Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Innisfree Health And Rehab, Llc during CMS and state inspections, most recent first.
The facility did not make the survey results easily accessible to residents, family members, and legal representatives. The survey book was placed at the back of the greeting desk, requiring residents to ask for assistance to view it. Staff interviews confirmed the book's location and the need for residents to request access, which the Administrator acknowledged as incorrect.
A facility failed to update a care plan for a resident with contracture management needs. The resident, with severe cognitive impairment and functional limitations, did not have a restorative program or functional maintenance plan included in their care plan. Observations showed the resident was not using a required hand roll, and there was no documentation of its use. The DON confirmed the lack of a comprehensive care plan, and the part-time LTC MDS coordinator was unavailable for guidance.
The facility failed to remove expired tube feeding and properly label insulin vials and inhalers with open dates, as observed in the medication room and carts. An LPN acknowledged the expired items needed disposal, and the DON was unaware of improper labeling practices, indicating a lapse in adherence to medication storage policies.
The facility failed to prepare pureed meals with the appropriate consistency, resulting in thick and unappetizing food for residents, including one with dysphagia. Dietary staff did not add sufficient liquid to pureed meals, leading to difficulties in consumption. The issue was confirmed by dietary staff and a speech therapist, who noted that the meals did not meet the required consistency standards.
The facility exhibited deficiencies in food handling and storage practices. Dietary staff failed to change gloves and wash hands after handling contaminated items, leading to potential food contamination. Additionally, food items in the refrigerator and freezer were not properly covered, sealed, or dated, and expired items were not discarded. The Activities Director confirmed that food storage protocols were not followed, compromising food safety.
The facility failed to properly store and manage oxygen and CPAP equipment for two residents, leading to deficiencies in infection prevention and control. A resident with severe cognitive impairment had oxygen tubing improperly stored, and another resident with Alzheimer's disease had CPAP equipment left unbagged. The facility lacked proper care plans and documentation for equipment maintenance, as confirmed by the DON and an LPN.
The facility failed to ensure residents had access to a functioning call system, affecting four residents with various impairments. Observations showed call lights were out of reach, and staff confirmed the absence of a policy for ensuring accessibility. This deficiency was identified through observations, record reviews, and staff interviews.
A facility failed to provide a written bed hold notice for a resident who was hospitalized, as required by their policy. The resident, who was cognitively intact, was transferred to the emergency room for altered mental status. The Business Office Manager contacted the resident's spouse, who was unsure if the resident would return, but no bed hold agreement was issued, resulting in non-compliance with the facility's policy.
A facility failed to include oxygen therapy in the care plan for a resident with shortness of breath, despite having an order for oxygen and an oxygen tank in the resident's room. The MDS Coordinators were unaware of the omission, and the facility lacked a policy on care plans.
A resident with severe cognitive impairment and musculoskeletal issues did not receive a prescribed hand roll for contracture management. Despite the care plan indicating the need for this device, observations and staff interviews confirmed its absence. The care plan lacked necessary restorative and functional maintenance programs, and the DON acknowledged the absence of a contracture management policy.
A resident was prescribed a PRN anti-anxiety medication for 45 days without proper justification or evaluation by a doctor. The Physician Assistant noted that the order was made by hospice, and there was no documented rationale in the clinical records. The DON stated that PRN medications should be limited to 14 days unless justified, and the facility lacked a policy for PRN medication.
A resident with coordination and mobility issues was not provided with a necessary plate guard during meals, despite it being indicated in their care plan. Staff interviews confirmed the lack of consistent provision of adaptive equipment, and the facility lacked a policy on adaptive equipment.
A facility failed to send home health referrals before a resident's discharge, resulting in delayed care. The resident, with a history of mobility issues and other conditions, was discharged with orders for PT, OT, nursing, and CNA services. However, the referral was sent two days post-discharge, delaying the start of home health services. The facility lacked a discharge policy, and the SSD did not keep fax confirmations, leading to a lapse in the discharge process.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to make the results of the most recent survey readily accessible to residents, family members, and legal representatives. Observations conducted over several days revealed that the survey book was located on the far back right-hand side of the greeting desk, making it difficult for residents, especially those in wheelchairs, to access without assistance. The survey book was not available in common areas such as the dining room, day room, or hallways, and residents were only seen near the greeting desk when accompanied by staff. Interviews with facility staff, including the receptionist, LPN, CNA Consultant, and the Director of Nursing, confirmed that the survey book was not easily accessible. The receptionist stated that the survey book was kept at the main entrance desk and that residents had to ask for it, often remaining at the desk to view it. The Administrator acknowledged that residents should not have to request the survey book and confirmed that the current practice was incorrect.
Failure to Update Care Plan for Contracture Management
Penalty
Summary
The facility failed to update the care plan for a resident with contracture and contracture management needs. The resident, who was admitted with diagnoses including dementia, muscle wasting, atrophy, and hemiplegia, had a severe cognitive impairment and functional limitations in range of motion. Despite these conditions, the care plan did not include a restorative program or a functional maintenance plan (FMP) that the resident was participating in. Additionally, there was no mention of a hand roll or device to prevent the worsening of the left-hand contracture, which was noted in the resident's closet care plan. Observations and interviews revealed that the resident was not using a hand roll, as required by the closet care plan, and there was no documentation of its use. The LTC MDS coordinator confirmed the resident's participation in a restorative program but acknowledged the absence of recommendations for a splint or brace following a therapy evaluation. The Director of Nursing (DON) confirmed the lack of documentation regarding the hand roll and the absence of a comprehensive care plan addressing the resident's needs. The LTC MDS coordinator, who works part-time, was not available to provide guidance on the development and completion of the MDS and care plan.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, resulting in expired and unlabeled medications being present in the medication room and carts. During an observation of the Long Term Care medication room, two bottles of tube feeding were found to be expired, yet still in current stock. The Licensed Practical Nurse (LPN) responsible for the area acknowledged that these bottles needed to be discarded. Additionally, during inspections of two medication carts, it was discovered that two insulin vials and three inhalers were not labeled with open dates, contrary to the facility's policy which requires dating when the manufacturer's seal is broken. The Director of Nursing (DON) was unaware that the nursing staff was labeling the bags instead of the insulin vials, which could lead to the loss of open date information if the bags were damaged or misplaced. The DON also believed that expiration date checks were conducted weekly, as assigned to LPN #5, but this was evidently not the case. These oversights in medication management highlight a lapse in adherence to the facility's medication storage policy, potentially compromising the safety and efficacy of the medications administered to residents.
Inadequate Consistency in Pureed Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that maintained an acceptable appearance and consistency for residents, particularly those on pureed diets. During observations, it was noted that the dietary staff did not add sufficient liquid to pureed meals, resulting in a thick and unappetizing consistency. For instance, the egg sausage bake was pureed without adding broth or any liquid, leading to a thick consistency both before and after cooking. Similarly, pureed biscuits and hash browns were also prepared with inadequate liquid, resulting in a sticky and thick texture. Resident #42, who has dysphagia following a cerebral infarction and requires a pureed diet with honey consistency, was unable to consume the meals due to their thickness. The resident reported difficulty eating the pureed pancake served at breakfast, describing it as too hard to cut and eat. The Assistant Dietary Manager and Dietary Aide confirmed that the pureed foods served were too thick and acknowledged the need for more liquid to achieve the appropriate consistency. The speech therapist also confirmed that pureed diets should resemble pudding or mashed potato consistency, indicating that the meals served did not meet these standards.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure proper food handling and storage practices, leading to multiple deficiencies. Dietary staff were observed not changing gloves or washing hands after handling contaminated items before touching food, which resulted in potential contamination of food served to residents. Specifically, a dietary staff member used gloves to handle a spray bottle and then directly handled food without changing gloves or washing hands. Another staff member was observed handling meal trays and beverages without washing hands after touching dirty objects. These actions were contrary to the facility's handwashing policy, which emphasizes the importance of hand hygiene in preventing contamination. Additionally, the facility did not adhere to proper food storage protocols. Observations revealed that food items in the refrigerator and freezer were not covered, sealed, or dated, and expired food items were not promptly discarded. Opened boxes of various food items, such as breaded pork patties, turkey burgers, and pie dough, were found unsealed in the freezer. Similarly, opened bags of food items in the emergency food supply and the Activities Room lacked proper sealing and open dates. The Activities Director confirmed that the food storage process was not followed, as items were not dated or sealed as required, compromising food safety.
Deficiencies in Infection Control for Oxygen and CPAP Equipment
Penalty
Summary
The facility failed to properly store and manage oxygen and CPAP equipment for two residents, leading to deficiencies in infection prevention and control. Resident #13, who had severe cognitive impairment and was on oxygen therapy for conditions including COPD, had oxygen tubing lying on the bed with the concentrator running while the resident was not present. There was no documented order for regular oxygen tubing changes to prevent infection, and the Medication Administration Record did not reflect consistent oxygen therapy administration. Additionally, the resident's progress notes indicated non-compliance with using the nasal cannula. Resident #52, diagnosed with Alzheimer's disease and obstructive sleep apnea, had a CPAP nasal pillow and tubing that were not properly stored, as they were found lying directly on the nightstand without a protective bag. The facility lacked a care plan for the CPAP use and maintenance, and there were omissions in the task of cleaning the CPAP equipment as documented in the Treatment Administration Record. Interviews with the DON and LPN #7 confirmed the lack of proper storage and cleaning procedures for both residents' equipment, highlighting a gap in the facility's infection control practices.
Inaccessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that residents had access to a functioning call system to request staff assistance, affecting four residents. Observations revealed that the call lights were not within reach for these residents, who had various impairments and required assistance for daily activities. For instance, one resident with communication difficulties and mobility impairments was observed with the call light cord on the floor, out of reach, and not clipped to the bed covers. Another resident, who required total staff assistance for mobility and personal hygiene, was found with the call light on the floor and requested help to place it within reach. Further observations showed that a resident with severe cognitive impairment and dependency on staff for mobility had the call light positioned behind the bed mattress, making it inaccessible. Similarly, another resident with multiple diagnoses, including dementia and arthritis, had the call light cord draped over the bed's metal piece, rendering it unreachable. These observations were confirmed by staff, who acknowledged that the call lights should be clipped to the bed covers or placed within reach to allow residents to call for assistance when needed. The facility lacked a policy or procedure for ensuring call lights were accessible to residents. The Director of Nursing and other staff confirmed the necessity of having call lights within reach and acknowledged the absence of a formal policy. The facility's failure to provide a working call system directly accessible to residents was identified through observations, record reviews, and staff interviews, highlighting a significant deficiency in ensuring resident safety and communication needs.
Failure to Provide Written Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written bed hold notice for a resident who was hospitalized, as required by their policy. The policy, revised in 2016, mandates that a bed hold policy be sent with the resident to the hospital and that the resident or their representative be contacted the next business day to determine if they wish to hold the bed. This should be documented on a bed hold form, which requires two signatures if contact is made by phone. However, in this case, the Business Office Manager (BOM) did not issue a bed hold agreement for the resident when they were transferred to the emergency room due to altered mental status. The resident involved was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, and was their own representative, although a spouse was listed as next of kin. The resident was admitted for skilled nursing care and later transferred to the emergency room. The BOM contacted the resident's spouse, who was unsure if the resident would return and stated they would notify the BOM by the following Monday. Despite this communication, no bed hold agreement was issued, resulting in a failure to comply with the facility's policy.
Oxygen Therapy Not Included in Care Plan
Penalty
Summary
The facility failed to ensure that oxygen therapy was included in the care plan for a resident diagnosed with shortness of breath. The resident had an order for oxygen therapy, prescribed as needed, and was observed to have an oxygen tank in their room. Despite this, the care plan did not reflect the resident's need for oxygen. Interviews with the Long Term Care MDS Coordinator and the Skilled MDS Coordinator revealed that they were unaware of why the oxygen therapy was not included in the care plan. Additionally, the facility administrator acknowledged that there was no existing policy on care plans.
Failure to Provide Contracture Management Device
Penalty
Summary
The facility failed to provide appropriate contracture management for a resident with severe cognitive impairment and musculoskeletal issues, including hemiplegia and contractures in the left hand and arm. Despite the resident's care plan indicating the need for a hand roll to prevent worsening of the contracture, no such device was provided. Observations revealed that the resident did not have a hand roll in place during activities or while in bed, and staff interviews confirmed the absence of the device. The resident's care plan, initiated after consultation with the LTC MDS Coordinator, did not include the necessary restorative program or functional maintenance plan. Interviews with facility staff, including a CNA and the DON, confirmed the lack of documentation and implementation of the hand roll for the resident's left hand. The DON acknowledged the absence of a policy for contracture management and was unsure of the guidance used by the LTC MDS Coordinator to develop the care plan. The LTC MDS Coordinator, who works part-time, was not available to provide further clarification. This oversight resulted in the resident not receiving the prescribed contracture management device, as outlined in their care plan.
Failure to Justify Extended PRN Anti-Anxiety Medication Order
Penalty
Summary
The facility failed to ensure that a resident did not have an order to receive a PRN anti-anxiety medication past 14 days without proper justification and evaluation by a doctor. The resident, who was cognitively intact with a BIMS score of 14, had an order for an anti-anxiety tablet to be administered every 2 hours as needed for anxiety related to an anxiety disorder for 45 days. However, there was no documented rationale for this PRN medication in the clinical records. Interviews revealed that the Physician Assistant did not order the medication and indicated that it was ordered by hospice, requiring her to put the order in her name. The Nurse Consultant confirmed the absence of information regarding the rationale for the medication order in the system. The Director of Nursing stated that PRN anti-anxiety medication should be ordered for only 14 days, and if ordered for more than 14 days, a documented rationale should be present in the clinical record. Additionally, the facility lacked a policy for PRN medication.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment for a resident who required it, leading to a deficiency. The resident, who had a diagnosis of unspecified lack of coordination, Parkinsonism, hemiplegia, and hemiparesis, was cognitively intact and required partial assistance with meals. The resident's care plan and tray card both indicated the need for a plate guard during meals. However, observations on multiple occasions revealed that the resident was not provided with a plate guard, and the resident expressed that there was only one section plate available in the building. Interviews with staff, including the Assistant Dietary Manager and a Certified Nurse Assistant, confirmed that the resident was not consistently provided with the necessary adaptive equipment, such as a plate guard. The Rehabilitation Director was informed of the resident's difficulties with spilling food but was unsure if an evaluation had been conducted. Additionally, the Director of Nursing stated that the facility did not have a policy on adaptive equipment, further contributing to the oversight in providing the required equipment for the resident.
Failure to Timely Send Home Health Referrals
Penalty
Summary
The facility failed to send home health referrals prior to the discharge of a resident, leading to a delay in the initiation of necessary home health services. The resident, who was cognitively intact and had a history of right femur fracture, muscle weakness, and other conditions, was discharged with orders for physical therapy, occupational therapy, nursing, and CNA services. However, the facility did not have a policy for the discharge process, and the Social Services Director (SSD) could not provide proof of when the referral was faxed, as no fax confirmations were kept. The home health agency confirmed receiving the referral two days after the resident's discharge, resulting in a delay in care. The resident's family reported that home health services did not start until four days post-discharge, and the resident sought medical treatment at a hospital shortly thereafter. The facility's Administrator acknowledged that referrals should not be sent after discharge, indicating a lapse in the discharge planning process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rogers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Rogers Rehab & Nursing Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Promenade Health And Rehabilitation | 1.5 mi | ★★★★★ | 5 | 0 |
| Ashley Rehabilitation And Health Care Center | 1.7 mi | — | 17 | 0 |
| Hampton Place Healthcare, Llc | 1.7 mi | ★★★★★ | 0 | 0 |
| Rogers Health And Rehabilitation Center | 1.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.