Luxe at Lutz Rehabilitation Center (The)

In the surveyor’s words

From the most serious findings on record at Luxe at Lutz Rehabilitation Center (The), in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 12, 2021

  Based on interviews with facility nursing and administrative staff , Resident #6's family member, Witness #1, the Medical Director, Resident #6's Primary Care Physician (PCP), and the Psychiatric Advanced Registered Nurse Practitioner (ARNP), review of the resident's medical record and facility policies, and observation of the facility layout including the location of Resident #6's room, hallways, exit doors and parking areas, it was determined facility staff failed to recognize the need for and provide necessary interventions for one Resident, (#6) of four residents sampled for risk of elopement, related to a change in condition, beginning on 01/15/2021 in which she displayed agitation, medication refusals, aggression, and subsequent exit seeking behavior. […]

• Immediate jeopardy, isolatedF610Feb 12, 2021

  Based on observation of the facility layout including the location of Resident #6's room, hallways, entrances, exits, and parking areas, review of resident medical records, facility policies and photographic evidence, and interviews with the facility's nursing and administrative staff, Resident #6's family member, Witness #1, the Medical Director, Resident #6's Primary Care Physician (PCP), and the Psychiatric Advanced Registered Nurse Practitioner (ARNP), the facility failed to thoroughly investigate how one resident of four sampled residents (Resident #6), with a previous history of verbalizing suicidal thoughts and wandering, was able to elope from the building. […]

• Immediate jeopardy, isolatedF689Feb 12, 2021

  Based on observation of the facility layout including the location of Resident #6's room, hallways, entrances, exits, and parking areas, review of resident medical records, facility policies and photographic evidence, and interviews with the facility's nursing and administrative staff, Resident #6's family member, a witness, the Medical Director, Resident #6's Primary Care Physician (PCP), and the Psychiatric Advanced Registered Nurse Practitioner (ARNP), it was determined that the facility failed to provide the level of supervision needed to prevent an elopement for one (Resident #6) of four residents sampled for elopement. […]

• Actual harm, isolatedF695May 7, 2025

  Based on interviews and record review, the facility failed to ensure continuous oxygen therapy was provided in consistent with professional standards of practice, related to failure to ensure the resident's record included accurate and active physician orders and on-going assessment of the resident's respiratory status and response to oxygen therapy, for two (#18 and #12) of two residents reviewed, resulting in Resident #18 experiencing respiratory distress requiring emergency hospitalization . Findings included: 1. […]

• No harm, potential for more than minimal, patternF842May 7, 2025

  Based on observation, staff interview and policy and procedure review, the facility did not ensure resident medical records and confidential medical information were safeguarded in a confidential manner that would prevent unauthorized access on two (100 and 200) of two halls toured. Findings included: A tour of the 200 hall was conducted on 5/5/25 at 9: 32 a.m. A two-tiered rack was observed in the hallway. The rack contained white binders with room numbers on them, and a DNR ( Do Not Resuscitate) book containing resident specific information. The binders were observed to be easily accessible to anyone walking down the hallway to include residents, family members, vendors and visitors. Subsequent tours of the 200 hall were conducted on 5/5/25 at 4: 45 p.m. and 5/6/25 at 10: 44 a.m. […]