The Heritage at Lowman Rehab and Healthcare

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to maintain safe temperatures in 4 of 4 refrigerators in the nourishment rooms on the units. This failure has the potential to cause harm by increasing the risk of foodborne illnesses.

Inspectors wroteBased on review of the facility policy, observation and interview, the facility failed to ensure outdated/expired medications were removed from the medication carts and not stored with other medications in use for residents in 3 of 8 medication carts.

Inspectors wroteBased on review of facility policy, interview and record review, the facility failed to ensure Resident (R)4 was offered showers and/or bed baths daily according to her preferences for 1 of 4 residents reviewed for Activities of Daily Living.

Inspectors wroteBased on review of the facility policy, the manufacturer's recommendations, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5%, for 2 of 25 opportunities for error. The medication error rate was 8%.

Inspectors wroteBased on record review, interviews, and review of facility policies, the facility failed to identify and communicate a change in the breakdown of skin in the perineal area for Resident (R)2 for 1 of 1 resident reviewed for changes in skin condition.

Inspectors wroteBased on interview and record review the facility failed to ensure trigger behaviors were identified for the use of an antipsychotic medication for one resident (Resident (R) 40) and failed to ensure psychotropic medications had an end date for three residents (R71, R10, R57). This failure placed the residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure three Residents (R)282, R71, and R36) discontinued medications were removed from two of four medication carts. This had the potential for the medications to be diverted or for residents to receive medications with no current physician order.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure pneumonia vaccinations were offered and/or provided for three of five residents (Residents (R) 25, R43, and R100) reviewed for immunizations of 30 sample residents. This failure placed the residents at risk for pneumonia.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure one resident (Resident (R) 108) of one resident out of a sample of 30 residents was given the opportunity to make choices regarding being able to utilize regular plates and utensils instead of Styrofoam containers and plastic utensils during a COVID-19 outbreak on the unit. This failure placed the resident for a diminished quality of life.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R) 95) reviewed for care planning of 30 sample residents was afforded the right to participate in his care planning process. This failure placed the resident at risk of not being aware of the goals and outcomes of his care.

Inspectors wroteBased on observation, record review, staff interview and policy review, the facility failed to ensure that a resident was assessed for self-administration of medications prior to medications being left at the bedside for one of 30 sampled residents (Resident (R)114). This failure had the potential for the resident to over medicate themselves or medications being accessed by other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) was accurate and complete prior to discharge from Medicare part A skilled services for two of three residents (Resident (R) 40 and R120) reviewed for SNF Beneficiary Protection of 30 sample residents. This failure placed the residents and/or representatives at risk of not being fully informed.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure Care Plans for behavioral symptoms were developed for three (Residents (R)115, R120, and R25) of 30 sampled residents reviewed for care plans. This failure could cause unmet care needs for the residents.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure the Comprehensive Care Plan was accurate for one resident (Residents (R) 40) of 30 sample residents reviewed for care plans. This failure placed the resident at risk of unmet care needs.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one Resident's (R) 94 heels were elevated as ordered out of three residents reviewed for pressure ulcers out of a sample of 30 residents. This failure had the potential for R94's deep tissue injury to reoccur.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to carry out orders for a splint/palm protector for one (Resident (R)94) of two residents reviewed for range of motion (ROM) out of a sample of 30 residents. This failure had the potential cause further decrease of ROM and/or pain for the resident.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to properly store an oxygen tank in one of three resident's room out of 30 sampled residents (Resident (R)100) and in one of four storage rooms ([NAME] unit). This failure had the potential for the pressurized oxygen inside the tank to rapidly escape causing injury or damage to surrounding objects or residents.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to maintain acceptable nutritional parameters by not monitoring weights for accuracy, accurately assessing weight changes after readmission, monitoring meal intake, providing meal assistance, providing meal set-up, and/or providing a meal tray for three (Residents (R)68, R120, and R115) of eight sampled residents reviewed for nutrition. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure a prophylactic antibiotic was monitored to ensure continued efficacy for one of two residents (Resident (R) 16) of 30 sample residents reviewed for antibiotic stewardship. This failure placed the resident at risk of unmet care needs related prolonged use of an antibiotic.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to maintain resident safety from harm for 1 of 1 resident. Specifically, while providing incontinent care to Resident (R)1 on 04/01/24, staff walked away from R1, resulting in R1 falling to the floor and suffering a hematoma of the scalp, skin tear and hematoma over the right elbow/forearm, and acute closed fracture of the tibia and fibula.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to secure 2 of 2 medication carts on 1 (Hall 400) of 4 halls.

Inspectors wroteBased on observation, interview, record review, and document and policy review, the facility failed to appropriately clean 1 of 2 glucometers following its use on Hall 400.

Inspectors wroteBased on observation, document review, and staff interview, the facility failed to follow the menus for the correct amount of food to be served for 21(Resident (R) 43, R42, R12, R41, R108, R112, R11, R75, R80, R62, R103, R160, R96, R99, R260, R16, R64, R98, R95, R24, and R51) of 21 resident trays observed. This had the potential to affect 114 of 120 residents in the facility who receive their meals from the kitchen and the potential for the 21 residents not to receive the appropriate calories and nutrients.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADLs) received the necessary services to maintain personal hygiene, specifically a shower. This involved one of 26 sampled residents (Resident (R) 107).