Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Chambers Health And Rehabilitation during CMS and state inspections, most recent first.
Inadequate IM injection administration competency: an LPN reconstituted an antibiotic vial and then administered only 1 cc from the syringe into the back of a resident’s arm, even though the order required the full 1 g IM dose. The LPN later admitted she did not give the full amount and could not identify the muscle site used. The DON confirmed the syringe did not contain the full dose and stated the medication should have been given in an appropriate large muscle site.
Medication Administration Error Rate Exceeded Allowed Threshold: An LPN reconstituted an antibiotic vial with 3.2 ml of diluent but administered only 1 cc of the medication to a resident being treated for a UTI. Surveyors observed the syringe contents during the injection, and the LPN later acknowledged that the full dose was not given. Review of the medication administration observations showed 2 errors in 26 opportunities, resulting in a 7.69% error rate.
The facility failed to remove expired food items and ensure proper hand hygiene among dietary staff, potentially affecting 47 residents. Expired items like parmesan cheese and cake mix were found, and a dietary aide was observed contaminating her hands and gloves, then handling food without washing hands, contrary to facility policy.
A facility failed to ensure staff used the required PPE when entering the room of a resident on contact and droplet precautions due to COVID-19. The Social Director entered the resident's room without wearing a face shield or goggles, despite signage indicating the need for such protection. The Infection Preventionist confirmed staff had been educated on transmission-based precautions, but the Social Director did not adhere to the required PPE protocols.
A resident's medications were left at the bedside, contrary to facility policy, which requires nurses to watch residents swallow their medications. Both an LPN and the DON confirmed that leaving medications at the bedside is not acceptable.
Inadequate IM Injection Administration Competency
Penalty
Summary
The facility failed to ensure a nurse demonstrated competency in administering an IM injection for one resident who was being treated for a UTI with an antibiotic injection ordered as 1 gram IM daily for 5 days. During observation of the medication pass, an LPN reconstituted a 1-gram vial of antibiotic powder with 3.2 ml of local numbing agent, withdrew the medication into a 5-cc syringe, and entered the resident’s room to administer the injection. The syringe was observed to contain only 1 cc of clear liquid, and the LPN confirmed that amount when asked. She then administered the injection into the back of the resident’s left arm. The resident’s physician order, order sheet, and eMAR all reflected the antibiotic injection solution reconstituted with 3.2 ml of local numbing agent and ordered as 1 gram IM daily. During interview, the LPN stated she did not remember how many ml she administered and later admitted that 3.2 ml should have been administered and that she did not administer 1 gram of antibiotic to the resident. She also stated she could not name the muscle where she placed the IM injection and acknowledged that the back of the arm is not a muscle site for IM injections. The DON confirmed that if 3.2 ml was used to reconstitute the vial, at least 3.2 ml should have been withdrawn, and that 1 ml in the syringe meant the full dose was not present. The DON stated that IM injections should be given in appropriate muscle sites and that the nurse should have used two syringes to deliver the full amount. The FDA label for the medication directed that the reconstituted solution be administered by deep IM injection into a large muscle mass such as the gluteal muscles or lateral thigh, and the facility’s medication administration and IM injection policies required verification of the correct medication, dosage, and route.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5% during observed medication administration for one resident who received medications from three LPNs. During observation, 26 medication administration opportunities were reviewed and 2 errors were observed, resulting in a 7.69% medication error rate. The deficiency involved a resident being treated for a UTI with an order for an antibiotic injection solution reconstituted from a 1 gram vial and administered IM once daily for 5 days. During the observed administration, an LPN reconstituted the antibiotic powder with 3.2 ml of local numbing agent, withdrew the medication into a syringe, and entered the resident’s room to give the injection. The syringe was observed to contain only 1 cc of clear liquid, and the LPN confirmed that amount when asked. She stated she was about to administer 1 cc and then injected that amount into the resident’s left arm. Later, the LPN acknowledged that 3.2 ml should have been administered and that she did not administer the full dose. The DON confirmed that if 3.2 ml was used to reconstitute the vial, at least 3.2 ml should have been withdrawn, and the APRN stated the resident did not receive the full dose of antibiotic medication.
Expired Food and Poor Hand Hygiene in Dietary Department
Penalty
Summary
The facility failed to ensure that expired food items were promptly removed from stock, which could potentially affect the quality and safety of meals served to 47 residents. During an inspection, it was observed that a container of grated parmesan cheese, a box of white cake mix, a container of chili powder, and an opened gallon of parsley flakes were all past their expiration dates. Additionally, an opened bottle of pancake syrup was not refrigerated as per the manufacturer's specifications, which could compromise food quality. Furthermore, the facility did not ensure that dietary staff adhered to proper handwashing techniques, increasing the risk of cross-contamination. A dietary aide was observed washing her hands but then contaminating them by turning off the faucet with bare hands. She proceeded to handle food items without changing gloves or washing her hands again, which included preparing sandwiches and hamburgers for residents. The facility's policy on handwashing was not followed, as the aide did not wash her hands after handling dirty objects before touching food items.
Failure to Use Required PPE for Resident on Droplet Precautions
Penalty
Summary
The facility failed to ensure that the required personal protective equipment (PPE) was utilized by staff before entering the room of a resident who was on contact and droplet precautions due to a COVID-19 diagnosis. The resident, identified as Resident #153, had an order for contact/droplet isolation from July 26, 2024, through July 30, 2024. On July 29, 2024, the Social Director was observed entering the resident's room wearing a blue disposable gown, gloves, and a white mask, but did not wear a face shield or goggles over her glasses, despite the signage on the door indicating the need for such protection. The Social Director acknowledged her failure to wear the appropriate PPE after being questioned by the surveyor. The Infection Preventionist confirmed that she was responsible for educating staff about transmission-based precautions and that staff had been in-serviced earlier in the year. The facility's policy on transmission-based precautions, revised in September 2022, and the COVID-19 infection prevention and control measures policy, dated April 2020, both indicated the necessity of wearing appropriate PPE, including eye protection, when entering the room of a resident on droplet precautions. Despite these policies, the Social Director did not adhere to the required precautions, leading to the deficiency noted in the report.
Medication Left at Bedside
Penalty
Summary
The facility failed to ensure that residents' medications were not left at the bedside, as observed with one resident who had a plastic cup of medication and a cup of water on their bedside table. The resident, who had diagnoses including hypertension and cirrhosis of the liver, confirmed they had taken their medication that morning. However, the Medication Administration Record indicated that several medications had been administered earlier that day, suggesting a discrepancy in medication administration practices. When questioned, an LPN confirmed that no residents in the facility were allowed to self-administer their medications and that the procedure required nurses to watch residents swallow their medications. The Director of Nursing also confirmed that leaving medications at the bedside was not acceptable and could lead to various negative outcomes, such as the resident not taking the medication or another resident taking it. The facility's medication administration policy emphasized that medications must be administered within one hour of their prescribed time and that nurses should return to missed residents to administer the medication.
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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 Carlisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barnes Healthcare | 9.1 mi | ★★★★★ | 0 | 0 |
| Maple Healthcare | 9.5 mi | ★★★★★ | 0 | 0 |
| Lonoke Health And Rehab Center, Llc | 9.8 mi | ★★★★★ | 7 | 0 |
| Des Arc Nursing And Rehabilitation Center | 18.3 mi | ★★★★★ | 0 | 0 |
| Cavalier Healthcare Of England | 20.4 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.