Inspection Reports for
Conway Healthcare and Rehabilitation Center
2603 Dave Ward Drive, Conway, AR, 72034
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to properly handle the discharge of Resident #81, who filed an appeal against an involuntary discharge.
Complaint Details
The complaint involved Resident #81's involuntary discharge despite filing an appeal. The Ombudsman and family confirmed the appeal was filed and the resident did not want to be discharged. The facility discharged the resident anyway, citing improper behavior and smoking policy violations, though staff interviews did not confirm physical abuse or smoking.
Findings
The facility discharged Resident #81 despite an active appeal against the discharge. Interviews and record reviews revealed conflicting accounts about the resident's behavior and the discharge process. The facility policy states residents cannot be discharged while an appeal is pending unless safety is endangered, which was not clearly demonstrated.
Deficiencies (1)
Facility failed to discharge Resident #81 properly after an appeal was filed, violating transfer/discharge policies.
Report Facts
Discharge notice period: 30
Brief Interview of Mental Status score: 15
Dates: Jul 23, 2024
Dates: Jul 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #5 | Certified Nurse Aide | Interviewed and indicated Resident #81 was never witnessed being physically abusive |
| Certified Nurse Aide #9 | Certified Nurse Aide | Interviewed and did not remember Resident #81 physically harming another resident |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed and did not know why Resident #81 was discharged; never witnessed abuse or smoking |
| Medical Director | Medical Director | Phone interview stated he did not know why Resident #81 was discharged |
| Administrator | Administrator | Interviewed and stated Resident #81 was discharged for improper behavior and smoking policy violations despite appeal |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The inspection was conducted due to complaints regarding improper discharge of Resident #81 despite an appeal, medication errors involving Residents #35, #52, and #76, failure to provide timely care and response to alarms for Residents #8 and #69, and infection control concerns during perineal care for Residents #69 and #74.
Complaint Details
The complaint investigation focused on Resident #81's discharge despite an appeal, medication errors including a significant error causing hospitalization of Resident #52, failure to respond to alarms and call lights for Residents #8 and #69, and infection control breaches during perineal care for Residents #69 and #74.
Findings
The facility failed to comply with regulations by discharging Resident #81 despite an appeal being filed, resulting in minimal harm. Medication errors were identified, including a significant error causing hospitalization of Resident #52 due to administration of another resident's medications. The facility also failed to respond timely to feeding tube alarms and call lights for Residents #8 and #69, and did not ensure proper hand hygiene during perineal care for Residents #69 and #74, risking cross contamination.
Deficiencies (5)
Failed to ensure Resident #81 was not discharged while an appeal was pending.
Failed to provide timely response to feeding tube alarm and call light for Resident #8 and Resident #69.
Medication error rate exceeded 5%, including substitution of unavailable eye drops for Resident #35 and administration of wrong medications to Resident #52 causing hospitalization.
Medication cart was found unlocked, risking resident safety.
Failed to ensure proper hand hygiene and glove changes during perineal care for Residents #69 and #74, risking cross contamination.
Report Facts
Medication error rate: 6.67
Medication administration observation count: 30
Brief Interview of Mental Status score: 15
Brief Interview of Mental Status score: 3
Brief Interview of Mental Status score: 13
Medication Administration Record date: 2024
Medication Administration Record date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Involved in medication error causing hospitalization of Resident #52 |
| LPN #7 | Licensed Practical Nurse | Responded to Resident #8's feeding tube alarm |
| CNA #4 | Certified Nursing Assistant | Observed providing perineal care to Resident #69 and Resident #74 |
| CNA #5 | Certified Nursing Assistant | Observed providing perineal care to Resident #69 |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding Resident #81 and call light response |
| CNA #9 | Certified Nursing Assistant | Interviewed regarding Resident #81 |
| LPN #12 | Licensed Practical Nurse | Administered medication to Resident #35 and observed unlocked medication cart |
| MAC #11 | Medication Assistant Certified | Administered medication to Resident #76 |
| Administrator | Facility Administrator | Interviewed regarding Resident #81 discharge and medication errors |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication errors, call light response, and infection control |
| Medical Director | Medical Director | Interviewed regarding Resident #81 discharge and medication error of Resident #52 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication availability and errors |
| Ombudsman | Interviewed regarding Resident #81 discharge appeal |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 31, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, focusing on potential hazards such as floor clutter, detached wall vinyl, and detached wall rails.
Findings
The facility failed to maintain a safe environment due to floor clutter, detached wall vinyl, detached wall rails, and wall damage posing potential hazards for falls. Maintenance requests for these issues were not documented, and repairs had not been made at the time of inspection.
Deficiencies (4)
Failure to maintain a safe and homelike environment due to floor clutter including cardboard boxes, clothes, and personal items obstructing pathways.
Detached 6-inch wall vinyl four feet in length in the dining room with brownish-black discolored stains and debris on the floor.
Detached wall rail, eight inches by five feet, held up by a bedside table in a resident room.
Detached vinyl trim six inches by two feet and wall gashes with fuzzy residue near resident sleeping area.
Report Facts
Detached wall vinyl length: 4
Detached wall rail size: 5
Detached vinyl trim size: 2
Detached vinyl trim width: 6
Wall gash size: 1
Wall gash size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Responded to questions about maintenance availability and facility conditions | |
| Corporate Nurse Consultant | Responded to questions about maintenance availability and stated repairs will be made immediately |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Date: May 6, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse involving two residents, Resident #47 and Resident #54, including verbal and physical altercations.
Complaint Details
The complaint investigation was substantiated with findings of repeated resident-to-resident verbal and physical abuse between Resident #47 and Resident #54, causing psychosocial harm risk. Immediate jeopardy was identified and later removed after implementation of a removal plan and staff training.
Findings
The facility failed to ensure residents were free from abuse, with continuous verbal and physical altercations between Resident #47 and Resident #54, posing psychosocial harm risk to all 66 residents. The facility implemented a removal plan and staff in-service training to address the issue, and no immediate jeopardy remained at the time of the survey.
Deficiencies (2)
Failure to protect residents from all types of abuse including physical and verbal abuse between residents.
Failure to update and implement an accurate care plan for Resident #54 regarding placement and behavior management.
Report Facts
Residents affected: 66
Dates of incidents: Incidents occurred on 03/11/2024, 04/10/2024, 04/12/2024, and ongoing through May 2024.
Observation times: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding resident altercations and interventions. | |
| Assistant Administrator | Participated in resident audits and staff in-service related to resident altercations. | |
| Nurse Consultant | Provided in-service education and coordinated behavioral health services. | |
| Licensed Practical Nurse #2 | LPN | Interviewed Resident #54 during altercation incident. |
| Certified Nursing Assistant #3 | CNA | Interviewed about frequency and management of resident altercations. |
| MDS Coordinator | Interviewed about importance of accurate care plans. |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 8
Date: May 6, 2024
Visit Reason
The inspection was conducted due to complaints and allegations related to resident safety, abuse, care plan accuracy, contracture management, medication use, infection control, and immunization practices.
Complaint Details
The complaint investigation was triggered by allegations of resident abuse, failure to provide adequate care and protection, medication concerns, infection control lapses, and immunization deficiencies. Immediate Jeopardy was identified related to resident-to-resident abuse but was removed after corrective actions were verified.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' call devices were within reach, failure to protect residents from abuse and altercations, failure to update care plans accurately, inadequate interventions to prevent contracture worsening, failure to ensure psychotropic medications were used appropriately, unsanitary food preparation and storage conditions, lapses in infection control practices related to laundry handling and trash management, and failure to provide pneumococcal vaccinations to residents.
Deficiencies (8)
Failed to ensure residents' call devices were in reach for 1 resident.
Failed to protect residents from verbal and physical abuse between two residents, resulting in Immediate Jeopardy that was later removed.
Failed to update care plan regarding resident placement and behaviors for 1 resident.
Failed to provide appropriate interventions to maintain or improve range of motion for 2 residents.
Failed to ensure residents were free from unnecessary psychotropic medication for 1 resident.
Failed to ensure dishes/utensils were stored under sanitary conditions and food preparation equipment was cleaned properly in the kitchen.
Failed to ensure hand hygiene was performed between resident rooms while delivering clean laundry and failed to keep trash barrel covered to prevent resident access.
Failed to provide pneumococcal vaccine for 2 residents.
Report Facts
Residents affected: 1
Residents affected: 66
Residents affected: 14
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Interviewed regarding call light accessibility and resident altercations |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding resident altercations and calming residents |
| Dietary Manager | Interviewed regarding resident altercations and kitchen sanitation | |
| Administrator | Interviewed regarding resident altercations, care plans, and infection control | |
| Assistant Administrator | Interviewed regarding resident altercations and staff in-service | |
| Nurse Consultant | Provided education and verified removal of Immediate Jeopardy | |
| Laundry #1 | Observed and interviewed regarding laundry handling and infection control | |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding psychotropic medication use for Resident #51 |
| ADON | Assistant Director of Nursing | Interviewed regarding psychotropic medication use, resident altercations, and infection control |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding resident altercations and contracture interventions |
| RN #1 | Registered Nurse | Interviewed regarding contracture interventions |
| Dietary Aide #3 | Observed food preparation and sanitation practices | |
| Infection Control Preventionist | Interviewed regarding vaccination and infection control practices | |
| Social Services | Interviewed regarding vaccination consent and ordering process |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate personal hygiene care for residents, specifically failure to ensure scheduled showers/baths, clean fingernails, and shaving of male residents.
Complaint Details
Complaint investigation focused on personal hygiene deficiencies for residents #02 and #03. Substantiation status is not explicitly stated but findings confirm deficiencies.
Findings
The facility failed to ensure residents #02 and #03 received showers/baths as scheduled, had clean fingernails, and were shaved appropriately. Observations and interviews confirmed residents had dirty fingernails with brown/black substances, body odor, and lack of shaving. Documentation showed missed showers and inconsistent hygiene care.
Deficiencies (1)
Failure to ensure residents were showered/bathed as scheduled, fingernails kept clean, and male residents shaved to promote good personal hygiene.
Report Facts
Residents affected: 2
Shower/bath frequency: 3
Dates of missed showers: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #01 | Interviewed regarding Resident #02's hygiene status | |
| Certified Nurse Aide (CNA) #01 | Interviewed regarding Resident #02's hygiene and shower schedule | |
| Certified Nurse Aide (CNA) #02 | Interviewed regarding Resident #03's hygiene and shower schedule | |
| Director of Nursing (DON) | Interviewed regarding shower schedules, hygiene policies, and shaving practices |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 17, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Conway Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were informed about advance directives, failure to provide Medicaid/Medicare beneficiary notifications, inadequate PASARR screenings for residents with mental disorders or intellectual disabilities, failure to provide scheduled showers for dependent residents, failure to provide oxygen therapy as ordered, and failure to ensure pureed food items were prepared to appropriate consistency.
Deficiencies (7)
Failed to ensure residents were provided information on their right to formulate an advance directive and documentation of decisions regarding advance directives for 1 of 19 sampled residents.
Failed to ensure residents received notification that their Medicare Part A Services were being terminated for 1 of 3 sampled residents.
Failed to provide referral to appropriate state-designated authorities for Level II PASARR evaluation for 1 of 6 sampled residents with new mental disorder diagnoses.
Failed to ensure PASARR screening was conducted for 1 of 6 sampled residents with mental disorder or intellectual disability since last annual survey.
Failed to ensure showers were given as scheduled for 1 of 6 sampled residents dependent on staff for showers.
Failed to ensure residents received oxygen therapy as ordered by the physician for 1 of 7 sampled residents receiving oxygen therapy.
Failed to ensure pureed food items were blended to a smooth, lump free consistency for residents requiring pureed diets for 2 of 2 meals observed.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 11
Residents receiving oxygen therapy: 17
Residents receiving continuous oxygen therapy: 3
Residents receiving oxygen as needed: 14
Residents reviewed for advance directives: 19
Residents reviewed for beneficiary notification: 3
Residents reviewed for PASARR evaluation: 6
Residents reviewed for PASARR screening: 6
Residents reviewed for shower assistance: 6
Residents reviewed for oxygen therapy: 7
Residents reviewed for pureed diets: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned in relation to advance directive, PASARR referral, shower scheduling, and oxygen therapy findings |
| Administrator | Administrator | Mentioned in relation to Medicare Part A notification and oxygen therapy findings |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Mentioned in relation to oxygen therapy findings |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Mentioned in relation to shower scheduling findings |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Mentioned in relation to shower scheduling findings |
| Dietary Employee #1 | Dietary Employee | Mentioned in relation to pureed food preparation findings |
| Dietary Supervisor | Dietary Supervisor | Mentioned in relation to pureed food preparation findings |
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