Inspection Reports for
Conway Healthcare and Rehabilitation Center

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.

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.

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.

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.

The complaint involved Resident #81 being discharged despite filing an appeal against the discharge. The appeal was filed on 07/23/2025, but the resident was discharged on 07/24/2025. The Ombudsman and family member confirmed the appeal and the resident's objection to discharge. The facility discharged the resident regardless of the appeal, violating policy.

The facility failed to comply with its policy by discharging Resident #81 despite an active appeal against the discharge. Interviews revealed conflicting accounts regarding the resident's behavior and reasons for discharge, with the Administrator citing improper behavior and smoking policy violations, while staff and the resident denied such behaviors. The facility policy states residents cannot be discharged while an appeal is pending unless safety is endangered.

The complaint investigation focused on Resident #81's improper discharge despite an appeal, medication errors including a significant error affecting 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.

The facility failed to prevent the discharge of Resident #81 despite an appeal being filed, failed to ensure timely response to feeding tube alarms and call lights for Residents #8 and #69, had a medication error resulting in Resident #52 receiving another resident's medications causing hospitalization, failed to maintain locked medication carts, and failed to ensure proper hand hygiene during perineal care for Residents #69 and #74.

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.

The facility failed to maintain a safe environment due to multiple hazards including clutter on the floor in resident rooms, detached wall vinyl and wall rails, discolored stains and debris in the dining room, and wall gashes near resident beds. Maintenance was not available at the time of inspection, and no maintenance requests for these issues were found in the facility's Maintenance Request Book.

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.

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.

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.

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.

The complaint investigation was substantiated with findings of continuous resident-to-resident abuse between Resident #47 and Resident #54, causing psychosocial harm risk to 66 residents. Immediate Jeopardy began on 2024-03-12 and was removed on 2024-05-06 after corrective actions were verified.

The facility failed to ensure residents were free from abuse due to continuous verbal and physical altercations between Resident #47 and Resident #54, affecting psychosocial wellbeing of residents. The Immediate Jeopardy was removed after the facility implemented a Removal Plan including 1:1 monitoring, staff in-service training, and mental health assessments. Noncompliance remained at a lower scope and severity with no actual harm.

The complaint investigation was triggered by allegations of resident-to-resident abuse involving Residents #47 and #54, including verbal and physical altercations occurring frequently in the facility, causing psychosocial harm and safety concerns for other residents. Immediate Jeopardy was identified and subsequently removed after corrective actions were verified.

The facility failed to ensure residents were free from abuse with continuous verbal and physical altercations between two residents, Resident #47 and Resident #54, posing psychosocial harm to residents. Additionally, the facility failed to ensure call lights were within reach for residents, and failed to update care plans and provide appropriate interventions for contractures and psychotropic medication management. Infection control and food safety deficiencies were also noted.

Complaint investigation focused on personal hygiene deficiencies for residents #02 and #03. Substantiation status is not explicitly stated but findings confirm deficiencies.

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.

The investigation was complaint-driven, focusing on personal hygiene issues for Residents #02 and #03. The complaint was substantiated with observations of dirty fingernails, body odor, and missed showers/baths as documented and confirmed by staff interviews.

The facility failed to provide scheduled showers/baths, maintain clean fingernails, and shave male residents as required, affecting at least two residents. Observations, interviews, and record reviews confirmed residents had dirty fingernails, body odor, and were not shaved as scheduled.

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.

The facility was found deficient in multiple areas including failure to provide residents with information and documentation regarding advance directives, failure to notify residents about Medicare Part A service termination, failure to conduct or update PASARR screenings for residents with mental disorders or intellectual disabilities, failure to provide scheduled showers for dependent residents, failure to ensure oxygen therapy was administered as ordered, and failure to provide pureed food items with appropriate consistency.