Conway Lakes Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Conway Lakes Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610Feb 1, 2025

  Based on interview, and record review, the facility failed to conduct an accurate and thorough investigation for a potential allegation of neglect related to elopement for 1 of 8 residents reviewed for elopement risk, (#3), and for a fall with major injury for 1 of 3 residents reviewed for falls, (#5), of a total sample of 10 residents. The facility's failure to investigate and determine the root cause of the elopement prevented them from implementing interventions and safeguards to mitigate elopement and prevent other cognitively impaired residents from exiting the facility unsupervised. […]

• Immediate jeopardy, isolatedF689Feb 1, 2025

  Based on observation, interview, and record review, the facility failed to appropriately evaluate, monitor, and prevent a cognitively impaired resident from exiting the facility unsupervised, for 1 of 8 residents reviewed for elopement risk, (#3) and failed to develop and implement appropriate interventions that included adequate supervision to prevent a fall with fractures for a cognitively impaired resident for 1 of 3 residents reviewed for falls, (#5), of a total sample of 10 residents. These failures contributed to the elopement of resident #3 and placed her at risk for serious injury, impairment, and/or death. […]

• Actual harm, isolatedF686Aug 22, 2024

  Based on interview, and record review, the facility failed to ensure necessary care and services were provided to promote healing and prevent infection of a facility acquired pressure ulcer for 1 of 2 cognitively impaired residents reviewed for pressure ulcer management, of a total sample of 20 residents, (#1). The facility's failure to ensure timely and adequate care and treatments for pressure injury and infection resulted in actual harm for a cognitively impaired resident at risk for development of pressure wounds. Resident #1 subsequently was transferred to a higher level of care with an admitting hospital diagnosis of sepsis with hypotension, and sacral wound. […]

• No harm, potential for more than minimal, widespreadF895Feb 1, 2025

  Based on interview, and record review, the facility failed to effectively communicate and implement the standards of its compliance and ethics program to promote ethical conduct, and failed to adequately enforce those requirements to deter violations, ensure the provision of quality care and promote the highest practicable well-being for resident #3 and all residents in the facility. Findings: According to the facility's undated Code of Conduct and Ethics Policy the organization believed in creating a culture of respect, integrity, and compassion. They were committed to providing the highest quality of care and expected each team member to utilize legitimate practices that aligned with their mission and values. […]

• No harm, potential for more than minimal, patternF812Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was safely stored and/or discarded in the areas of the main reach-in coolers, the pot/pan sink sanitizing solution was at the correct concentration and failed to ensure food preparation surfaces were not cross-contaminated during production in accordance with professional standards for food service safety. Findings:1.On 9/08/25 at 9:36 AM, an initial walk-through tour of the kitchen was conducted with the Dietary Manager (DM). In the reach-in cooler a white plastic container had a label that read: Turkey Prepared date 7/07/25, Use by 7/10/25. […]