Inspection Reports for
Lowry Hills Care and Rehabilitation
10201 E 3RD AVE, AURORA, CO, 80010-4301
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
24.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
371% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate discharge planning and failure to ensure residents received necessary care and services upon discharge from the facility.
Complaint Details
The complaint investigation focused on allegations that the facility failed to provide adequate discharge planning and coordination of services for residents discharged to the community, resulting in harm. Specific complaints included failure to arrange home health services, failure to provide medication instructions, and inadequate discharge care plans. Additional complaints involved failure to provide timely incontinence care, meaningful activity engagement, and dietary accommodations.
Findings
The facility failed to ensure safe and coordinated discharge planning for residents, resulting in residents being discharged without necessary home health services or medication instructions. Additionally, the facility failed to provide timely incontinence care, meaningful activity engagement, and accommodate dietary preferences for certain residents.
Deficiencies (4)
Failure to ensure safe discharge planning and coordination of home health services for residents #1 and #5, resulting in actual harm.
Failure to provide timely incontinence care for Resident #6, who was incontinent and required assistance every two hours.
Failure to provide ongoing personalized activity programs and meaningful engagement for Residents #1 and #6.
Failure to provide food and drinks that accommodated Resident #4's vegetarian diet preference and dietary restrictions.
Report Facts
Residents reviewed for discharge planning: 13
Residents affected by discharge planning deficiencies: 2
Residents reviewed for ADL care: 13
Residents affected by ADL care deficiencies: 1
Residents reviewed for activities programming: 10
Residents affected by activities programming deficiencies: 2
Residents reviewed for dietary accommodations: 13
Residents affected by dietary deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed regarding discharge planning, ADL care, and facility policies. |
| Social Services Director | SSD | Interviewed multiple times regarding discharge planning and coordination of services. |
| Nursing Home Administrator | NHA | Provided facility policies and follow-up documentation. |
| Activities Director | AD | Interviewed regarding activities programming and resident engagement. |
| Registered Dietitian | RD | Interviewed regarding dietary accommodations and resident preferences. |
| Dietary Manager | DM | Interviewed regarding meal planning and resident food preferences. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate discharge planning and care, failure to provide necessary assistance with activities of daily living, lack of meaningful activities programming, and failure to accommodate dietary preferences.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate discharge planning and coordination of home health services for residents #1 and #5, resulting in harm. It also found failures in providing timely incontinence care for Resident #6, lack of meaningful activity engagement for Residents #1 and #6, and failure to accommodate dietary preferences for Resident #4.
Findings
The facility failed to ensure safe and thorough discharge planning for residents, including arranging necessary home health services and medication education. It also failed to provide timely incontinence care, meaningful activity engagement, and accommodate dietary preferences for vegetarian and allergy restrictions.
Deficiencies (4)
F 0627: The facility failed to ensure residents #1 and #5 had person-centered discharge plans with necessary care and services in place, resulting in actual harm including hospitalization due to lack of medication education and service coordination.
F 0677: The facility failed to provide Resident #6 timely incontinence care, leaving him soiled for over four hours, and did not consistently check or assist with toileting as required.
F 0679: The facility failed to provide ongoing personalized activity programs and meaningful engagement for Residents #1 and #6, neglecting their interests and preferences.
F 0806: The facility failed to provide Resident #4 a vegetarian diet per physician orders and resident preference, and served food containing chocolate despite resident's dietary restrictions.
Report Facts
Residents reviewed for ADLs: 13
Residents reviewed for activities programming: 10
Residents reviewed for dietary preferences: 4
BIMS score: 15
BIMS score: 12
Observation duration: 4.15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director (SSD) | Interviewed regarding discharge planning failures and coordination of home health services | |
| Director of Nursing (DON) | Interviewed regarding discharge planning, medication education, and care coordination | |
| Assistant Director of Nursing (ADON) | Interviewed regarding discharge instructions and follow-up | |
| Activities Director (AD) | Interviewed regarding activity programming and resident engagement | |
| Registered Dietitian (RD) | Interviewed regarding dietary accommodations and menu planning | |
| Dietary Manager (DM) | Interviewed regarding dietary accommodations and menu planning | |
| Certified Nurse Aides (CNAs) | Observed and interviewed regarding incontinence care and resident engagement | |
| Registered Nurse (RN) #1 | Interviewed regarding incontinence care expectations and observations |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 22, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on wound care practices and adherence to enhanced barrier precautions and hand hygiene protocols.
Findings
The facility failed to maintain a proper infection control program by not providing a clean location for wound care supplies and failing to ensure staff followed enhanced barrier precautions and proper hand hygiene during wound care activities. Multiple observations showed staff not donning gowns during high contact care, improper glove use, and failure to perform hand hygiene.
Deficiencies (3)
Failure to provide a clean location for wound care supplies.
Failure to follow enhanced barrier precautions (EBP) including not donning gowns during high contact care.
Failure to perform proper hand hygiene during wound care activities.
Report Facts
Number of glove changes by LPN #2 during wound care: 4
Date of wound care observations: Apr 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed during wound care for Resident #9; failed to perform hand hygiene after glove removal |
| LPN #3 | Licensed Practical Nurse | Observed during wound care for Resident #3; failed to clean bedside table and perform hand hygiene |
| CNA #2 | Certified Nurse Aide | Observed failing to don gown during high contact care and not performing hand hygiene after assisting roommate |
| CNA #3 | Certified Nurse Aide | Observed failing to don gown during high contact care for Resident #9 |
| CNA #5 | Certified Nurse Aide | Observed failing to don gown prior to high contact care for Resident #8 |
| CNA #6 | Certified Nurse Aide | Observed failing to don gown prior to high contact care for Resident #8 |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control deficiencies and staff practices |
| Clinical Resource | Clinical Resource | Interviewed with DON regarding infection control deficiencies |
| Treatment Nurse | Treatment Nurse | Interviewed regarding education provided to staff on gown use and hand hygiene |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 22, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on wound care practices and adherence to enhanced barrier precautions and hand hygiene protocols.
Findings
The facility failed to maintain an effective infection control program by not providing a clean location for wound care supplies and not consistently following enhanced barrier precautions and proper hand hygiene during wound care activities.
Deficiencies (3)
F 0880: The facility failed to provide a clean location for wound care supplies, placing them on soiled bedside tables mixed with residents' personal food items.
F 0880: Staff failed to consistently use gowns during high contact wound care activities, including CNAs not donning gowns when repositioning residents with wounds.
F 0880: Staff did not consistently perform hand hygiene during wound care, including failure to use hand hygiene after glove removal and before applying new gloves.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to complaints regarding resident-to-resident physical abuse incidents involving Resident #2 and Resident #3.
Complaint Details
The complaint investigation involved two incidents of physical abuse by Resident #2 towards Resident #3 on 2/8/25 and 2/19/25. The facility unsubstantiated the abuse due to no injuries and no intent to harm. Resident #2 had severe cognitive impairments and delusional behaviors. The facility implemented one-on-one supervision and other interventions.
Findings
The facility failed to protect Resident #3 from physical abuse by Resident #2 in two separate incidents on 2/8/25 and 2/19/25. Both incidents were investigated but unsubstantiated due to lack of injuries, intent to harm, and unclear circumstances. Resident #2 exhibited delusional and aggressive behaviors requiring one-on-one supervision.
Deficiencies (1)
Failure to protect Resident #3 from physical abuse by Resident #2.
Report Facts
Residents affected: 3
Residents involved in incidents: 2
BIMS score Resident #3: 8
BIMS score Resident #2: 2
One-on-one supervision dates: 4
One-on-one supervision restart date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided facility policy, interviewed regarding interventions and training related to Resident #2. |
| CNA #2 | Certified Nurse Aide | One-on-one caregiver for Resident #2, interviewed about training and behavior monitoring. |
| CNA #1 | Certified Nurse Aide | Interviewed about knowledge of Resident #2's behaviors and triggers. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed about Resident #2's behaviors and documentation of interventions. |
| Regional Clinical Consultant | Regional Clinical Consultant (RCC) | Interviewed with DON regarding training and interventions. |
| Social Services Assistant | Social Services Assistant (SSA) | Interviewed regarding psychosocial support and investigations. |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding psychosocial support and investigations. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to complaints of resident-to-resident physical abuse incidents involving Resident #2 and Resident #3.
Complaint Details
The complaint involved two incidents of physical abuse by Resident #2 towards Resident #3 on 2/8/25 and 2/19/25. The facility investigation was unable to substantiate the abuse due to no injuries and no intent to harm. Resident #2 had severe cognitive impairments and delusions causing aggressive behaviors. Resident #3 denied feeling unsafe and injuries. The facility implemented one-on-one supervision for Resident #2.
Findings
The facility failed to protect Resident #3 from physical abuse by Resident #2 in two separate incidents on 2/8/25 and 2/19/25. Both incidents were unsubstantiated due to lack of injuries, intent to harm, and unclear recollections, but Resident #2 exhibited aggressive and delusional behaviors requiring one-on-one supervision.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Resident #3 was physically abused by Resident #2 in two incidents, with the facility unable to substantiate the abuse due to no injuries or intent to harm.
Report Facts
Residents in sample: 7
Residents involved in abuse incidents: 3
BIMS score: 8
BIMS score: 2
Dates of incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #2's behaviors and documentation of behavior tracking |
| Certified Nurse Aide #1 | CNA | Interviewed about knowledge of Resident #2's behaviors and triggers |
| Certified Nurse Aide #2 | CNA | One-on-one caregiver for Resident #2, interviewed about training and care |
| Director of Nursing | DON | Provided facility policies, interviewed about Resident #2's condition and interventions |
| Regional Clinical Consultant | RCC | Interviewed with DON regarding staff training and Resident #2's care |
| Social Services Assistant | SSA | Interviewed about psychosocial support and investigations related to Resident #2 |
| Social Services Director | SSD | Interviewed about role assisting SSA and Resident #2's behaviors |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to complete a Level II PASRR for a resident and failure to provide scheduled bathing and personal hygiene care to dependent residents.
Complaint Details
The complaint investigation found that the facility did not complete a required Level II PASRR for Resident #33 and failed to provide scheduled bathing for Residents #69 and #35. The social services director and director of nursing acknowledged these issues and described corrective actions including audits and submission of assessments.
Findings
The facility failed to ensure a Level II PASRR was completed for Resident #33 as recommended, and failed to provide scheduled showers to Residents #69 and #35 who were dependent on staff for bathing, resulting in missed showers over multiple months. Staff interviews confirmed these deficiencies and plans to address them.
Deficiencies (2)
Failed to ensure a Level II PASRR was completed for Resident #33 as recommended.
Failed to provide scheduled showers to Residents #69 and #35 who were dependent on staff for bathing.
Report Facts
Residents reviewed for PASRR: 34
Residents with missing Level II PASRR: 1
Residents reviewed for ADL bathing: 34
Residents with missed showers: 2
Showers missed by Resident #69: 11
Showers missed by Resident #35: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Interviewed regarding Level II PASRR completion for Resident #33 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PASRR requirements and missed showers for Residents #69 and #35 |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed about shower schedules and procedures |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Interviewed about CNA responsibilities for showers |
Inspection Report
Routine
Deficiencies: 12
Date: May 7, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including medication administration, PASRR screening, activities of daily living assistance, nutrition monitoring, medication storage, infection control, and staff training.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consents for psychotropic medications, incomplete PASRR Level II assessments, missed showers for dependent residents, failure to obtain weekly weights per physician orders, expired medications and improper medication labeling, failure to provide mechanically altered diets as ordered, inadequate hand hygiene and food storage practices in dietary services, improper cleaning and disinfection of resident rooms and shower rooms, and lack of annual performance reviews and in-service training for certified nurse aides.
Deficiencies (12)
F0552: Facility failed to ensure informed consents were obtained for psychotropic medications for three residents (#46, #25, #47).
F0645: Facility failed to ensure a Level II PASRR was completed for one resident (#33) as recommended.
F0677: Facility failed to ensure two residents (#69, #35) dependent on staff for bathing received their scheduled showers.
F0684: Facility failed to obtain weekly weights per physician orders for two residents (#60, #58).
F0730: Facility failed to complete annual performance reviews and provide annual in-service training for five certified nurse aides (#1, #4, #5, #6, #7).
F0757: Facility failed to ensure resident #46's drug regimen was free from unnecessary drugs by administering acetaminophen exceeding recommended maximum dose and failing to administer antihypertensive medication per order.
F0761: Facility failed to ensure medications and biologicals were stored and labeled properly, including expired medications and unlabeled insulin pens and Tubersol vials.
F0805: Facility failed to ensure residents on mechanical soft diets received food prepared according to diet orders; food items were not pureed or slurried as required.
F0812: Facility failed to ensure staff performed proper hand hygiene while washing and handling dishes and failed to label, date, and dispose of food timely in the nourishment refrigerator.
F0880: Facility failed to maintain an infection control program by not properly cleaning and disinfecting resident rooms and shower rooms, not training housekeeping staff adequately, and not adhering to disinfectant contact times.
F0921: Facility failed to maintain a safe, sanitary, and comfortable shower room environment including presence of damaged tiles, holes in walls, stained shower curtains, unsanitary chairs, and improper storage of personal hygiene items and sharps.
F0947: Facility failed to ensure five certified nurse aides (#1, #4, #5, #6, #7) received the required 12 hours of annual in-service training for continued competence.
Report Facts
Residents reviewed: 34
Residents affected by psychotropic consent deficiency: 3
Residents affected by PASRR deficiency: 1
Residents affected by shower deficiency: 2
Residents affected by weight monitoring deficiency: 2
Certified nurse aides without annual performance reviews: 5
Certified nurse aides without annual in-service training: 5
Expired insulin pen days past expiration: 30
Expired medication days past expiration: 30
Acetaminophen overdose mg: 650
Missing floor tiles: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #1 | Dietary Aide | Observed failing to perform hand hygiene before handling clean dishes |
| HSKP #1 | Housekeeper | Observed using cleaner instead of disinfectant and not cleaning high-touch surfaces |
| HSKP #2 | Housekeeper | Observed using cleaner instead of disinfectant and not cleaning high-touch surfaces |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration deficiencies |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication, infection control, and staff training |
| IP | Infection Preventionist | Interviewed regarding infection control deficiencies |
| SDC | Staff Development Coordinator | Interviewed regarding lack of CNA annual training documentation |
| DM | Dietary Manager | Interviewed regarding mechanical soft diet and nourishment refrigerator deficiencies |
| DOH | Director of Housekeeping | Interviewed regarding housekeeping and shower room cleaning deficiencies |
Inspection Report
Routine
Deficiencies: 12
Date: May 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, PASRR screening, activities of daily living assistance, nutrition status, nurse aide training, medication storage, food preparation, infection control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, incomplete PASRR Level II assessments, missed showers for dependent residents, failure to obtain weekly weights as ordered, lack of annual performance reviews and training for nurse aides, improper medication administration exceeding recommended doses, expired and improperly labeled medications, failure to provide mechanically altered diets as prescribed, inadequate hand hygiene and food storage practices, insufficient infection control cleaning procedures, and unsafe and unsanitary shower room conditions.
Deficiencies (12)
Failure to obtain informed consent for psychotropic medications for three residents (#46, #25, #47).
Failure to complete Level II PASRR for Resident #33 as recommended.
Failure to provide scheduled showers for dependent residents #69 and #35.
Failure to obtain weekly weights per physician orders for Residents #60 and #58.
Failure to complete annual performance reviews and in-service training for five CNAs (#1, #4, #5, #6, #7).
Failure to ensure Resident #46's acetaminophen dose did not exceed 3 grams in 24 hours and failure to administer Hydralazine as ordered for high blood pressure.
Failure to properly store and label medications including expired insulin pens, vaccines, and other medications in medication rooms and carts.
Failure to provide mechanically altered diets according to prescribed texture for residents on mechanical soft diets.
Failure to perform proper hand hygiene while washing and handling clean dishes and failure to properly label, date, and dispose of food in nourishment refrigerator.
Failure to maintain infection control program including proper cleaning and disinfecting of resident rooms and high-touch surfaces, use of correct disinfectants, adherence to disinfectant contact times, and proper housekeeping training.
Failure to maintain a safe, sanitary, and functional shower room including presence of stains, holes in walls, missing tiles, unsanitary storage of personal items, full sharps container, and use of inappropriate shower chairs.
Failure to ensure certified nurse aides received required 12 hours of annual in-service training.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for PASRR: 34
Residents reviewed for ADL assistance: 34
Residents reviewed for nutrition status: 34
Certified nurse aides reviewed for training and performance: 5
Acetaminophen dose exceeded: 650
Expired medication days past expiration: 27
Expired medication days past expiration: 6
Expired medication days past expiration: 180
Expired medication days past expiration: 30
Handwashing duration: 15
Missing floor tiles: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and informed consent for Resident #46 |
| RN #2 | Registered Nurse | Observed medication storage and handling of expired medications |
| DA #1 | Dietary Aide | Observed washing dishes without proper hand hygiene |
| HSKP #1 | Housekeeper | Observed cleaning resident rooms without disinfectant and not cleaning high-touch surfaces |
| HSKP #2 | Housekeeper | Observed cleaning resident rooms without disinfectant and improper cleaning techniques |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, nurse aide training, infection control, and shower room conditions |
| NHA | Nursing Home Administrator | Interviewed regarding policies, procedures, and deficiencies |
| DM | Dietary Manager | Interviewed regarding mechanical soft diet preparation and nourishment refrigerator monitoring |
| IP | Infection Preventionist | Interviewed regarding infection control program and housekeeping training |
| SDC | Staff Development Coordinator | Interviewed regarding nurse aide training and education tracking |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to complete a Level II PASRR for a resident and failure to provide scheduled showers to dependent residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to complete a Level II PASRR for Resident #33 and failure to provide scheduled bathing for Residents #69 and #35.
Findings
The facility failed to ensure a Level II PASRR was completed for one resident as required. Additionally, the facility failed to provide scheduled showers to two residents dependent on staff for bathing, resulting in missed hygiene care.
Deficiencies (2)
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities. The facility failed to ensure a Level II PASRR was completed for Resident #33 as recommended after a Level I PASRR.
F 0677 Provide care and assistance to perform activities of daily living. The facility failed to ensure Residents #69 and #35, dependent on staff for bathing, received their scheduled showers as documented in shower logs and resident interviews.
Report Facts
Residents reviewed for PASRR: 34
Residents affected: 1
Residents affected: 2
Showers missed by Resident #69: 11
Showers missed by Resident #35: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Interviewed regarding Level II PASRR completion for Resident #33 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PASRR requirements and shower schedules for Residents #69 and #35 |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed about shower provision and documentation |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Interviewed about CNA responsibilities for showering residents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to prevent and properly treat pressure injuries in residents, specifically focusing on two residents who developed pressure ulcers during their stay.
Complaint Details
The investigation focused on substantiated complaints that the facility did not prevent pressure injuries in residents #8 and #9. Resident #9 developed a facility-acquired unstageable wound that progressed to stage 3. Resident #8 developed a stage 3 pressure injury without timely treatment orders or pressure relief interventions.
Findings
The facility failed to implement timely and appropriate interventions to prevent and treat pressure injuries for two residents at risk. Both residents developed pressure injuries that worsened due to lack of proper wound care orders, delayed assessments, and failure to provide pressure relief devices such as boots and air mattresses.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to residents.
Report Facts
Deficiencies cited: 1
Pressure injury dimensions: 5
Pressure injury dimensions: 3
Pressure injury dimensions: 2.5
Staff educated: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed regarding wound care responsibilities and facility-acquired wounds | |
| Nursing Home Administrator (NHA) | Interviewed about MDS assessment and wound acquisition status | |
| Certified Nurse Aide (CNA) #1 | Interviewed about awareness and care related to resident's pressure injury | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about pressure injury treatment and failure to offer pressure relief boots |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pressure injury prevention and management standards, focusing on residents at risk or with pressure injuries.
Findings
The facility failed to implement timely and appropriate interventions to prevent and treat pressure injuries for two residents (#8 and #9). Both residents developed pressure injuries that worsened due to lack of proper wound care orders, offloading devices, and staff education. The facility acknowledged these failures and planned corrective actions including staff education and updating care plans.
Deficiencies (1)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Report Facts
Residents affected: 2
Pressure injury dimensions: 5
Pressure injury dimensions: 3
Pressure injury dimensions: 2.5
Staff educated: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #1 | LPN | Interviewed regarding Resident #8's pressure injury care and lack of pressure relief boot use. |
| Assistant director of nursing | ADON | Interviewed about facility acquired pressure injuries and corrective actions planned. |
| Certified nurse aide #1 | CNA | Interviewed about care provided to Resident #8 and lack of pressure relief device use. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to allegations of sexual abuse involving two residents at Lowry Hills Care and Rehabilitation.
Complaint Details
The complaint investigation substantiated that Resident #1 was sexually abused by Resident #2 on two separate dates, 3/22/23 and 4/6/23. Resident #1 did not consent to the sexual acts and expressed feeling unsafe until Resident #2 was discharged. The facility failed to adequately supervise Resident #2 and re-evaluate Resident #1's sexual consent status after the incidents.
Findings
The facility failed to protect Resident #1 from non-consensual sexual abuse by Resident #2 on two occasions, despite moving Resident #1 to a different hallway and implementing safety checks. Staff supervision was inadequate, allowing Resident #2 to access Resident #1's room and commit abuse again before his discharge.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 from sexual abuse by Resident #2 on 3/22/23 and 4/6/23, despite Resident #1's lack of consent and efforts to separate them.
Report Facts
Residents affected: 3
Mental status score: 13
Mental status score: 14
Mental status score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding facility response and supervision failures |
| Assistant Director of Nursing | ADON | Interviewed about incident response and supervision |
| Social Service Director | SSD | Interviewed about sexual consent documentation and resident interviews |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to allegations of sexual abuse involving two residents at Lowry Hills Care and Rehabilitation. The investigation focused on incidents where Resident #2 engaged in non-consensual sexual acts with Resident #1.
Complaint Details
The complaint investigation substantiated that Resident #1 was sexually abused by Resident #2 on two separate occasions while she was sleeping and unable to consent. Resident #2 was found with his pants down and private parts in Resident #1's mouth. The facility failed to prevent the abuse despite moving Resident #1 and implementing safety checks on Resident #2.
Findings
The facility failed to protect Resident #1 from sexual abuse by Resident #2 on two occasions, 3/22/23 and 4/6/23, despite moving Resident #1 to a different hallway and implementing 15-20 minute checks on Resident #2. Resident #2 was found to have engaged in non-consensual sexual acts while Resident #1 was sleeping. The facility did not adequately supervise Resident #2, and no re-evaluation of sexual consent was conducted after the incidents.
Deficiencies (1)
Failure to protect Resident #1 from sexual abuse by Resident #2 on 3/22/23 and 4/6/23.
Report Facts
Resident mental status score: 13
Resident mental status score: 14
Resident mental status score: 13
Safety check interval: 15
Safety check interval: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Interviewed regarding facility response and investigation of sexual abuse incidents |
| Assistant Director of Nursing | ADON | Interviewed about observations and actions taken during incidents |
| Social Service Director | SSD | Interviewed about sexual consent documentation and resident interviews |
Inspection Report
Routine
Deficiencies: 9
Date: Jan 26, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, medication administration, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, honoring resident choices, responding to grievances, providing adequate assistance with activities of daily living, ensuring resident safety and supervision, maintaining medication error rates below 5%, proper medication storage and labeling, sanitary food service conditions, and infection prevention and control practices.
Deficiencies (9)
Failure to ensure residents #60 and #67 participated in care planning meetings and development of person-centered plans of care.
Failure to honor resident #19's right to receive showers consistently according to preference.
Failure to provide prompt responses and resolutions to resident grievances regarding missing laundry and personal belongings.
Failure to provide timely incontinent care, consistent feeding assistance, and update care plan for resident #55.
Failure to provide adequate supervision and monitoring for resident #20 who eloped multiple times and returned intoxicated; failure to assess and address risks related to substance use disorder.
Medication error rate of 7.41% due to incorrect medication administration for residents #29 and #45.
Failure to ensure medications and biologics were stored and labeled properly, including insulin vials and tubersol with missing open dates, expired wound dressings on treatment cart, and medication carts with loose pills.
Failure to maintain kitchen sanitation including hanging dust on pipes and light fixtures, cobwebs, and chipped paint on food preparation tables.
Failure to maintain infection control during wound care for resident #237 including failure to sanitize hands between tasks, failure to disinfect multi-use ointments and wound cleanser, and failure to use barrier pads when setting up wound care supplies.
Report Facts
Medication error rate: 7.41
Number of elopement occasions: 17
Expired wound dressings: 15
Loose tablets: 58
MDS BIMS score: 3
MDS BIMS score: 15
MDS BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed and interviewed regarding wound care deficiencies and medication administration errors |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including wound care, medication administration, resident supervision, and infection control |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration errors |
| CNA #4 | Certified Nurse Aide | Interviewed regarding resident supervision and behaviors |
| CNA #5 | Certified Nurse Aide | Interviewed regarding resident supervision and behaviors |
| DM | Dietary Manager | Interviewed regarding kitchen sanitation |
| NHA | Nursing Home Administrator | Interviewed regarding resident supervision, behavioral health, and kitchen sanitation |
| DOR | Director of Rehabilitation | Interviewed regarding resident supervision and GPS tracking device |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 26, 2023
Visit Reason
Routine inspection of Lowry Hills Care and Rehabilitation to assess compliance with regulatory requirements including resident care, safety, medication administration, infection control, and facility environment.
Findings
The facility had multiple deficiencies including failure to ensure resident participation in care planning, failure to honor resident preferences for care, unresolved resident grievances about lost property, inadequate assistance with activities of daily living, unsafe environment hazards, insufficient behavioral health care for a resident with substance use disorder, medication errors exceeding 5%, improper medication storage and labeling, unsanitary kitchen conditions, and inadequate infection prevention and control practices.
Deficiencies (10)
F0553: Facility failed to ensure residents #60 and #67 participated in care planning meetings and were invited to attend care plan meetings to discuss and develop person-centered plans of care.
F0561: Facility failed to honor resident #19's preference for shower frequency, resulting in inconsistent shower provision and missed scheduled showers.
F0585: Facility failed to respond promptly and effectively to multiple resident grievances regarding missing laundry and personal belongings, causing ongoing resident frustration.
F0677: Facility failed to provide timely incontinent care, consistent feeding assistance, and update care plan for resident #55 to reflect feeding assistance needs.
F0689: Facility failed to provide adequate supervision and monitoring for resident #20 who eloped multiple times, failed to assess and address substance use disorder, and failed to ensure resident #42 had a safe mattress fit to prevent injury.
F0740: Facility failed to provide necessary behavioral health care and services for resident #20, including monitoring for substance use disorder and addressing intoxication upon return.
F0759: Facility had a medication error rate of 7.41% with errors including incorrect medication dispensed and improper tablet splitting for residents #29 and #45.
F0761: Facility failed to ensure medications and biologics were stored and labeled properly, including insulin vials and pens without open dates and expired wound dressings on treatment cart.
F0812: Facility kitchen was unsanitary with hanging dust on pipes and light fixtures, cobwebs, and food prep tables with chipped paint and uneven surfaces.
F0880: Facility failed to maintain infection control during wound care for resident #237, including failure to sanitize hands and supplies, use barrier pads, and disinfect multi-use ointments and wound cleanser.
Report Facts
Medication error rate: 7.41
Medication errors: 2
Expired wound dressings: 15
Loose tablets: 58
Resident elopements: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication errors and wound care deficiencies; interviewed about medication administration and infection control |
| LPN #1 | Licensed Practical Nurse | Observed preparing medications with errors; interviewed about medication administration |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication tablet splitting |
| DON | Director of Nursing | Interviewed multiple times about resident care, medication administration, elopement monitoring, and infection control |
| DM | Dietary Manager | Interviewed about kitchen sanitation and cleaning |
| NHA | Nursing Home Administrator | Interviewed about resident behavioral health care and kitchen sanitation |
| RN #7 | Certified Nurse Aide | Interviewed about resident #55 incontinent care and feeding assistance |
| CNA #4 | Certified Nurse Aide | Interviewed about resident #20 elopement and behaviors |
| CNA #5 | Certified Nurse Aide | Interviewed about resident #20 elopement and laundry issues |
| DOR | Director of Rehabilitation | Interviewed about GPS tracking device for resident #20 and resident #42 bed safety |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 10
Date: Oct 14, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, assistance with activities of daily living, prevention of pressure ulcers, restorative care, accident prevention, pharmaceutical services, medication administration, infection control, and quality assurance. Specific failures included inadequate staffing, failure to provide adaptive eating utensils, failure to provide showers and nail care, failure to prevent pressure injuries, failure to provide restorative services, failure to investigate accidents and abuse thoroughly, and failure to maintain an effective QAPI program.
Deficiencies (10)
Failed to provide care in a dignified manner for Resident #68 who experienced violent tremors and was not assisted timely with adaptive eating utensils.
Failed to ensure residents received assistance with activities of daily living including showers and nail care for Residents #51, #58, #63, #64 and #77.
Failed to prevent pressure injury development and provide timely treatment for Resident #29, resulting in an unstageable pressure injury to the coccyx.
Failed to provide restorative care to Resident #56, resulting in lack of range of motion maintenance and splint use.
Failed to ensure safe transfers with Hoyer lift for Resident #56, resulting in two injuries and falls.
Failed to provide pharmaceutical services to ensure availability and administration of Apokyn for Resident #68 and Buprenorphine for Resident #182.
Failed to ensure medication administration was free from errors, with a medication error rate of 8.11% for Resident #42.
Failed to provide meaningful activities and stimulation for Resident #74, who was left in bed with television off and no activities offered.
Failed to maintain an effective quality assurance and performance improvement program to identify and address quality of care, quality of life, and infection control concerns.
Failed to ensure infection prevention and control practices including appropriate use of PPE and hand hygiene during wound care and isolation precautions.
Report Facts
Resident census: 80
Medication administration error rate: 8.11
Pressure injury size: 4.5
Pressure injury size: 6
Pressure injury size: 2
Pressure injury size: 4.5
Pain level: 7
Pain level: 6
Pain level: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Involved in physical altercation with Resident #4 on 10/2/21 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including medication availability, restorative care, staffing, and infection control |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication administration and Resident #68's medication unavailability |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed regarding restorative care and Hoyer lift transfers for Resident #56 |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding Hoyer lift transfers and staffing shortages |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding medication administration and wound care |
| Pharmacist | Pharmacist | Interviewed regarding medication orders and availability for Residents #68 and #182 |
| Physician | Physician | Interviewed regarding medication orders and Resident #68's tremors |
| Interim Nursing Home Administrator | Interim Nursing Home Administrator | Interviewed regarding investigation of Resident #68's care, staffing, and quality assurance |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding restorative care and quality assurance |
| Registered Dietician | Registered Dietician | Interviewed regarding adaptive eating equipment for Resident #68 |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 21
Date: Oct 14, 2021
Visit Reason
Annual recertification survey and complaint investigation of Lowry Hills Care and Rehabilitation to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, adequate assistance with activities of daily living, prevention of pressure ulcers, restorative care, accident prevention, pharmaceutical services, medication administration, infection control, and quality assurance. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (21)
F550: The facility failed to provide dignified care to Resident #68 who experienced violent tremors and was not provided timely assistance or adaptive eating utensils, causing distress and psychosocial harm.
F553: The facility failed to ensure three residents (#231, #31, #49) were invited to participate in their care plan meetings, limiting their involvement in person-centered care.
F561: The facility failed to honor breakfast meal choices for five residents (#64, #77, #10, #73, #49), limiting resident self-determination.
F565: The facility failed to respond to resident grievances and failed to provide follow-up to residents #1 and #31 regarding their complaints.
F584: The facility failed to maintain a safe, clean, and homelike environment for residents #51, #58, #64, and #77, including unclean rooms, lack of towels, and broken shower facilities.
F600: The facility failed to protect residents from abuse, including physical altercations between residents and abuse by staff toward Resident #4.
F610: The facility failed to thoroughly investigate abuse allegations and failed to assess residents for injury and pain after altercations.
F610: The facility failed to investigate and provide staff training after Resident #56 was injured during mechanical lift transfers, resulting in repeated injuries.
F658: The facility failed to ensure residents #42 and #72 received treatment and care in accordance with professional standards, including failure to notify physicians of medication refusals and improper medication administration.
F676: The facility failed to provide assistance with activities of daily living to residents #51, #58, #63, #64, and #77, including failure to provide regular showers and nail care.
F679: The facility failed to provide meaningful person-centered activities for Resident #74, who was left in bed without activities or assistance to use the television.
F686: The facility failed to prevent pressure injury development for Resident #29 by not providing timely turning and repositioning, accurate skin assessments, and timely treatment interventions.
F688: The facility failed to provide restorative care to Resident #1 and #56 to maintain or improve range of motion, with restorative aides pulled to floor duties and inconsistent care.
F689: The facility failed to ensure Resident #56's safety during mechanical lift transfers, resulting in injury and repeated falls due to inadequate staffing and training.
F725: The facility failed to provide sufficient nursing staff to meet resident care needs, resulting in delays in assistance, missed showers, and inadequate care.
F755: The facility failed to provide pharmaceutical services to meet resident needs, including failure to provide Apokyn medication for Resident #68 and Buprenorphine for Resident #182 in a timely manner.
F759: The facility failed to maintain a medication error rate of 5% or less on one unit, with missed administration of ocean spray, advair disk, and fluticasone for Resident #42.
F760: The facility failed to prevent significant medication errors by not timely notifying physicians and following up when Apokyn and Buprenorphine medications were unavailable for Residents #68 and #182.
F810: The facility failed to provide special eating equipment and utensils, including adaptive devices, plate guard, and weighted silverware, for Resident #68, resulting in the resident eating with his hands.
F867: The facility failed to implement an effective quality assurance program to identify and address quality of care, quality of life, and infection control concerns, resulting in repeat deficiencies.
F880: The facility failed to maintain an infection prevention and control program, including failure to wear appropriate PPE and perform hand hygiene during wound care and isolation precautions.
Report Facts
Resident census: 80
Medication administration observation error rate: 8.11
Refusals of lasix medication: 16
Refusals of potassium chloride: 10
Refusals of lasix medication: 14
Refusals of potassium chloride: 8
Missed doses of Buprenorphine: 3
Pain assessments with pain level 7: 3
Pain assessments with pain level 6: 5
Pain assessments with pain level 5: 1
Pain assessments with pain level 4: 2
Pain assessments with pain level 3: 2
Pain assessments with pain level 1: 2
Pain assessments with pain level 0: 10
Residents needing assistance with transfers: 62
Residents dependent for toilet use: 12
Residents needing one or two person assistance with bathing: 47
Residents dependent for bathing: 24
Residents with pressure ulcers: 2
Residents needing rehabilitative services: 14
Residents needing mechanical lift for transfers: 17
Residents in chair most of the time: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Involved in physical altercation with Resident #4; removed from schedule after investigation |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding care deficiencies, staffing, medication issues, and infection control |
| Interim Nursing Home Administrator | Interim Nursing Home Administrator | Interviewed regarding multiple deficiencies, investigations, and facility follow-up |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed medication pass and interviewed regarding medication refusals and unavailability |
| Certified Nurse Aide #4 | Certified Nurse Aide | Interviewed regarding staffing shortages and care delays |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed regarding restorative care and mechanical lift transfers |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding fall assessments and staffing |
| Pharmacist | Pharmacist | Interviewed regarding medication orders and pharmacy services |
| Physician | Physician | Interviewed regarding medication orders and resident conditions |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed wound care and interviewed regarding infection control practices |
| Registered Dietician | Registered Dietician | Interviewed regarding adaptive eating equipment and dietary staff training |
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