Inspection Reports for
Lowry Hills Care and Rehabilitation

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.