Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Chapel Woods Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of psychotic disorder was left unsupervised outside overnight after staff failed to verify their whereabouts, assuming the resident had returned inside. Staff did not perform required visual checks or two-hour rounds, resulting in the resident remaining outside in cold temperatures until discovered the next morning by the DON.
A medication error rate of 8% was observed in an LTC facility, involving incorrect documentation and substitution of medications for a resident. A resident did not receive the prescribed laxative and was given incorrect eye drops due to unavailability, without notifying the provider. Facility policies on medication administration were not followed, contributing to the deficiency.
The facility failed to thoroughly investigate allegations of abuse and neglect for several residents, as required by their policy. A resident made allegations of abuse, but the facility was unable to provide documentation of interviews or assessments conducted to verify the claims. Another resident was found with a bruise of unknown origin, but the facility could not produce records of the assessments. A third resident reported an incident of abuse by a CNA, but the facility did not provide documentation of assessments for non-interviewable residents. Interviews with the DON and Administrator revealed they acknowledged the importance of thorough investigations but were unable to provide the necessary documentation.
A resident with severe cognitive impairment and multiple health conditions fell out of bed, sustaining a major injury. The incident was not reported or documented by staff, leading to a delay in medical assessment. Interviews revealed that CNAs did not follow protocol by notifying a nurse before moving the resident. The facility's failure to adhere to fall management protocols resulted in a deficiency in supervision and accident prevention.
The facility failed to ensure proper hand hygiene and glove use among dietary staff, leading to potential food contamination. Expired food items and improperly labeled food were found in storage areas, and hot food items were not maintained at the required temperature. These deficiencies indicate lapses in food safety and hygiene practices.
The facility failed to consistently implement the process for dispensing controlled substances, resulting in discrepancies in the narcotic count on a medication cart. An LPN did not sign out Diazepam given to a resident's family member, and there were discrepancies in Hydro-APAP counts for two residents. The DON confirmed that the facility's policy required two nurses to perform narcotic counts and report discrepancies, but this was not followed.
The facility did not address pharmacist recommendations for three residents regarding psychotropic medications. A resident with dementia was not given a recommended dose reduction for Quetiapine despite a fall. Another resident with severe cognitive impairment continued receiving Buspirone without physician response to a recommended dose reduction. A third resident's PRN antianxiety medication was not reassessed within the expected timeframe.
A facility failed to update a resident's care plan to include monitoring details for high-risk medications. The resident, diagnosed with dementia and altered mental status, was taking several high-risk drugs, but the care plan lacked information on side effects or symptoms to monitor. The MDS Coordinator confirmed that care plans should include such details, as per facility policy.
A resident with COPD and heart failure experienced inconsistent toenail care, leading to discolored, thick, and jagged nails. The resident's care plan indicated nail care should occur on bath days, but records showed irregular bathing and nail care. Interviews with CNAs revealed discrepancies in responsibility and execution of nail care, contrary to the facility's policy requiring regular maintenance.
The facility did not serve meals according to the planned menu, affecting the nutritional needs of residents. A dietary aide prepared pureed cheesy biscuits for 10 residents but failed to serve them to 7 residents during the meal service, as she forgot to do so.
A facility failed to ensure staff used proper PPE during high contact activities for a resident on Enhanced Barrier Precautions due to a PEG tube. An LPN was observed administering medication with only gloves, contrary to the facility's policy requiring gown and gloves to prevent MDRO spread. The LPN admitted the mistake, and the DON confirmed the PPE requirements.
Resident Left Unsupervised Outside Overnight Due to Inadequate Rounding and Supervision
Penalty
Summary
A cognitively impaired resident with diagnoses of schizophrenia and psychotic disorder with hallucinations was left outside alone, unsupervised, and after hours in the secured unit's courtyard. The resident had a moderate cognitive impairment, required supervision or touch assistance with activities of daily living, and was identified as an elopement risk with a care plan intervention specifying supervision in the courtyard. On the evening of the incident, the resident requested to sit outside after supper. Staff opened the courtyard door, and residents went outside. Later, staff assumed all residents had returned inside and closed the door without verifying the whereabouts of the cognitively impaired resident. Throughout the night, staff failed to account for the resident's presence. Certified Nursing Assistants (CNAs) and nursing staff assumed the resident was in the bathroom when not seen in the room and did not perform visual checks or rounds as required. Rounds that were supposed to occur every two hours were not consistently performed, and staff did not check the resident's room or other areas to confirm the resident's location. The resident remained outside overnight in cold temperatures, knocking on the door and attempting to stay warm. The resident was discovered missing during morning rounds, and the Director of Nursing (DON) located the resident outside in the courtyard. The resident was brought inside, and a body audit revealed no negative findings. The incident was determined to be a failure to protect the resident from neglect, as the facility did not ensure adequate supervision and failed to follow care plan interventions and rounding protocols, resulting in the resident being left outside unsupervised for an extended period.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8% during a medication administration observation. This deficiency involved one registered nurse and two certified med techs administering medications to two sampled residents and one non-sampled resident. Specifically, Resident #7 did not receive the prescribed [brand name] laxative powder, as the resident reportedly refused it and would request it only when feeling constipated. Despite this, the medication was incorrectly documented as administered. Additionally, an incorrect eye drop medication was administered to Resident #7 due to the unavailability of the prescribed [brand name - carboxymethylcellulose sodium] eye drops, which were substituted with [brand name - Polyethylene Glycol 440 / Propylene Glycol] eye drops without notifying the provider. The facility's policies on medication administration were not adhered to, as evidenced by the failure to verify medication orders and the inappropriate substitution of medications. The Director of Nursing stated that any medication refusal should be communicated to the doctor and documented, and that substitutions should not occur without provider notification. The Advanced Practice Nurse was unaware of the resident's refusal to take the laxative, and the Unit Manager confirmed the delivery of the correct eye drops on the day of observation. The facility's policies clearly define medication errors, including the administration of the wrong drug or failure to administer a prescribed drug, which were not followed in this instance.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for several residents, as required by their policy. Resident #1, who was not cognitively intact, made allegations of abuse on 10/31/2024. However, the facility was unable to provide documentation of interviews or assessments conducted on that date to verify the claims. Similarly, Resident #4, also not cognitively intact, was found with a bruise of unknown origin on 11/13/2024, but the facility could not produce records of the assessments that were supposed to be conducted on that day. Resident #5 reported an incident of physical and verbal abuse by a CNA on 11/05/2024. Although the CNA was suspended pending investigation, the facility did not provide documentation of assessments for non-interviewable residents on the relevant halls. Resident #6, who had a fall on 11/14/2024, was reviewed for neglect, but again, the facility failed to provide evidence of interviews or body audits conducted as part of the investigation. Interviews with the Director of Nursing and the Administrator revealed that both acknowledged the importance of conducting thorough investigations, including resident interviews and assessments, following allegations of abuse or neglect. However, they were unable to provide the necessary documentation to confirm that these procedures were followed. The facility's Abuse Prevention policy mandates prompt and thorough investigations, but the lack of documentation indicates a failure to adhere to this policy.
Failure to Report and Monitor Resident Fall
Penalty
Summary
The facility failed to properly assess, report, and monitor a fall incident involving a resident with severe cognitive impairment and multiple health conditions, including chronic obstructive pulmonary disease and osteoarthritis. The resident, identified as a high fall risk, reportedly rolled out of bed and sustained a major injury, which was not immediately reported or documented by the staff. The incident came to light only after the resident complained of knee pain, leading to an investigation that revealed a lack of adherence to the facility's fall protocol. Interviews with staff members indicated a lack of awareness and proper response to the fall incident. Certified Nursing Assistants (CNAs) involved in the incident did not follow the protocol of notifying a nurse before moving the resident, which is a critical step in ensuring the resident's safety and proper assessment of injuries. The facility's policy requires immediate evaluation and documentation of falls, but this was not followed, resulting in a delay in medical assessment and treatment for the resident's injuries. The investigation revealed that the CNAs involved did not report the fall, and one CNA was terminated for attempting to cover up the incident. The facility's failure to ensure that staff adhered to established protocols for fall management and reporting led to a significant delay in addressing the resident's injury, highlighting a deficiency in the facility's supervision and accident prevention measures.
Deficiencies in Hand Hygiene, Food Storage, and Temperature Control
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use among dietary staff, leading to potential contamination of food items. Dietary Aide #1 was observed handling bananas and a blender without washing hands or changing gloves after contamination. Similarly, Dietary Aide #3 used contaminated gloves to handle bread, acknowledging the need for handwashing and using tongs. These actions were contrary to the facility's policy on employee cleanliness and handwashing techniques. The facility also did not adhere to proper food storage and labeling practices. Observations revealed expired food items, such as milk and pudding, in the refrigerators at various stations. Additionally, several food items, including breadsticks, pizza sauce, and crackers, were found without proper labeling of opened or received dates. This lack of proper labeling and removal of expired items could lead to the use of spoiled or unsafe food products. Furthermore, the facility did not maintain the required temperature for hot food items. A pan of pureed cheesy garlic biscuits was found at 84 degrees Fahrenheit, below the required temperature for serving hot food. The Dietary Manager confirmed that the biscuits were intended to be served hot, indicating a failure to ensure food safety standards were met during meal preparation and service.
Inconsistent Controlled Substance Dispensing Process
Penalty
Summary
The facility failed to consistently implement the process for dispensing controlled substances, leading to discrepancies in the narcotic count on one of the medication carts. During a random narcotic count, it was observed that the number of Diazepam tablets for a resident did not match the recorded balance, as one tablet was missing. The LPN involved stated that the medication was given to the resident's family member without signing it out in the narcotic log, which was against the facility's policy. Additionally, there were discrepancies in the count of Hydro-APAP tablets for two residents, where the actual count was less than the recorded balance. The LPN admitted to administering the medication but failing to sign it out in the narcotic log. The Director of Nursing (DON) confirmed that the facility's policy required two nurses to perform the narcotic count at shift change and sign the count sheet immediately. The policy also required that any discrepancies be reported to the DON. The DON stated that the narcotic log was audited regularly, and the responsibility for this task was assigned to the nurse manager. The facility's Controlled Substances policy indicated that controlled substances should only be surrendered to a resident on pass or therapeutic leave, or to a responsible party upon discharge. However, the policy was not followed in these instances, leading to potential medication diversion.
Failure to Address Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to address pharmacist medication regimen review recommendations for three residents regarding unnecessary and psychotropic medications. Resident #3, diagnosed with dementia and altered mental status, was prescribed Quetiapine Fumarate for anxiety. Despite a recommendation from the pharmacy to gradually reduce the dose due to a documented fall, the medication was not adjusted by the Advanced Practice Registered Nurse as of the review date. Resident #69, with severe cognitive impairment and depression, was prescribed Mirtazapine and Buspirone. The pharmacy recommended a gradual dose reduction for Buspirone, but there was no response from the attending physician, and the resident continued to receive the same dose. Resident #2, diagnosed with dementia and anxiety, was on antianxiety therapy with a PRN order for an antianxiety medication. The medication was administered frequently over several months, but the PRN order was not reassessed by the physician within the expected 30-day period. The Assistant Director of Nursing confirmed that the PRN medication should have been reassessed, indicating a lapse in following up on medication orders and ensuring appropriate medication management.
Failure to Update Care Plan for High-Risk Medications
Penalty
Summary
The facility failed to revise the care plan for a resident to reflect their most recent care needs. The resident, diagnosed with dementia and altered mental status, was found to be cognitively intact according to a recent assessment. The resident was taking several high-risk medications, including an antipsychotic, an antidepressant, an antibiotic, a diuretic, and an antiplatelet. However, the care plan did not specify which side effects or symptoms to monitor for these medications, despite the facility's policy requiring care plans to be updated with such information. The MDS Coordinator, responsible for updating care plans, acknowledged that high-risk medications should be care planned to guide staff in monitoring residents for symptoms and reactions. The facility's policy, revised in December 2016, mandates that care plans be revised as residents' conditions change and at least quarterly. Despite this, the care plan for the resident in question was not updated to include necessary monitoring details for the high-risk medications prescribed.
Inconsistent Toenail Care for Resident
Penalty
Summary
The facility failed to consistently provide toenail care for a resident, leading to a deficiency in care. On observation, the resident's toenails were found to be discolored, thick, and jagged, indicating a lack of regular maintenance. The resident, who has chronic obstructive pulmonary disease and heart failure, reported that toenail trimming was supposed to occur on bath days, which were believed to be Tuesdays and Fridays. However, the care plan indicated that nail care should be performed on bath days, which were actually scheduled for Tuesday, Thursday, and Saturday. Despite this, records showed inconsistent bathing and nail care, with the resident receiving various types of baths and refusing one on a specific date. Interviews with CNAs revealed discrepancies in the provision of nail care. CNA #11 confirmed the condition of the resident's toenails and stated that nail care was the responsibility of the night shift CNAs and should be done during showers. CNA #5, who provided whirlpool baths, believed nail care was given the previous week but could not specify a date. CNA #6, who assisted with showers, did not recall providing nail care on a specific date. The facility's policy on nail care emphasized daily cleaning and regular trimming to prevent injuries, but this was not consistently followed, leading to the observed deficiency.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, which is necessary to meet the nutritional needs of the residents. During the noon meal preparation, a dietary aide pureed 10 servings of cheesy biscuits and portioned them into bowls, which were then placed in the refrigerator. However, during the meal service, 7 out of 8 residents did not receive the pureed cheesy biscuits as intended. The dietary aide later admitted in an interview that she forgot to serve the pureed cheesy biscuits to the remaining 7 residents.
Failure to Use Proper PPE During High Contact Resident Care
Penalty
Summary
The facility failed to ensure that staff donned the proper Personal Protective Equipment (PPE) while performing high contact resident activities for a resident on Enhanced Barrier Precautions (EBP). Resident #76, who had memory problems and a history of coughing or choking during meals or when swallowing medications, required EBP due to a Percutaneous Endoscopic Gastrostomy (PEG) tube. On October 23, 2024, a surveyor observed a Licensed Practical Nurse (LPN) administering medication to Resident #76 via the PEG tube while wearing only gloves and no additional PPE. During an interview, the LPN admitted to not wearing a gown, acknowledging the mistake. The Director of Nursing (DON) confirmed that staff should wear a gown and gloves when administering medication through a PEG tube to protect the resident from potential infections. The facility's policy on Enhanced Barrier Precautions specified that high contact resident care activities, such as device care or use, require the use of gown and gloves to prevent the spread of multi-drug resistant organisms (MDRO).
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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 Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belle View Estates Rehabilitation And Care Center | 13.2 mi | ★★★★★ | 0 | 0 |
| The Woods, A Nightingale Community | 14.5 mi | ★★★★★ | 0 | 0 |
| The Green House Cottages Of Southern Hills | 25.3 mi | ★★★★★ | 0 | 0 |
| St Johns Place Of Arkansas, Llc | 25.7 mi | ★★★★★ | 3 | 0 |
| The Blossoms At Star City Rehab & Nursing Center | 26.1 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.