Luxe Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 1, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, self-reported incident (SRI) review, hospital record review, death certificate review, and policy review, the facility failed to ensure residents were transferred safely and appropriately to prevent significant injury. This resulted in Immediate Jeopardy on [DATE] at approximately 6:00 P.M. when Resident #17, who was dependent of two staff members and the use of a mechanical sling lift for safety and the inability to bear weight, was transferred from her bed to her wheelchair by Certified Nursing Assistant (CNA) #400 and #402 without the use of a mechanical sling lift. […]

• Actual harm, isolatedF684Oct 9, 2024

  Based on closed medical record review, hospital record review, interview, and facility policy review, the facility failed to ensure Resident #139, who was admitted to the facility on [DATE] was provided antibiotics timely and as ordered at the time of hospital discharge and failed to ensure laboratory testing associated with the antibiotic use was completed as required to properly treat the resident's osteomyelitis and to prevent complications. Actual harm occurred on 10/01/24 when Resident #139 was transferred to the hospital for treatment of Vancomycin toxicity and acute kidney injury after the facility failed to monitor the antibiotic through laboratory testing. This affected one resident (#139) of eight residents reviewed for laboratory monitoring/testing. […]

• Actual harm, isolatedF684Aug 29, 2024

  Based on interviews, observations, record reviews, and facility policy review, the facility failed to complete vital signs and a transfer form when change of condition was required for Resident #115. This affected one resident (#115) for change of condition and the facility also failed to order daily weights for Resident #442 after surgery upon readmission affecting one resident (#443) reviewed. The facility census was 140. Findings include: 1. Review of Resident #115's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a chronic or unspecified gastric ulcer with hemorrhage, long term (current) use of aspirin, acute post hemorrhagic anemia, Barrett's Esophagus without dysplasia, gastrostomy status, hematemesis, and unspecified dementia. […]

• Actual harm, isolatedF686Aug 29, 2024

  Based on observation, record review, staff interviews, review of wound notes, and facility policy review, the facility failed to accurately assess an identified pressure area and implement interventions to prevent a stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling pressure ulcer to the interdigit of the left fourth and fifth toe and the left fifth toe) for Resident #38. […]

• Actual harm, isolatedF689Aug 29, 2024

  Based on observation, record review, fall investigation review, staff interview and safety belt installation instructions, the facility failed to properly secure one resident (Resident #38) during a transport in the facility's bus. Actual harm occurred on 05/06/24 when Resident #38 who was in a manual wheelchair was placed in the facility bus for transport. The wheelchair was secured with the wheelchair tie down and belts, however, the resident was not secured as recommended with both a torso and pelvic seat belt. The resident slid out of the wheelchair onto the floor of the bus and sustained a left femoral shaft fracture and left great toe fracture. This affected one (Resident #38) of six residents reviewed for falls. […]