discarded from the medication carts.

Inspectors wroteBased on observations and interviews, the facility failed to be designed or equipped to assure full visual privacy for each resident for six out of 10 rooms. Specifically, the facility failed to ensure residents had privacy curtains that provided them with full visual privacy for resident room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER].

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services for one (#8) of five residents reviewed for ADLs out of 51 sample residents. Specifically, the facility failed to ensure Resident #8 received timely meal assistance.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#104) of five residents out of 51 sample residents reviewed for skin assessments. Specifically, the facility failed to assess and obtain orders for the care of Resident #104's controlled ankle motion (CAM - a device that provides protection after orthopedic procedures and assists in offloading pressure) boot for her right leg.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with with limited range of motion received appropriate treatment and services to increase range of motion for one (#8) of one resident out of 51 sample residents. Specifically, the facility failed to provide passive range of motion services for Resident #8's left hand, which had a contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff and prevents normal movement of a joint or other body part).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#29) of three residents reviewed for accident hazards out of 51 sample residents. Specifically, the facility failed to ensure Resident #29, who was an elopement risk, was assessed timely and accurately for a wander guard (wearable tags/bracelets and door sensors that automatically alert staff or lock doors near a restricted exit).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for one (#7) of two residents out of 51 sample residents. Specifically, the facility failed to ensure oxygen administered according to physician's orders for Resident #7.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one resident (#1) reviewed for dialysis out of 51 sample residents. Specifically, the facility failed to:-Ensure thorough dialysis documentation was in place for Resident #1; and,-Consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center for Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to provide pharmaceutical services to meet the needs of one (#64) of five residents out of 51 sample residents. Specifically, the facility failed to ensure Resident #64's anti-anxiety medication was ordered and delivered to the facility in a timely manner.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were followed during high contact resident care areas for Resident #9, who had an indwelling urinary catheter and Resident #3, who had a tracheostomy (airway created through the neck); and, -Ensure Resident #83 and Resident #9's urinary catheter drainage bags and catheter tubing were not dragging on the ground.

Inspectors wroteBased on observations and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies and advocacy groups. Specifically, the facility failed to:-Ensure the required posting contained the correct phone number for the State Agency; and, -Ensure the required posting contained contact information for other pertinent state agencies and advocacy groups.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility's most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years. Specifically, the facility failed to ensure residents, family members, and legal representatives had full access to review the facility's most recent survey findings for 2025, including recertifications, complaint investigations, and plans of correction.

Inspectors wroteIII. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged home on [DATE]. According to the [DATE] CPO, diagnoses included multiple sclerosis (a disease that damages nerves and affects muscle control), muscle weakness and autistic disorder (developmental disorder). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial assistance with ADLs. The MDS assessment revealed the resident was going to stay at the facility for long term care. B. Resident #1's representative interview Resident #1's representative was interviewed on [DATE] at 10:30 a.m. The representative said Resident #1 discharged from the facility to home (on [DATE]). The representative said the facility did not set up any home health services for the resident when he was discharged home. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services and assistance for bathing for one (#6) of three residents reviewed for ADLs out of 13 sample residents. Specifically, the facility failed to provide Resident #6, who had cognitive impairments, incontinence care in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#1 and #6) of three residents reviewed for activities programming out of 10 sample residents. Specifically the facility failed to: -Offer and provide personalized activity programs for Resident #1 and Resident #6 as documented in their care plans; -Ensure Resident #1 and Resident #6 were invited and encouraged to attend activities of their preference; and, -Ensure Resident #6 was meaningfully engaged during activities.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food and drinks that accommodated resident allergies, intolerances and preferences for one (#4) of four residents out of 13 sample residents. Specifically, the facility failed to ensure Resident #4 was provided a vegetarian diet per her preference.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to ensure: -A clean location was provided for wound care supplies; and, -Enhanced barrier precautions (EBP) and proper hand hygiene were followed for wound care activities.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of three residents were free from abuse out of seven sample residents. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #2.

Inspectors wroteBased on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for three (#46, #25 and #47) of five residents reviewed for unnecessary medications out of 34 sample residents. Specifically, the facility failed to ensure informed consents, which included the risks associated with taking a psychotropic medication, were obtained for Resident #46, Resident #25 and Resident #47.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five (#1, #4, #5, #6 and #7) of five certified nurse aides. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #1, #4, #5, #6 and #7 in order to determine potential training needs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure staff performed hand hygiene appropriately while washing dishes and handling clean dishes; and, -Ensure food was labeled, dated and disposed of timely in the nourishment refrigerator.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an environment for residents, staff and the public that is safe, functional, sanitary and comfortable for one of two shower rooms at the facility. Specifically, the facility failed to ensure the shower room was sanitary and safe for residents to use.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (#1, #4, #5, #6 and #7) of five certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure CNA #1, #4, #5, #6 and #7 received 12 hours of training annually.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Level II preadmission and resident review (PASRR) was completed for one (#33) of three residents out of 34 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being. Specifically, the facility failed to ensure a Level II PASRR was in place for Resident #33.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#69 and #35) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure Resident #69 and Resident #35, who were dependent on staff for bathing, received their scheduled showers.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#60 and #58) of six residents out of 34 sample residents reviewed for nutrition status. Specifically, the facility failed to obtain weekly weights per the physician's orders for Resident #60 and Resident #58.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (#46) of five residents reviewed for unnecessary medications out of 34 sampled residents. Specifically the facility failed to ensure: -Acetaminophen (pain medication) administered to Resident #46 did not exceed the recommended 3 grams (gm) in a 24-hour period; and, -As needed (PRN) medication was administered per physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of three medication carts and one of two medication storage rooms. Specifically the facility failed to: -Ensure expired medications and vaccines were disposed of timely; -Ensure insulin pens (medication used for glucose control) were labeled with open dates; and, -Ensure Tubersol (used to test for tuberculosis) vials were labeled with open dates.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanical soft diets had food prepared according to their diet orders of mechanical soft as indicated on their meal tray cards.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of six units. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff used the correct surface disinfectant products; and, -Ensure surface disinfectant times were adhered to.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#8 and #9) of five residents reviewed for pressure injuries out of 15 sample residents. Resident #8, was admitted on [DATE] for long term care. The resident was admitted without a pressure injury to the right heel. The resident was at risk for developing pressure injuries. The facility failed to proactively implement treatment interventions to prevent the resident from developing a deep tissue pressure injury to her right heel on 11/1/23 that was staged as stage 3 on 11/28/23. No treatment orders or physician orders were in place to promote prevention and active healing of the pressure injury. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in one of one facility kitchens. Specifically, the facility failed to: -Ensure the overall kitchen area were free from hanging dust; and -Ensure serving tables are free from chipped paint.

Inspectors wroteBased on record review, observation,and interviews the facility failed to provide prompt responses and resolutions to grievances from residents. Specifically, the facility failed to respond to resident grievances regarding missing laundry and implement an acceptable resolution for the resident right to keep and use personal belongings and have the facility protect the resident property from theft and or loss.

Inspectors wroteBased on observation and interviews the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; -Vials of tubersol (used to test for Tuberculosis) were labeled appropriately with open dates; -Ensure the treatment cart was kept free from expired wound dressing supplies; and, -Medication carts were kept clean and free of loose pills.

Inspectors wroteBased on interviews and record review the facility failed to ensure two residents (#60 and #67) of two residents reviewed out of 39 sample residents, had the right to participate in the development and implementation of his or her person centered plan of care. Specifically the facility failed to conduct consistent care planning meetings and invite Resident #60 and #67 to attend a care plan meeting to discuss and develop a person centered plan of care and services that the facility would provide to them.

Inspectors wroteBased on interviews and record review the facility failed to honor resident choices for one (#19) of two reviewed for self-determination, out of 39 sample residents. Specifically, the facility failed to ensure dependent Resident #19, received showers consistently according to the resident's preference.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure one (#55) of three residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene, out of 39 sample residents. Specifically, the facility failed to: -Provide timely incontinent care; -Provide timely consistent feeding assistance; and, -Update care plan for Resident #55 to reflect feeding assistance needs.

Inspectors wroteBased on record review, interview, and observation the facility failed to ensure the residents' environment remained as free from accident hazards as possible, for two (#20 and #42) of six residents reviewed for accident/hazards out of 39 sample residents Specifically, the facility failed to: -Provide effective monitoring and supervision of Resident #20's safety when the resident left the facility without notifying facility staff of an extended absence;. -Provide health assessment and document the assessment (if done) of Resident #20 upon the resident's return from extended and overnight absences for the facility when the resident was out in the community in potential unsafe conditions unsupervised by facility staff; [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#20) out of one resident reviewed for a person-centered care plan that supports the resident's behavioral health needs, out of 39 sample residents. Specifically, the facility failed to: -Develop and follow a process to ensure a resident with a substance abuse history was properly monitored for unsafe addicting chemical substances use; -Ensure the facility staff monitored the resident for chemical substance withdrawals and documented concerns when the resident presented with intoxication; [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for two residents (#29 and #45). Specifically, the facility had a medication error rate of 7.41%, which was two errors out of 27 opportunities for error.

Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Perform wound care in a sanitary manner for Resident #237; and, -Sanitize multiple use items after use; when providing wound care for Resident #237.