AURORA, CO- LOWRY HILLS CARE AND REHABILITATION

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Based on interviews and record review the facility failed to ensure two residents (#60 and #67) of two
residents reviewed out of 39 sample residents, had the right to participate in the development and
implementation of his or her person centered plan of care.

Specifically the facility failed to conduct consistent care planning meetings and invite Resident #60 and #67 to attend a care plan meeting to discuss and develop a person centered plan of care and services that the facility would provide to them.

Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Based on interviews and record review the facility failed to honor resident choices for one (#19) of two reviewed for self-determination, out of 39 sample residents.

Specifically, the facility failed to ensure dependent Resident #19, received showers consistently according to the resident’s preference.

Honor the resident’s right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on record review, observation, and interviews the facility failed to provide prompt responses and resolutions to grievances from residents.

Specifically, the facility failed to respond to resident grievances regarding missing laundry and implement an acceptable resolution for the resident right to keep and use personal belongings and have the facility protect the resident property from theft and or loss.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on observation, record review, and interviews, the facility failed to ensure one (#55) of three residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene, out of 39 sample residents.
Specifically, the facility failed to:
-Provide timely incontinent care;
-Provide timely consistent feeding assistance; and,
-Update care plan for Resident #55 to reflect feeding assistance needs.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on record review, interview, and observation the facility failed to ensure the residents’ environment remained as free from accident hazards as possible, for two (#20 and #42) of six residents reviewed for accident/hazards out of 39 sample residents
Specifically, the facility failed to:
-Provide effective monitoring and supervision of Resident #20’s safety when the resident left the facility without notifying facility staff of an extended absence;.
-Provide health assessment and document the assessment (if done) of Resident #20 upon the resident’s return from extended and overnight absences for the facility when the resident was out in the community in potential unsafe conditions unsupervised by facility staff;
–Provide Resident #20 with appropriate interventions and supervision to prevent the resident from eloping and being missing for hours before staff became aware of the resident’s absence; and,
-Ensure Resident #42 had a safe and appropriate mattress that was a compatible fit for the bed frame; so the mattress was not extending over the bed frame or slipping off the bed frame.

Resident #20’s progress notes were reviewed, the note revealed Resident #20 eloped from the facility on at least 17 occasions between 9/5/22 and 1/26/23 without staff being aware of the resident’s location/whereabouts. When staff did notice the resident was not in the building, usually several hours later they did not make attempts to locate the resident or check on the resident’s safety. The resident record revealed that the resident found to be hanging out behind local business that were several miles from the facility, was without staff assistance to help the resident care for activity of care needs that she was assessed to need assistance with. The resident was found under the influence of a chemically addictive substance, heavily soiled with urine and feces and disheveled upon her return to the facility.

On several occasions the resident’s whereabouts was unknown to facility staff for hours at a time.

On most occasions and no staff went to check on the resident’s well being when they did discover the resident had been missing from the facility for hours at a time; particularly given that the resident was assessed to need long term care services with extensive assistance with activities of daily living tasks such as toileting, transferring, and personal hygiene. Additionally, the resident was known to the facility to have a substance use disorder.

There were delays in reporting the resident’s absence to leadership and in staff taking action to make sure the resident was in a safe situation and had not been victimized while being out for extended periods of time of up to 24 hours or more and with the potential to have been using chemically addictive substances. Notes revealed that on a couple of occasions the resident was observed to be intoxicated upon her return to the facility. There was no document assessment of the resident substance use or how that would impact her safety when in the community unsupervised for extended periods of time. The facility did not develop and implement interventions to respond to the resident substance use disorder. Progress notes were not detailed
and failed to document if the resident was assessed for injuries or condition upon return from being out for hours at a time and overnight on several elopement occasions (see note below for more detail).

Cross-reference F740 for the facility’s failure to address the resident’s mental health needs including substance abuse.