Inspection Reports for
Chambers Health and Rehabilitation
1001 East Park Street, Carlisle, AR, 72024
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 2
Date: Dec 11, 2025
Visit Reason
The inspection was conducted to evaluate nursing competency in medication administration, specifically the administration of intramuscular injections, and to assess medication error rates during medication administration.
Findings
The facility failed to ensure a nurse demonstrated competency in administering an intramuscular injection to Resident #6, resulting in the resident receiving only 1 ml of medication instead of the prescribed 3.2 ml. Additionally, the medication error rate was 7.69%, exceeding the acceptable threshold of 5%.
Deficiencies (2)
Failed to ensure nurse competency in administration of intramuscular injection, resulting in underdosing Resident #6.
Medication error rate exceeded 5 percent, with a 7.69% error rate observed during medication administration.
Report Facts
Medication error rate: 7.69
Medication administration opportunities observed: 26
Medication errors observed: 2
Medication dose administered: 1
Medication dose ordered: 3.2
Duration of antibiotic treatment: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Nurse who administered incorrect dose of intramuscular injection to Resident #6 | |
| Director of Nursing (DON) | Confirmed medication dose expectations and nurse competency requirements | |
| Advanced Practice Registered Nurse (APRN) | Received report from LPN #1 about incomplete medication administration |
Inspection Report
Routine
Census: 47
Deficiencies: 3
Date: Aug 1, 2024
Visit Reason
The inspection was conducted based on routine observation and interview to assess compliance with food safety, hand hygiene, and infection prevention and control practices in the facility.
Findings
The facility failed to ensure expired food items were promptly removed, dietary staff practiced proper hand washing, and manufacturer specifications for food storage were followed, potentially affecting 47 residents. Additionally, staff failed to use required personal protective equipment (PPE) when entering a resident's room on contact and droplet precautions for COVID-19.
Deficiencies (3)
Expired food items were found in the kitchen, including grated parmesan cheese, white cake mix, chili powder, parsley flakes, and pancake syrup not refrigerated after opening.
Dietary staff failed to practice proper hand washing and glove use, contaminating gloves and food items during meal preparation.
Staff failed to wear required face protection (face shield or goggles) when entering a resident's room on contact and droplet precautions for COVID-19.
Report Facts
Residents affected: 47
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Dietary Aide | Observed contaminating gloves and food items during meal preparation |
| Social Director | Social Director | Observed failing to wear face shield or goggles when entering COVID-19 isolation room |
| Infection Preventionist | Infection Preventionist | Interviewed and confirmed responsibility for staff education on transmission-based precautions |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 26, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration and storage regulations in the facility.
Findings
The facility failed to ensure that residents' medications were not left at bedside, specifically for one resident (Resident #4). Medications were observed left unattended at the bedside, which is against facility policy and professional standards.
Deficiencies (1)
Failure to ensure residents' medications were not left at bedside, risking potential harm.
Report Facts
Residents sampled: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | LPN #1 confirmed no residents self-administer medications and that medications should not be left at bedside | |
| Director of Nursing | Confirmed it was not acceptable to leave medications at bedside and explained potential outcomes |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 10, 2023
Visit Reason
The inspection was conducted to assess compliance with care planning, safety regarding water temperature, and medication administration practices at Chambers Health and Rehabilitation.
Findings
The facility failed to revise a resident's care plan to include oxygen therapy as ordered, maintained unsafe hot water temperatures in 20 resident rooms risking scalding, and had a medication error rate of 5.71% due to missed or delayed doses of Neurontin for a resident.
Deficiencies (3)
Failed to review and revise the care plan with change of resident orders for oxygen therapy for 1 of 2 sampled residents.
Failed to maintain hot water temperature in resident rooms at a safe temperature to prevent scalding in 20 resident rooms on the 200 Hall.
Medication error rate was 5.71%, including missed and delayed doses of Neurontin for a resident.
Report Facts
Residents affected: 1
Residents affected: 20
Medication error rate: 5.71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication error finding related to Neurontin administration |
| Director of Nurses | DON | Interviewed regarding care plan revisions and medication administration |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan revisions |
| Minimum Data Sets Coordinator | MDS Coordinator | Interviewed regarding care plan revisions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide appropriate treatment for skin issues and failure to ensure proper respiratory care including oxygen tubing and nebulizer tubing maintenance for sampled residents.
Complaint Details
The investigation was complaint-driven, focusing on skin care and respiratory care issues for residents #1 and #2. The complaints were substantiated with findings of inadequate treatment and maintenance.
Findings
The facility failed to ensure identified skin concerns were reported to the physician and treatments ordered for 2 of 3 sampled residents with skin issues. Additionally, the facility failed to ensure oxygen tubing, nebulizer tubing, and storage bags were changed, labeled, and dated according to physician orders for 2 of 3 sampled residents receiving oxygen therapy.
Deficiencies (2)
Failure to provide appropriate treatment and care for skin issues for residents with documented skin concerns.
Failure to ensure oxygen tubing, nebulizer tubing, and storage bags were changed, labeled, and dated according to physician orders.
Report Facts
Residents sampled: 3
Residents affected: 2
Oxygen flow rate: 3
BIMS score: 10
BIMS score: 15
Dates on oxygen equipment: Feb 14, 2023
Date on oxygen humidifier bottle: May 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Provided information about oxygen humidifier bottle and storage bag change frequency | |
| Licensed Practical Nurse (LPN) #2 | Accompanied surveyor and notified about resident complaint of wheezing | |
| Certified Nursing Assistant (CNA) #1 | Assisted with body audit and discussed availability of skin cream | |
| Certified Nursing Assistant (CNA) #2 | Assisted Resident #2 during skin observation | |
| Director of Nursing (DON) | Provided explanations about skin care procedures, oxygen equipment maintenance, and telehealth consultation | |
| Administrator | Provided facility policies and explained procedures for skin issue discovery and treatment |
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