Inspection Reports for
Chapel Woods Health and Rehabilitation
1440 East Church Street, Warren, AR, 71671
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
35% occupied
Based on a December 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a cognitively impaired resident who was left outside alone, unsupervised, and after hours, raising concerns of neglect.
Complaint Details
The complaint investigation substantiated that Resident #1 was left outside alone overnight on 05/04/2025, resulting in immediate jeopardy to resident health or safety. The facility disputed the citation but implemented corrective actions and the immediate jeopardy was removed on 05/09/2025.
Findings
The facility failed to ensure Resident #1 was supervised and safe, resulting in the resident being left outside overnight in cold temperatures. Immediate jeopardy was identified and later removed after the facility implemented a plan of removal including staff training, increased rounds, and administrative actions against involved staff.
Deficiencies (1)
Failure to protect Resident #1 from neglect by leaving the resident outside alone and unsupervised after hours.
Report Facts
Residents affected: 1
Temperature: 47
Date of incident: May 4, 2025
Date immediate jeopardy removed: May 9, 2025
2-hour rounds start date: May 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Placed on administrative leave related to the neglect incident. |
| CNA #1 | Certified Nursing Assistant | Placed on administrative leave and interviewed regarding the neglect incident. |
| CNA #2 | Certified Nursing Assistant | Placed on administrative leave related to the neglect incident. |
| CNA #3 | Certified Nursing Assistant | Placed on administrative leave and interviewed regarding the neglect incident. |
| Director of Nursing | Director of Nursing (DON) | Located Resident #1 outside and involved in corrective action planning and staff training. |
| LPN #5 | Licensed Practical Nurse | Day nurse who last saw Resident #1 before the incident. |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was conducted to ensure the medication error rate was less than 5 percent during medication administration observation in the facility.
Findings
The facility failed to ensure the medication error rate was less than 5 percent, with an observed medication error rate of 8.00% during medication administration involving 1 of 2 sampled residents and 1 non-sampled resident. Errors included failure to administer a prescribed laxative and substitution of eye drops without proper authorization.
Deficiencies (1)
Failed to ensure medication error rate was less than 5 percent during medication administration observation, resulting in an 8.00% error rate.
Report Facts
Medication administration opportunities observed: 25
Medication errors: 2
Medication error rate: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT #2 | Certified Med Tech | Administered medications and involved in medication errors |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and procedures |
| Advanced Practice Nurse | Advanced Practice Nurse | Interviewed by telephone regarding medication orders and resident care |
| Unit Manager | Unit Manager | Interviewed regarding medication stock and delivery |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted to investigate allegations of abuse and neglect involving several residents at Chapel Woods Health and Rehabilitation.
Complaint Details
The complaint investigation involved 3 of 6 sampled residents reviewed for abuse (#1, #4, #5) and 1 of 1 sampled resident reviewed for neglect (#6). The investigation found incomplete documentation and missing assessments for resident interviews and body audits after allegations. The complaint was substantiated with findings of inadequate investigation procedures.
Findings
The facility failed to ensure allegations of abuse and neglect were thoroughly investigated for multiple residents. Documentation of resident interviews and assessments/body audits following allegations was missing, and responsible staff could not provide evidence that these investigations were completed as required.
Deficiencies (1)
Failure to thoroughly investigate allegations of abuse and neglect for residents #1, #4, #5, and #6, including missing documentation of resident interviews and assessments/body audits.
Report Facts
Residents reviewed for abuse: 6
Residents reviewed for neglect: 1
BIMS score: 6
BIMS score: 6
BIMS score: 13
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in allegation of rough care and suspended during investigation |
| Director of Nursing | Director of Nursing | Interviewed regarding missing documentation and responsibility for ensuring investigations |
| Administrator | Administrator | Interviewed regarding missing documentation and responsibility for ensuring investigations |
| Licensed Practical Nurse | Licensed Practical Nurse | Assessed residents for signs of abuse on 11/13/2024 |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 25, 2024
Visit Reason
The inspection was conducted to review the facility's pharmaceutical services, specifically focusing on the process for dispensing controlled substances and ensuring compliance with medication management policies.
Findings
The facility failed to consistently implement the process for dispensing controlled substances, resulting in discrepancies in narcotic counts and improper documentation of medication removal and administration. The Director of Nursing confirmed procedural lapses in signing out medications and reconciling narcotic logs.
Deficiencies (1)
Failure to ensure consistent implementation of controlled substance dispensing process, including discrepancies in narcotic counts and failure to sign out medications properly.
Report Facts
Medication tablets discrepancy: 1
Medication tablets discrepancy: 1
Medication tablets discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Performed narcotic count and involved in medication discrepancies |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Witnessed medication handling during narcotic count |
| Director of Nursing | Director of Nursing | Interviewed regarding narcotic count procedures and responsible for narcotic log audits |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Oct 25, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including medication management, resident care, dietary services, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to update care plans to reflect residents' current needs, inconsistent provision of toenail care, improper narcotic medication dispensing and documentation, failure to address pharmacist medication regimen review recommendations, failure to serve meals according to planned menus, poor dietary hygiene and food storage practices, and failure to use proper personal protective equipment during high contact resident care activities.
Deficiencies (7)
Failed to ensure care plan was revised to reflect resident's most recent care needs for high-risk medications.
Failed to ensure toenail care was consistently provided during resident care.
Failed to ensure the process for dispensing controlled substances was consistently implemented to decrease potential for diversion.
Failed to ensure pharmacist medication regimen review recommendations were addressed for residents on psychotropic medications.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs.
Failed to ensure dietary staff washed hands and changed gloves when contaminated; expired food items were discarded; foods were properly stored and dated; and hot food was maintained at required temperature.
Failed to ensure staff donned proper Personal Protective Equipment while performing high contact resident activities on Enhanced Barrier Precautions.
Report Facts
Deficiencies cited: 7
Medication administration documentation: 11
Medication administration documentation: 17
Medication administration documentation: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Temperature: 84
Freezer temperature: -10
Refrigerator temperature: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in narcotic medication count and dispensing deficiency |
| LPN #4 | Licensed Practical Nurse | Witnessed medication dispensing to family member |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding narcotic medication policies and infection control PPE |
| MDS Coordinator | Interviewed regarding care plan updates and MDS process | |
| CNA #11 | Certified Nursing Assistant | Interviewed regarding toenail care for Resident #22 |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding whirlpool baths and nail care |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding shower assistance for Resident #22 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding PRN antianxiety medication reassessment |
| LPN #2 | Licensed Practical Nurse | Observed administering medication without proper PPE |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding PPE noncompliance |
| Dietary Aide #1 | Dietary Aide | Observed and interviewed regarding food preparation and hygiene deficiencies |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and preparation policies |
| Dietary Aide #3 | Dietary Aide | Observed and interviewed regarding glove use and food handling |
Inspection Report
Routine
Census: 49
Deficiencies: 8
Date: Dec 14, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements in a nursing home facility.
Findings
The facility had multiple deficiencies including failure to update resident care plans, failure to invite residents and families to care plan meetings, inadequate nail care for residents, inconsistent oxygen administration, medication errors, improper medication storage and labeling, insufficient food portions served according to menu, and poor food safety and sanitation practices in the kitchen.
Deficiencies (8)
Failed to update resident care plan to reflect needs of Resident #10 with lower extremity edema and diuretic use.
Failed to invite Resident #10 and family to care plan meetings.
Failed to ensure nails were trimmed to maintain hygiene and prevent skin tears for 49 residents.
Failed to ensure oxygen was administered at ordered flow rate and nasal cannula was dated for Resident #230; potential to affect 9 residents.
Medication errors by staff resulted in a 7.32% error rate affecting 84 residents.
Medications not properly labeled, expired medications not removed, medication carts left unlocked, and medications not stored securely.
Failed to serve enough food portions according to planned menu; kitchen ran out of baked squash casserole affecting multiple residents.
Food safety and sanitation deficiencies including uncovered food in freezer, expired food in refrigerators, poor hand hygiene by dietary staff, and unsanitary kitchen conditions.
Report Facts
Residents affected by nail care deficiency: 49
Medication error rate: 7.32
Residents affected by medication errors: 84
Residents affected by oxygen therapy deficiency: 9
Residents affected by food portion deficiency: 20
Expired medications found: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding importance of care planning, medication administration, and medication cart security |
| MDS Coordinator | MDS Coordinator | Interviewed about care planning and resident condition awareness |
| Social Director | Social Director | Interviewed about invitations to care plan meetings |
| Medication Assistant Certified #1 | Medication Assistant Certified | Administered medications and involved in medication error |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about nail care responsibilities and medication cart security |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about expired medication procedures |
| Administrator | Administrator | Provided medication administration and storage policies |
| Activity Director | Activity Director | Interviewed about resident activity participation and documentation |
| Dietary Employee #2 | Dietary Employee | Interviewed about food portion shortages |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 3, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide necessary care and services to maintain resident hygiene needs, failure to ensure physician reviews and documentation of progress notes and orders at required visits, and failure to ensure physician face-to-face visits were conducted and documented timely.
Complaint Details
The visit was complaint-related, focusing on failure to provide adequate personal hygiene care and failure to maintain timely and complete physician documentation and visits. The Registered Nurse Consultant acknowledged issues with bathing schedules and missing documentation. The facility began audits and plans to improve compliance after discovery of these issues.
Findings
The facility failed to ensure residents received regular bathing as required for 3 of 4 sampled residents, failed to ensure physician or physician-designee signed and dated progress notes and orders at each required visit for 3 sampled residents, and failed to ensure physician face-to-face visits were conducted and documented at least every 60 days for 3 sampled residents. Documentation was missing or incomplete, and some orders were not implemented timely.
Deficiencies (3)
Failure to provide regular bathing for residents requiring assistance with activities of daily living (Residents #4, #6, and #7).
Failure of physician or physician-designee to sign and date progress notes or write, sign, and date orders at each required visit for Residents #1, #2, and #3.
Failure to ensure physician face-to-face visits were conducted and documented at least every 60 days for Residents #1, #2, and #3.
Report Facts
Residents affected: 3
Residents affected: 3
Residents with order changes not recognized: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Consultant (RNC) | Acknowledged lack of bathing documentation and issues with progress notes and orders | |
| Advanced Practice Registered Nurse (APRN) | Signed progress notes, acknowledged monitoring blood sugars, and discussed plans to improve compliance | |
| Administrator | Provided information about physician supervision and acknowledged problems with physician documentation |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 8
Date: Sep 15, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely notification of resident transfers/discharges, incomplete Minimum Data Set (MDS) assessments, inadequate care planning for dialysis patients, incomplete discharge summaries, failure to follow physician orders for wound care, improper feeding tube care, improper use and documentation of psychotropic medications, and food safety and hygiene violations in the kitchen.
Complaint Details
The visit was complaint-related focusing on multiple issues including notification failures for hospital transfers, incomplete assessments, care planning deficiencies, medication management, and food safety concerns.
Findings
The facility was found deficient in multiple areas including failure to notify residents and representatives in writing about hospital transfers, incomplete MDS assessments, inadequate dialysis care plans, missing discharge summary details, failure to follow wound care orders, improper feeding tube positioning, lack of documentation for psychotropic medication use, and poor kitchen sanitation and employee hygiene practices. All deficiencies were cited with minimal harm or potential for actual harm.
Deficiencies (8)
Failure to provide timely written notification to residents and representatives about hospital transfers in a language they could understand.
Failure to complete comprehensive Minimum Data Set (MDS) assessment within 14 days after admission.
Failure to revise and update Plan of Care to include hemodialysis frequency and interventions for emergent situations.
Failure to ensure discharge summary included a recapitulation of resident's stay and course of treatment.
Failure to follow physician orders for discontinuation of bandage on skin tear.
Failure to maintain head of bed at 45 degrees for residents with gastrostomy tubes to prevent complications.
Failure to ensure psychotropic medications ordered on PRN basis for longer than 14 days were accompanied by physician documentation including evaluation and rationale.
Failure to maintain kitchen sanitation including intact door frames, floor tiles, base boards, ceiling tiles, and air vents; failure of dietary employees to wash hands properly and prevent contamination during food handling.
Report Facts
Residents affected by notification failure: 24
Sample residents reviewed for notification: 11
Residents affected by incomplete MDS assessment: 66
Residents affected by dialysis care plan deficiency: 1
Residents affected by discharge summary deficiency: 1
Residents affected by wound care deficiency: 1
Residents affected by feeding tube care deficiency: 3
Residents affected by psychotropic medication deficiency: 1
Total census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Provided bed hold policy and documentation related to resident transfers | |
| Director of Nursing | Provided information on notification policies, medication regimen reviews, and discharge summary responsibilities | |
| Assistant Director of Nursing | Discussed responsibility for MDS completion | |
| Licensed Practical Nurse #2 | Interviewed about care of resident returning from dialysis | |
| Licensed Practical Nurse #3 | Interviewed about care of resident returning from dialysis | |
| Certified Nursing Assistant #1 | Observed and interviewed regarding feeding tube positioning | |
| Dietary Employee #1 | Observed handling food and drink without proper handwashing | |
| Dietary Employee #2 | Observed handling food and drink without proper handwashing and contamination of equipment | |
| MDS Consultant | Interviewed about MDS completion responsibilities | |
| Social Services Director | Interviewed about discharge summary responsibilities |
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