Lowry Hills Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lowry Hills Care and Rehabilitation, in the surveyor’s own words.

• Actual harm, patternF725Oct 14, 2021

  Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide an adequate number of nursing staff to address the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility failed to: -Provide care and services in a dignified, respectful manner and environment (cross-reference F550); -Provide necessary care and services to ensure residents' activities of daily living (ADL) needs were met (cross-reference F676); -Provide necessary care and services to prevent… […]

• Actual harm, isolatedF627Jun 26, 2025

  III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged home on [DATE]. According to the [DATE] CPO, diagnoses included multiple sclerosis (a disease that damages nerves and affects muscle control), muscle weakness and autistic disorder (developmental disorder). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial assistance with ADLs. The MDS assessment revealed the resident was going to stay at the facility for long term care. B. Resident #1's representative interview Resident #1's representative was interviewed on [DATE] at 10:30 a.m. The representative said Resident #1 discharged from the facility to home (on [DATE]). […]

• Actual harm, isolatedF686Dec 6, 2023

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

• Actual harm, isolatedF600Apr 18, 2023

  Based on interviews and record review the facility failed to ensure one (#1) of three sample residents were free from sexual abuse. The facility failed to protect Resident #1 who no longer wanted her prior consensual intimate relationship with Resident #2. On 3/22/23 (one day after Resident #1 returned from the hospital) Resident #2 came into Resident #1's room while she was sleeping and without her consent did a sexual act on her. Resident #1 said she was sleeping on 3/22/23 and the sexual act was non-consensual. After the 3/22/23 abuse, Resident #1 was moved to a different hallway in the facility to keep her away from Resident #2. On 4/6/23 Resident #2 came into her new room while she was sleeping and did a sexual act to her which again, which Resident #1 said also was non-consensual. […]

• Actual harm, isolatedF550Oct 14, 2021

  Based on observations, interviews and record review, the facility failed to ensure care was provided for one (#68) of one resident out of 37 sample residents in a manner and in an environment that maintained or enhanced the resident's dignity and respect, in full recognition of his or her individuality. The facility failed to provide timely assistance and adaptive utensils for Resident #68, who was experiencing violent tremors while attempting to eat his meals. Staff failed to respond appropriately and in a timely manner to assist the resident in a dignified manner, causing the resident distress and psychosocial harm. Cross-reference F725 failure to provide sufficient nursing staffing, and F810 failure to provide adaptive eating utensils. Findings include: I. […]