Inspection Reports for
Chapel Ridge Health and Rehab
4623 Rogers Avenue, Fort Smith, AR, 72903
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 8, 2025
Visit Reason
The inspection was conducted to assess the accuracy of the Minimum Data Set (MDS) assessments, specifically regarding the correct coding of PASARR level II status and medication classifications for sampled residents.
Findings
The facility failed to ensure the MDS accurately reflected a level II PASARR for Resident #16 and failed to correctly identify medication classes for Resident #64, including medications without physician orders being reflected on the MDS. The inaccuracies were confirmed through interviews and record reviews.
Deficiencies (2)
Failure to ensure the Minimum Data Set (MDS) assessment accurately reflected a level II PASARR for Resident #16.
Failure to accurately identify medication class under Section N on the MDS for Resident #64, including reflecting medications without a physician's order.
Report Facts
Assessment Reference Date: Sep 16, 2024
Discontinued medication dates: Jun 4, 2024
Discontinued medication dates: May 9, 2024
Discontinued medication dates: Oct 22, 2024
MDS Assessment Reference Dates: May 8, 2024
MDS Assessment Reference Dates: Aug 6, 2024
MDS Assessment Reference Dates: Nov 6, 2024
MDS Assessment Reference Dates: Feb 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Confirmed Resident #16 had a level II PASARR and provided related documentation | |
| MDS Coordinator in-training | Acknowledged coding errors in MDS for Resident #16 and provided information on MDS coding process | |
| Director of Nursing (DON) | Acknowledged PASARR coding error for Resident #16 | |
| Licensed Practical Nurse (LPN) MDS Coordinator #2 | Reported still in training and that outside source was completing assessments | |
| Off-site MDS Coordinator #2 | Reported working with facility since September 2024 and acknowledged some errors in MDS completion |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Feb 16, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and ensure resident rights, safety, and quality of care at Chapel Ridge Health and Rehab.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meals, inaccurate resident assessments, inadequate assistance with activities of daily living, failure to manage injuries of unknown origin, unsafe transfer practices, improper medication storage, failure to honor resident food preferences, unsafe food storage practices, ineffective quality assurance processes, infection control lapses related to staff belongings in laundry, and maintenance issues with room conditions.
Deficiencies (12)
Failure to ensure staff sat at eye level while assisting residents with meals to promote dignity for 3 sampled residents.
Failure to ensure Minimum Data Set accurately reflected contractures to bilateral wrists for 1 resident.
Failure to provide regular grooming assistance including shaving for 1 resident.
Failure to manage injuries of unknown origin, failure to report and investigate possible abuse, and delay in treatment for 1 resident.
Failure to ensure an order was made for Physical Therapy after admission assessment for contractures for 1 resident.
Failure to ensure environment was free of accident hazards and provide adequate supervision to prevent accidents for 2 residents.
Failure to ensure narcotics box was permanently affixed in medication room refrigerator.
Failure to ensure resident standing orders/food preferences were honored for 2 residents.
Failure to ensure foods in freezer were sealed and contained to minimize foodborne illness and cross contamination.
Failure to develop and implement appropriate QAPI plans to prevent repeated deficiencies related to food storage.
Failure to ensure staff personal belongings were not stored on laundry folding table with resident clothing and blankets.
Failure to maintain residential rooms in safe clinical condition due to detached vinyl baseboard molding in 3 rooms.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 86
Rooms affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Observed not sitting at eye level assisting resident with meal; interviewed about contracture assessment and medication storage |
| Certified Nursing Assistant #5 | CNA | Observed assisting resident transfer with gait belt; observed placing gait belt on resident |
| Licensed Practical Nurse #1 | LPN | Observed assisting resident transfer; interviewed about shaving and medication storage |
| Director of Nursing | DON | Interviewed multiple times regarding dignity, privacy, injury reporting, transfer safety, medication storage, infection control, and maintenance issues |
| Licensed Practical Nurse #4 | LPN | Interviewed about dignity, privacy, injury reporting, transfer safety |
| Certified Nursing Assistant #6 | CNA | Interviewed about dignity, privacy, and transfer safety |
| Certified Nursing Assistant #1 | CNA | Interviewed about shaving resident |
| Licensed Practical Nurse #5 | LPN | Interviewed about skin treatment and unlabeled medicine cups |
| Dietary Employee #1 | Dietary Employee | Observed in kitchen and interviewed about food storage |
| Dietary Employee #2 | Dietary Employee | Interviewed about food storage responsibility |
| Dietary Employee #3 | Dietary Employee | Interviewed about food storage and standing orders |
| Laundry Aide #2 | Laundry Aide | Interviewed about personal belongings on folding table |
| Laundry Aide #3 | Laundry Aide | Interviewed about personal belongings on folding table |
| Laundry Supervisor #1 | Laundry Supervisor | Interviewed about personal belongings on folding table |
| Maintenance #1 | Maintenance | Interviewed about vinyl baseboard molding issues |
| Administrator | Administrator | Interviewed about QAA Committee and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent accident hazards, specifically related to staff not safely pushing a resident in a wheelchair which resulted in a fall with injury.
Complaint Details
The complaint investigation found that staff failed to safely push Resident #2 in a wheelchair, leading to a fall and injury. The incident was substantiated with supporting documentation including incident reports, hospital notes, witness statements, and staff interviews.
Findings
The facility failed to prevent accident hazards as staff did not safely push Resident #2 in a wheelchair, resulting in a fall with injury including a hematoma and bruising. Multiple staff interviews and documentation confirmed the incident and identified contributing factors such as a loose foot pedal on the wheelchair.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident falling from a wheelchair with injury.
Report Facts
Residents sampled: 2
Date of incident: Apr 4, 2023
Assessment Reference Date: Mar 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in the incident as the staff pushing the resident when the fall occurred |
| CNA #2 | Certified Nursing Assistant | Interviewed about wheelchair safety procedures |
| CNA #3 | Certified Nursing Assistant | Interviewed about wheelchair safety procedures |
| NA #1 | Nursing Assistant | Interviewed about wheelchair safety procedures |
| LPN #1 | Licensed Practical Nurse | Interviewed about wheelchair safety procedures |
| Director of Nursing | Director of Nursing | Interviewed about wheelchair safety procedures |
| Administrator | Administrator | Interviewed about wheelchair safety procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident (Resident #4) fell and was injured while being transferred with a mechanical Hoyer lift by only one staff member, contrary to facility policy requiring two staff members for such transfers.
Complaint Details
The complaint investigation substantiated neglect when a CNA transferred Resident #4 alone using a mechanical lift, causing the resident to fall and sustain a head laceration requiring hospital treatment. Immediate suspension of the CNA and further investigation were conducted.
Findings
The facility failed to ensure two staff members were present during the use of a Hoyer lift to transfer Resident #4, resulting in a fall and head injury. The investigation confirmed neglect, and corrective actions including staff inservice education, suspension of the involved CNA, and monitoring of mechanical lift transfers were initiated.
Deficiencies (1)
Failure to ensure two staff members were present when operating a Hoyer lift to transfer a resident, leading to a fall and injury.
Report Facts
Deficiencies cited: 1
Fall laceration length: 4
Number of sutures: 9
Monitoring frequency: 5
Monitoring duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Admitted transferring Resident #4 alone with mechanical lift leading to fall; suspended pending investigation | |
| Licensed Practical Nurse (LPN) #1 | Provided hospital note documenting Resident #4's fall and injury | |
| Administrator | Provided multiple statements and facility policy documents; confirmed two staff required for Hoyer lift | |
| Director of Nursing (DON) | Confirmed two staff required for Hoyer lift and described incident details |
Inspection Report
Routine
Census: 81
Deficiencies: 5
Date: Nov 18, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete Significant Change in Status MDS assessments timely, incomplete care plans addressing oxygen, smoking, and anticoagulant therapy, improper storage and maintenance of respiratory equipment, unsafe food handling practices in the dietary department, and unsafe water temperatures exceeding recommended limits in resident shower areas.
Deficiencies (5)
Failure to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a decline in Activities of Daily Living for a resident.
Failure to develop and implement complete care plans addressing oxygen, smoking, and anticoagulant therapy needs for sampled residents.
Failure to ensure nebulizer tubing and CPAP/BIPAP masks and tubing were properly stored and oxygen tubing changed per physician orders, and oxygen set at prescribed rates.
Failure to ensure foods stored in the refrigerator were labeled and dated, and failure of dietary staff to wash hands between dirty and clean tasks to prevent cross contamination.
Failure to maintain water temperatures below 120 degrees Fahrenheit in resident shower areas, with documented temperatures up to 124 degrees.
Report Facts
Residents affected: 81
Water temperature: 124
Oxygen tubing change frequency: 7
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Interviewed about oxygen tubing change frequency and infection risks | |
| Director of Nursing (DON) | Interviewed about oxygen tubing change policy and storage of respiratory equipment | |
| Minimum Data Set (MDS) Coordinator | Interviewed about timing of Significant Change MDS and care plan responsibilities | |
| Dietary Manager (DM) | Provided information on dietary practices and handwashing policy | |
| Dietary Employees #1, #2, #3 | Observed and interviewed regarding food handling and hygiene practices | |
| Maintenance Employee | Tested and adjusted water temperatures in resident shower areas | |
| Registered Nurse Consultant | Interviewed about policies for MDS and care plans |
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