Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lowry Hills Care And Rehabilitation during CMS and state inspections, most recent first.
Two residents with significant care needs were discharged home without comprehensive discharge plans, confirmed home health services, or adequate instructions regarding medications and care. In both cases, documentation was lacking, and necessary arrangements for services and follow-up were not completed, resulting in one resident being hospitalized after a seizure due to missed medications.
A resident with dementia and incontinence did not receive timely incontinence care, remaining in a soiled and saturated brief for over four hours despite multiple staff interactions. Staff failed to follow the care plan requiring checks every two hours, and documentation did not match observed care provided.
Two residents did not receive personalized activity programming as outlined in their care plans, resulting in missed opportunities for engagement in preferred activities such as music, reading, outdoor time, and social interaction. Staff did not consistently invite or assist these residents to participate in group or individual activities, and meaningful engagement was not provided, despite clear documentation of their interests and needs.
A resident with multiple diagnoses, including dementia and MS, was not provided with a prescribed vegetarian diet and was served chocolate cake despite needing to avoid chocolate. The care plan did not reflect the resident's dietary preferences or restrictions, and staff did not consistently use the vegetarian menu extension, resulting in the resident receiving inappropriate meals.
Staff failed to maintain infection control during wound care by not providing a clean area for supplies, not using gowns for high-contact care, and not performing proper hand hygiene or glove changes between tasks. Supplies were placed among personal items, and staff assisted multiple residents without changing gloves or using hand sanitizer, despite being aware of required protocols.
A resident with severe cognitive impairments and a history of aggression physically abused another resident on two occasions. The facility's investigations were inconclusive due to a lack of witnesses and injuries. Staff interviews revealed inadequate training and communication about the assailant's behaviors, contributing to the deficiency.
The facility failed to obtain informed consent for psychotropic medications for three residents. One resident with a court-ordered guardianship was administered Zyprexa without the guardian's consent. Another resident was given olanzapine without being informed of possible drug interactions. A third resident was administered Seroquel and Zoloft without prior informed consent. Staff interviews confirmed that informed consents should be obtained before medication administration.
The facility failed to complete annual performance reviews and provide regular in-service education for five CNAs. The DON confirmed that the reviews and subsequent training had not been conducted, and a full audit would be necessary to identify which employees required evaluations.
The facility failed to maintain sanitary food handling and storage practices. A dietary aide repeatedly handled soiled and clean dishes without proper hand hygiene, and multiple food items in the nourishment refrigerator were not labeled, dated, or disposed of timely. Despite previous education on hand hygiene and food safety policies, these standards were not consistently followed, leading to unsanitary conditions.
The facility failed to maintain a sanitary and safe environment in one of its shower rooms. Observations revealed damp and stained chairs, a dirty shower curtain, holes in the walls, debris in the grout, missing floor tiles, and personal hygiene items and trash on the floor. Staff interviews indicated a lack of awareness and adherence to cleaning procedures.
The facility failed to ensure that five CNAs received the required 12 hours of annual in-service training. The SDC admitted that there was no process to track the training hours and was working on developing a tracking form and new employee training packets.
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice by not obtaining weekly weights per physician's orders for two residents. One resident with severe protein-calorie malnutrition and another with severe cognitive impairment did not have their weights monitored as required, leading to a deficiency in care.
A resident was administered acetaminophen in excess of the recommended dose and was not given hydralazine as needed for high blood pressure. Staff failed to notify the physician of these issues, leading to potential health risks for the resident.
The facility failed to properly store and label medications, including not disposing of expired medications and not labeling insulin pens and Tubersol vials with open dates. Expired medications were found in the main nurses' medication room and the 400 hall medication cart, posing risks to residents.
The facility failed to provide mechanically altered diets as prescribed, serving residents inappropriate food textures such as non-pureed stuffed peppers, non-slurried wheat rolls, and non-pureed corn. The dietary manager and staff were not adequately trained, leading to these deficiencies.
The facility failed to maintain an infection control program, as housekeeping staff did not follow proper cleaning techniques, were not appropriately trained, used incorrect surface disinfectant products, and did not adhere to disinfectant times. Observations revealed improper cleaning practices, and interviews confirmed a lack of training and awareness among staff.
The facility failed to complete a Level II PASRR for a resident with mild neurocognitive disorder and major depressive disorder, despite a recommendation for the assessment. The resident was cognitively intact and required minimal assistance with daily activities. Interviews with staff confirmed the oversight.
The facility failed to provide scheduled showers to two residents who were dependent on staff for bathing. Resident #69 and Resident #35 missed multiple scheduled showers and bed baths over several months, despite their care plans indicating the need for assistance with bathing. Staff interviews confirmed the importance of scheduled showers for hygiene and skin integrity, but the reason for the missed showers was not determined.
Failure to Ensure Safe and Person-Centered Discharge Planning
Penalty
Summary
The facility failed to ensure that two residents were provided with the necessary care and services to support a safe and person-centered discharge to the community. One resident, who was cognitively intact but required substantial assistance with all activities of daily living (ADLs) due to multiple sclerosis and muscle weakness, was discharged home without a documented care plan addressing discharge goals and needs. The resident's representative reported that there was no discharge planning until a few days prior to discharge, and that the facility did not arrange for home health services or complete the necessary Medicaid waiver in time. As a result, the resident was discharged without confirmed services in place, despite assurances that home health care would begin the same day. Documentation in the electronic medical record (EMR) did not show a completed plan for follow-up monitoring or contingency actions if services could not be started immediately. Another resident, also cognitively intact and dependent on staff for all ADLs due to quadriplegia and other complex medical needs, was discharged home without a thorough discharge plan. The resident's representative stated that the facility did not complete the waiver services application, did not provide a medication list or instructions, and did not arrange for a primary physician. After discharge, the resident experienced a seizure and was hospitalized, with the representative reporting that they were unaware the resident was supposed to take anti-seizure medications. Review of the EMR did not reveal documentation of a comprehensive discharge plan, updated care plan, or evidence that the resident or representative received necessary information regarding medications or care needs at discharge. Staff interviews confirmed that discharge planning was not always documented, and that in both cases, there was no formal discharge care plan or documentation of interdisciplinary team (IDT) involvement at discharge. The facility's own policy required that discharge planning begin on admission, be regularly updated, and be fully documented, including referrals and updates to the care plan. However, the records for both residents lacked evidence of these required actions, and the facility failed to ensure that the residents' needs and preferences were met or that they were prepared for a safe transition to the community.
Failure to Provide Timely Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary incontinence care and assistance with activities of daily living (ADLs) for a resident with cognitive impairment and incontinence. According to the care plan, the resident required assistance with toileting and was to be checked every two hours. However, direct observation revealed that the resident was not offered or provided incontinence care for over four and a half hours while he remained in his wheelchair, despite multiple interactions with CNAs. The resident's brief was found to be soiled and saturated only after survey staff intervened and notified a registered nurse, prompting care to be provided. Documentation inconsistencies were also noted, as CNA task records indicated incontinence care was provided at a time when the resident was observed napping in the dining room. Staff interviews confirmed that the expectation was to provide incontinence care every two hours and to address refusals by re-approaching the resident within 15 to 20 minutes. Despite these policies, the resident did not receive timely care, and staff did not follow the established protocol for managing incontinence and refusals.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program that met the individualized needs and preferences of two residents, as required by their care plans. For one resident with multiple sclerosis and autism, who was cognitively intact, the care plan specified interests such as reading, writing, music, pet visits, outdoor time, and spiritual activities. However, records and interviews revealed that this resident was not invited to activities, did not receive assistance to go outside, and did not participate in pet visits or spiritual activities, despite these being documented as important to him. Another resident with dementia, blindness, and chronic kidney disease, who required moderate ADL assistance, was also not provided with activities aligned with his preferences. Observations showed that staff did not offer or facilitate engagement in music, news, coffee time, or other preferred activities, even though these were outlined in his care plan. The resident was often left in his room or in common areas without meaningful interaction or stimulation, and staff did not provide reminders or assistance to participate in group or individual activities. Staff interviews confirmed that while activity preferences were assessed and calendars provided, there was inconsistency in inviting and encouraging residents to participate in activities. The activities director acknowledged that CNAs may need reminders and re-education to ensure residents are consistently engaged according to their care plans. The lack of personalized activity programming and failure to offer or encourage participation resulted in unmet physical, mental, and psychosocial needs for the affected residents.
Failure to Accommodate Dietary Preferences and Restrictions
Penalty
Summary
The facility failed to provide food and drinks that accommodated a resident's allergies, intolerances, and preferences, specifically not ensuring a vegetarian diet as prescribed and preferred by the resident. Despite a physician's order and meal ticket indicating a vegetarian diet, the resident was served non-vegetarian food, including a pork chop at lunch and marble cake containing chocolate at dinner, which the resident was supposed to avoid due to a prior medical procedure. The resident reported that her food choices were repetitive and that she was not offered a vegetarian diet during her stay. Review of the care plan revealed it did not identify the resident's preference for a vegetarian diet or her inability to eat chocolate cake. Staff interviews confirmed that although a vegetarian menu extension existed, it was not utilized for this resident. The dietary manager stated that the resident would communicate her food preferences directly to the kitchen, but a specific vegetarian menu was not consistently provided. The registered dietitian acknowledged learning only recently about the resident's need to avoid chocolate, confirming that the cake served contained chocolate.
Failure to Maintain Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during wound care for several residents. Staff did not consistently provide a clean location for wound care supplies, with one instance where dressing change supplies were placed on a resident's bedside table among personal food items without cleaning the table or creating a clean field. This was contrary to facility policy, which requires setting up a clean field for wound care supplies. Staff also failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during high-contact care activities. Certified nurse aides (CNAs) assisted with repositioning residents for wound care without donning gowns, as required for high-contact activities involving residents with wounds. In several cases, CNAs and licensed practical nurses (LPNs) did not change gloves or perform hand hygiene between dirty and clean tasks, such as after removing soiled dressings or cleaning wounds and before applying new dressings. One CNA left a resident's bedside during wound care to assist another resident and returned without changing gloves or performing hand hygiene. Interviews with staff confirmed awareness of the required procedures, including the need for gowns during wound care and the importance of hand hygiene after glove removal and between tasks. However, staff acknowledged that these practices were not consistently followed, citing issues such as lack of hand sanitizer or paper towels, but also recognizing that these were not valid reasons to omit hand hygiene. The director of nursing and other clinical leaders confirmed that the observed practices did not meet facility policy or CDC guidelines.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. The incidents involved two altercations between the residents, where one resident was the victim of hair-pulling and coffee-splashing by the other resident. Despite the incidents, the facility's investigations were unable to substantiate the abuse due to a lack of witnesses and the absence of injuries or intent to harm. The victim, who had moderate cognitive impairments, did not recall the incidents and denied feeling unsafe. The assailant, who had severe cognitive impairments and a history of delusional thinking and aggression, was involved in multiple incidents of aggression. The facility's interventions included one-on-one supervision and psychological support, but the interventions were not consistently documented or effectively communicated to the staff. The assailant's behaviors were not adequately monitored, and there was no behavior monitoring order in place until after the survey began. Staff interviews revealed a lack of training and communication regarding the assailant's behaviors and triggers. The DON acknowledged the challenges in creating effective interventions due to the assailant's cognitive fluctuations and delusions. The facility's failure to implement and document appropriate interventions and staff training contributed to the deficiency, as the staff was not adequately prepared to manage the assailant's aggressive behaviors.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of psychotropic medications for three residents. Resident #46, who was moderately cognitively impaired and had a court-ordered guardianship, was administered Zyprexa without the guardian's consent. The resident's electronic medical record did not contain an informed consent signed by the guardian, and the consent form provided was signed by the resident without a date, despite the resident being unable to make decisions due to confusion from medical diagnoses. Staff interviews confirmed that the informed consent should have been obtained from the guardian before administering the medication. Resident #25, who was cognitively intact, was administered olanzapine without being informed of the possible interactions with his other medications, including mirtazapine. The resident's electronic medical record lacked documentation indicating that he was informed of the risks associated with the medication. Although a medication review was conducted during the survey, it did not specifically document that the resident was informed of the risks of taking olanzapine. Staff interviews revealed that informed consents should be obtained upon the resident's arrival and for any new medication orders. Resident #47, who was cognitively intact and diagnosed with generalized anxiety disorder and bipolar depression, was administered Seroquel and Zoloft without informed consent. The resident's electronic medical record showed that the informed consents for these medications were signed during the survey, not prior to the administration. Staff interviews confirmed that informed consents should be signed before administering psychotropic medications to ensure residents and their representatives are aware of the risks and side effects.
Failure to Complete Annual Performance Reviews and In-Service Education for CNAs
Penalty
Summary
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 certified nurse aides. Specifically, the facility had not completed annual performance reviews for CNAs #1, #4, #5, #6, and #7 to determine potential training needs. The Evaluation Process policy, revised on 4/12/24, mandates a formal written evaluation of employees' work performance, including job performance, achieving goals, attendance record, and adherence to workplace policies. However, the facility was unable to provide annual performance evaluations for 2023 for the five CNAs mentioned above. The Director of Nursing (DON) confirmed that the annual performance reviews for CNAs #1, #4, #5, #6, and #7 had not been completed, and consequently, these CNAs had not received the required annual in-service education based on the outcome of their reviews. The DON, who had only been employed at the facility during the week of the survey, stated that she was unaware of which employees had their performance reviews completed by the previous DON and would need to conduct a full audit to determine which employees required their performance evaluations to be completed.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner, specifically in the areas of hand hygiene and food labeling. During lunch meal service, a dietary aide (DA) repeatedly handled soiled dishes and then clean dishes without performing proper hand hygiene. The DA was observed lifting the dish machine door, handling soiled dishes, and then immediately touching clean and sanitized dishes without washing her hands. This occurred multiple times, including instances where the DA used gloves to handle dirty dishes and then touched clean items without changing gloves or washing hands. Despite the facility's policy and previous education on hand hygiene, the DA did not adhere to these standards, leading to potential cross-contamination of clean dishes used for food production. In addition to hand hygiene issues, the facility also failed to ensure that food in the nourishment refrigerator was properly labeled, dated, and disposed of in a timely manner. Observations revealed multiple items in the refrigerator that were either not labeled, not dated, or had expired dates. These included plastic food containers, a fast food sandwich bag, a sandwich in a clear bag, a container of carrot juice, an open yogurt container, and individual portion cups. Some items had resident names but no dates, while others had neither. The facility's policy required that all food be labeled, dated, and monitored for expiration, but this was not consistently followed. Interviews with staff, including the director of housekeeping, dietary manager (DM), and nursing home administrator (NHA), confirmed that hand hygiene education had been provided but was not effectively implemented. The dietary aide admitted to not receiving recent handwashing education until the survey. The DM and NHA acknowledged that the dietary staff were responsible for monitoring the refrigerator and removing expired items, but this was not done consistently. The failure to follow proper hand hygiene and food labeling procedures led to unsanitary conditions in the facility's food handling and storage areas.
Facility Fails to Maintain Sanitary and Safe Shower Room
Penalty
Summary
The facility failed to maintain a sanitary and safe environment in one of its shower rooms, as observed on 5/7/24. The shower room between unit 100 and 200 had two wooden fabric woven chairs that were damp and stained, a shower curtain divider with brown and black stains that touched the ground, and multiple holes in the walls with jagged tile edges. The grout in the shower room had hardened debris, and there were missing floor tiles by the shower entrance. Additionally, personal hygiene items, trash, and a razor were found on the floor, and the sharps container was full. No disinfectant products were visible for CNAs to use between residents, except for a bottle of glass cleaner on the floor. Interviews with staff revealed a lack of awareness and adherence to cleaning procedures. Housekeeper #1 was unaware of the need to clean the shower room, and the Director of Housekeeping acknowledged that the shower room was not being cleaned according to the facility's procedures. The Director of Nursing and the Infection Preventionist confirmed that the chairs used in the shower room were inappropriate due to their porous surfaces and potential to harbor bacteria. They also noted that all items should be picked up off the floor, sharps should be disposed of properly, and broken tiles and holes in the wall should be repaired to prevent pathogen development.
Failure to Provide Required Annual Training for CNAs
Penalty
Summary
The facility failed to ensure that five certified nurse aides (CNAs) received the required 12 hours of annual in-service training for continued competence. The facility's policy mandates that each nurse aide must receive at least 12 hours of in-service training annually, based on their employment date. However, a review of the training records revealed that documentation of the annual training was not maintained for the five CNAs. The Staff Development Coordinator (SDC) admitted that the facility did not have a process to track the required training hours and was in the process of developing a tracking form and new employee training packets. The SDC also mentioned that a skills fair was planned for June 2024 to address the training needs.
Failure to Monitor Weekly Weights as Ordered
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two residents reviewed for nutrition status. Specifically, the facility did not obtain weekly weights per the physician's orders for Resident #60 and Resident #58. Resident #60, who was under 65 years old and had severe protein-calorie malnutrition among other diagnoses, had a physician's order for weekly weights starting from 2/26/24. However, the facility did not record any weights between 2/3/24 and 4/1/24, during which the resident lost 4.3 pounds, or 4.4% of his body weight. This weight loss was not significant but indicated a failure to follow the physician's orders for weekly monitoring. Resident #60 expressed concern about his recent weight during an interview on 5/1/24, highlighting the facility's oversight in monitoring his nutritional status as required by the physician's order and facility policy. The facility's policy stated that newly admitted residents and those with weight loss should have their weight monitored weekly for four weeks, but this was not adhered to in Resident #60's case. Resident #58, who was over 65 years old and had severe cognitive impairment along with other diagnoses, also had a physician's order for weekly weights starting from 4/17/24. However, her weight was not obtained after her initial admission weight on 4/3/24. The electronic medical record (EMR) noted that weights were not applicable or the resident was not available on the scheduled dates, and there was no documentation of refusal except for one instance on 4/25/24. The facility updated the physician's order on 5/6/24 to weigh Resident #58 every Tuesday for four weeks, but this was during the survey and did not address the initial failure to follow the physician's orders. Interviews with staff, including a CNA and an LPN, revealed that residents were supposed to be weighed upon admission and then every two weeks, with more frequent weighing if requested. Staff were also expected to document refusals and notify a nurse if a resident refused to be weighed. The DON confirmed that staff should obtain residents' weights per the facility policy and document any refusals. Despite these procedures, the facility did not adhere to the physician's orders for weekly weights for both residents, leading to a deficiency in providing appropriate treatment and care according to professional standards of practice.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #46's drug regimen was free from unnecessary drugs. Specifically, the resident was administered acetaminophen in excess of the recommended maximum dose of 3 grams in a 24-hour period. On two occasions, the resident received an additional 650 mg of acetaminophen over the maximum recommended dose, and there was no documentation that the physician was notified of this excessive dosage. Additionally, the resident had an as-needed order for hydralazine to be administered for systolic blood pressure over 160 mmHg, but the medication was not administered on two occasions when the resident's blood pressure exceeded this threshold. There was also no documentation that the physician was notified of the missed doses of hydralazine. Resident #46, who is over 65 years old, has multiple diagnoses including atrophy of the kidney, cerebral infarction, osteomyelitis of the lumbar vertebra, dementia with psychotic disturbances, and hypertension. The resident is dependent on staff for various activities of daily living and has moderate cognitive impairment. The resident's medication regimen included scheduled acetaminophen and as-needed acetaminophen for pain, as well as as-needed hydralazine for high blood pressure. Interviews with staff revealed a lack of awareness and adherence to the physician's orders. An LPN stated she was unaware of the as-needed order for hydralazine and acknowledged the risks of not administering antihypertensive medication. The DON confirmed that nurses should check blood pressure before administering antihypertensive medications and that not administering these medications could place the resident at risk. The DON also stated that exceeding the recommended dose of acetaminophen could strain the resident's liver and that the physician should be notified in such cases, which was not done.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards. Specifically, the facility did not dispose of expired medications and vaccines in a timely manner, and failed to label insulin pens and Tubersol vials with open dates. Observations revealed that expired medications, including Lantus insulin pens, Tubersol vials, and a Spivax Covid-19 vaccine, were found in the main nurses' medication room. Additionally, an opened Novolog insulin vial was found to be six months past the recommended use-by date. Registered Nurse #2 acknowledged that expired medications should have been removed to prevent administration to residents. Further observations in the 400 hall medication cart revealed that Latanoprost eye drops were stored well past their recommended use-by dates, and a vial of Lantus insulin with no open date was found stored improperly. Registered Nurse #1 confirmed that it was the nurses' responsibility to remove expired medications and acknowledged the risks associated with using expired medications, including reduced effectiveness and potential bacterial growth in eye drops. The Director of Nursing (DON) confirmed that insulin medications were only good for 30 days once opened and emphasized the importance of labeling medications with open dates. However, the DON's understanding of the expiration periods for Novolog, Lantus, and Latanoprost did not align with the manufacturer's guidelines. The DON reiterated that it was the nurses' responsibility to ensure expired and discontinued medications were removed from the medication carts and refrigerators to maintain medication efficacy for residents.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure residents who were prescribed mechanical soft diets received food prepared according to their diet orders. During a lunch meal service, it was observed that the mechanically altered items were not prepared correctly. Specifically, the stuffed pepper was not pureed, the corn was not served in a pureed form, and the wheat roll was not slurried. These discrepancies were noted despite the facility's dietary manual and mechanically altered diet menu specifying the required modifications for these items. The cook identified the incorrect items as mechanical soft foods, and the dietary manager admitted to not following the mechanically altered menus, instead using the dietary manual as a guideline. Further interviews revealed that the dietary manager was new to the facility and unfamiliar with the menu program, which contributed to the failure in providing the correct mechanically altered foods. Additionally, a certified nurse aide (CNA) reported not receiving training on mechanically altered diets or how to recognize if a modified texture diet was prepared incorrectly. This lack of training and awareness among staff members further exacerbated the issue, leading to residents receiving food that did not meet their prescribed dietary needs. The nursing home administrator (NHA) acknowledged the deficiencies and mentioned that the facility planned to transition to the International Dysphagia Diet Standardization Initiative (IDDSI) with the help of speech therapists for staff training. However, at the time of the incident, the facility's failure to adhere to the prescribed mechanical soft diet modifications resulted in residents being served inappropriate food textures, posing a potential risk to their health and safety.
Inadequate Infection Control Practices in Housekeeping
Penalty
Summary
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 infections on two of six units. Specifically, the facility did not ensure that housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high-frequency touch areas such as call lights, door handles, and handrails. Additionally, housekeeping staff were not appropriately trained on housekeeping procedures, did not use the correct surface disinfectant products, and did not adhere to surface disinfectant times as required by the facility's policy and procedure. During observations, it was noted that housekeeping staff used a surface cleaner instead of a disinfectant to clean the surfaces in resident rooms. Housekeeping staff used the same cleaning agent-soaked cloth to clean multiple surfaces and did not sanitize or clean high-frequency touch areas. For example, in one instance, a housekeeper used a toilet brush to clean both the inside and outside of the toilet bowl, which is against proper cleaning protocols. Interviews with housekeeping staff revealed that they were not trained properly and were unaware of the high-frequency touch areas that needed to be disinfected. The Director of Housekeeping (DOH) acknowledged the deficiencies and stated that there were areas of opportunity to improve housekeeping and routine room cleaning procedures. The DOH admitted that the facility disinfectant needed to be used when cleaning resident rooms and that high-frequency touch areas needed to be disinfected. The Director of Nursing (DON) and the Infection Preventionist (IP) also confirmed that surface disinfectant times should be adhered to and that only approved facility disinfectant products should be used. They emphasized that housekeeping staff should change cleaning cloths and gloves and complete hand hygiene appropriately between different areas of cleaning the resident rooms.
Failure to Complete Level II PASRR for Resident
Penalty
Summary
The facility failed to ensure a Level II preadmission and resident review (PASRR) was completed for one of the residents reviewed. Specifically, Resident #33, who was younger than 65 and had diagnoses including mild neurocognitive disorder, nonpsychotic mental disorder, and major depressive disorder, was recommended for a Level II PASRR evaluation. However, the facility did not complete this assessment. The resident was cognitively intact with a BIMS score of 14 out of 15 and required minimal assistance with activities of daily living. Despite the recommendation for a Level II PASRR, there was no evidence that it had been completed, and the resident's behavior care plan indicated resistance to care related to major depression. Interviews with the social services director (SSD) and the director of nursing (DON) confirmed the oversight. The SSD acknowledged that a Level II PASRR was recommended but not completed and stated that she would immediately submit a request for the assessment. The DON emphasized the importance of completing a Level II assessment to document triggers for behaviors and determine the level of care needed. The SSD conducted an audit of all Level I PASRRs to ensure compliance moving forward, but this action was taken after the deficiency was identified.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not provide scheduled showers to Resident #69 and Resident #35, who were dependent on staff for bathing. This deficiency was identified through observations, record reviews, and interviews with the residents and staff members. Resident #69, who had diagnoses including chronic kidney disease, congestive heart failure, and traumatic brain injury, reported that he had not received his scheduled showers for three weeks. The review of shower logs confirmed that Resident #69 missed multiple scheduled showers from February to May 2024. The ADL care plan for Resident #69 indicated that he required supervision and assistance with showering due to his self-care performance deficit. Similarly, Resident #35, who had diagnoses including Guillain-Barre syndrome, muscle weakness, and morbid obesity, also reported not receiving his scheduled bed baths. The review of shower logs revealed that Resident #35 missed several scheduled bed baths from February to April 2024. The ADL care plan for Resident #35 indicated that he required assistance with bathing and preferred sponge baths when a full bath or shower could not be tolerated. Interviews with staff members, including CNAs and the DON, confirmed the importance of scheduled showers for hygiene and skin integrity, but they were unable to explain why the showers were missed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Park Rehabilitation & Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Center At Lowry, Llc | 1.1 mi | ★★★★★ | 11 | 0 |
| Hilltop Park Post Acute | 2.2 mi | ★★★★★ | 1 | 0 |
| Veterans Community Living Center At Fitzsimons | 2.4 mi | ★★★★★ | 0 | 0 |
| Berkley Manor Care Center | 2.4 mi | ★★★★★ | 23 | 0 |
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