Inspection Reports for
Innisfree Health and Rehab, LLC
301 South 24th Street, Rogers, AR, 72758
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 11
Date: Nov 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, dietary services, and safety systems in a nursing home setting.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, failure to provide written bed hold notice, incomplete care plans especially related to oxygen and contracture management, improper medication orders and storage, inadequate food preparation and dietary practices, improper infection control related to oxygen and CPAP equipment, and failure to maintain accessible call light systems for residents.
Deficiencies (11)
Failed to post the results of the most recent survey in a place readily accessible to residents and their representatives.
Failed to provide written bed hold notice for a resident transferred to hospital.
Failed to include oxygen therapy on the care plan for a resident using oxygen.
Failed to update care plan to include contracture management and provide hand roll device for contracture prevention.
Failed to ensure psychotropic medication PRN orders had proper duration, justification, and evaluation.
Failed to label insulin vials and inhalers with open dates and remove expired tube feeding from stock.
Failed to prepare pureed food with appropriate consistency and moisture to encourage nutritional intake.
Failed to provide adaptive eating equipment (plate guard) for a resident who required it.
Failed to ensure dietary staff changed gloves and washed hands appropriately; failed to properly store, cover, seal, date, and discard expired food items.
Failed to properly store oxygen tubing and CPAP tubing and mask; no policy for cleaning and storage of these devices.
Failed to ensure call light systems were accessible and within reach of residents in their beds.
Report Facts
Deficiencies cited: 11
Residents affected: 4
Residents reviewed for medication: 5
Residents reviewed for contracture management: 1
Residents reviewed for oxygen therapy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Named in medication storage and oxygen tubing findings |
| LPN #7 | Licensed Practical Nurse | Named in oxygen tubing and CPAP equipment storage findings |
| LPN #10 | Licensed Practical Nurse | Named in medication storage findings |
| LPN #11 | Licensed Practical Nurse | Named in medication storage findings |
| Certified Nurse Assistant #8 | CNA | Named in contracture management findings |
| Certified Nurse Assistant #12 | CNA | Named in adaptive equipment findings |
| Director of Nursing | DON | Named in multiple findings including survey book access, care plans, medication policies, infection control, and call light system |
| Business Office Manager | BOM | Named in bed hold notice deficiency |
| Dietary Manager | Dietary Manager | Named in food preparation and dietary findings |
| Assistant Dietary Manager | ADM | Named in food preparation and dietary findings |
| Physician Assistant | Physician Assistant | Named in medication order findings |
| Rehabilitation Director | Rehabilitation Director | Named in adaptive equipment findings |
| Nurse Consultant | Nurse Consultant | Named in medication and call light system findings |
| CNA Consultant | CNA Consultant | Named in dietary and call light system findings |
Inspection Report
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The inspection was conducted to evaluate the facility's discharge process and compliance with sending home health referrals prior to resident discharge.
Findings
The facility failed to send home health referrals prior to discharge for one of two residents reviewed, resulting in a delay in care. The referral for Resident #200 was faxed two days after discharge, contrary to facility policy expectations.
Deficiencies (1)
Facility failed to send home health referrals prior to discharge for Resident #200, causing delay in care.
Report Facts
Residents reviewed for discharge process: 2
Residents affected by deficiency: 1
Date referral faxed: Jul 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Stated referral was faxed one or two days prior to discharge but no fax confirmations were kept |
| Administrator | Administrator | Stated facility had no discharge policy and acknowledged referral was faxed post discharge |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Nov 17, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident dignity during feeding assistance, medication administration practices, personal hygiene care, dietary and food service issues, and infection control practices.
Complaint Details
The investigation was complaint-driven focusing on dignity in feeding assistance, medication administration practices, personal hygiene, dietary services, food preparation and storage, and infection control. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during feeding assistance, improper medication administration in public areas, inadequate personal hygiene and nail care, failure to follow planned menus and provide appropriate food consistency, lack of assistive eating devices, improper food handling and storage practices, and failure to implement proper infection prevention and control measures.
Deficiencies (8)
Failure to treat residents with dignity by standing over them during feeding assistance and referring to a resident as a feeder in front of others.
Administering insulin injection to a resident while seated in the dining area, contrary to facility policy.
Failure to provide adequate nail care and personal hygiene for residents dependent on staff.
Failure to follow the planned written menu, resulting in residents not receiving the correct food items or portions.
Failure to provide food prepared in the appropriate consistency for residents on pureed diets.
Failure to provide assistive eating devices such as handled cups and knives for residents who require them.
Improper food storage, handling, and sanitation practices in the kitchen, including uncovered food, unclean utensils, and lack of proper hand hygiene and hair/beard coverings.
Failure to implement proper infection prevention and control practices, including inadequate hand hygiene before and after glove use and medication administration.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Administered insulin injection in dining area |
| CNA #5 | Certified Nursing Assistant | Stood over resident while feeding and referred to resident as a feeder |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity in feeding and medication administration practices |
| LPN #3 | Licensed Practical Nurse | Failed to perform hand hygiene before and after insulin administration |
| Administrator | Facility Administrator | Interviewed regarding dietary and assistive device deficiencies |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with professional standards of respiratory care, specifically regarding the proper storage and handling of oxygen tubing for residents requiring supplemental oxygen.
Findings
The facility failed to ensure respiratory care was consistent with professional standards as oxygen tubing was not stored in bags or closed containers when not in use, potentially contaminating the tubing. This issue was observed in two residents (Resident #5 and Resident #40) and could affect 13 residents with physician orders for oxygen.
Deficiencies (1)
Oxygen tubing was hanging over the oxygen concentrator and not stored in a bag, risking contamination.
Report Facts
Residents affected: 13
Sample residents reviewed: 7
Residents with tubing not stored properly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding proper storage of oxygen tubing |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about removal and storage of oxygen tubing and care plan documentation |
| Director of Nursing | Director of Nursing | Interviewed about respiratory care policy and proper oxygen tubing storage |
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