Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Chandler Post Acute And Rehabilitation during CMS and state inspections, most recent first.
Multiple resident rooms and bathrooms were found without accessible or functioning call light systems, including instances where call lights were out of reach or did not activate hallway indicators. Staff confirmed the malfunctioning systems, and observations showed that residents would be unable to alert staff for assistance if needed.
A resident with diabetes was administered Metformin mixed with pudding prior to breakfast, rather than with a meal as ordered by the physician. Multiple LPNs and the DON confirmed that a spoonful of pudding does not constitute a meal, and facility policy and drug references specify that Metformin should be given with meals. The medication was given before the scheduled breakfast, contrary to the physician's order.
A resident with multiple medical conditions and intact cognition reported to police that an x-ray technician had committed sexual abuse during a procedure. The resident stated she informed a nurse at the time, but the facility did not document or report the allegation to mandated authorities within the required two-hour window. Staff interviews and record reviews confirmed that the incident was not reported as required by facility policy and state regulations.
A resident with intact cognition and multiple medical conditions alleged that an x-ray technician committed sexual abuse during care. The resident reported the incident to a nurse, but the facility did not initiate an internal investigation, document the allegation, or report it to the State Agency as required. Staff and administration were unaware of the allegation despite police involvement, and no interviews or evidence collection were conducted in accordance with facility policy.
A resident with multiple medical and behavioral issues had an allegation of abuse by a staff member that was not documented in the clinical record, despite facility policy and staff expectations requiring such documentation. Interviews with nursing staff and the DON confirmed that no progress note or specific entry about the incident was made, resulting in incomplete medical records.
A resident with multiple diagnoses did not receive scheduled doses of pain and anti-anxiety medications due to a disagreement with an RN over the administration method. The RN failed to follow protocol for medication waste and did not supervise the resident, who has a history of pocketing medications. This led to the resident's agitation and refusal of care throughout the day.
A resident with multiple diagnoses, including coronary artery disease, was not provided with appropriate care due to a lack of documentation and communication of changes in condition. Despite observations of new bruising and a cooler left leg, staff failed to document these findings or use a scale to assess pulse intensity. The resident was later hospitalized with serious conditions and passed away, highlighting deficiencies in the facility's adherence to professional standards of practice.
Failure to Maintain Functional Call Light Systems in Resident Rooms and Bathrooms
Penalty
Summary
Surveyors observed that several resident rooms in the behavioral unit were not equipped with a working call system to summon staff assistance. In one room, the call light was found on the floor behind the bed and out of the resident's reach during multiple observations. Another room lacked a call light entirely for resident use. Additionally, in a bathroom, the call light string was positioned too high on the wall, making it inaccessible to a resident who might fall and be on the floor. Further checks revealed that pulling the call light string or pressing the call button in some rooms did not activate the hallway indicator light, confirming that the call lights were not functioning. Staff interviews corroborated these findings. A CNA confirmed that the call lights in two rooms were not working and acknowledged that this would leave residents unable to alert staff for assistance. An LPN described the staffing levels and the reliance on call lights for residents who could verbalize their needs, while nonverbal residents were checked every 15 minutes. Facility documentation and policy review indicated a commitment to resident safety and accident prevention, but the observed deficiencies in the call system contradicted these stated practices.
Failure to Administer Metformin as Ordered with Meals
Penalty
Summary
A deficiency was identified when a resident with Type 2 Diabetes Mellitus, hypoglycemia, and Post-Traumatic Stress Disorder was not administered Metformin as ordered by the physician. The physician's order specified that Metformin 500 mg should be given by mouth with meals for diabetes management. However, during a medication administration observation, an LPN crushed the Metformin tablet, mixed it with pudding, and administered it to the resident before the scheduled breakfast meal, contrary to the order to give the medication with meals. Interviews with nursing staff revealed a misunderstanding or disregard for the physician's order. The LPN who administered the medication stated that he typically gives medications one hour before or after the scheduled time and that the resident preferred taking medication with pudding. He also indicated that he would not contact the physician if a resident refused a meal but would still administer Metformin, even if the resident did not eat. Other LPNs and the DON confirmed that a spoonful of pudding or applesauce is not considered a meal and that medications ordered to be given with meals should be administered with or directly after a meal, not before. Review of the facility's policies and reference materials, including the Nursing Drug Handbook and Medlineplus.gov, confirmed that Metformin should be given with meals to decrease gastrointestinal upset. The facility's policies require accurate implementation of medication orders and administration as per the physician's instructions. The failure to administer Metformin with a meal, as ordered, was observed and confirmed through staff interviews and record review.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to mandated entities within the required two-hour timeframe. The incident involved a resident with diagnoses including myoneural disorder, toxic encephalopathy, dysphagia, ataxia, and PTSD, who was cognitively intact according to a recent BIMS assessment. The resident reported to police that an unknown male x-ray technician had touched her breast during a medical procedure at the facility, and that she had informed a nurse at the time, who responded that the alleged perpetrator had left the building. Despite the resident's report to facility staff, there was no evidence in the facility's self-report incident logs or the State Agency database that the allegation was reported as required. Police initiated an investigation after the resident's hospital discharge, contacting facility staff for information about the alleged incident and requesting video footage, which was ultimately unavailable. Interviews with staff, including the ADON, Administrator, and DON, revealed that while staff were aware of the two-hour reporting requirement and the need to ensure resident safety, none of the key personnel recalled being informed of the abuse allegation or conducting an internal investigation related to the resident's claim. Facility policy required immediate reporting of abuse allegations to supervisors, the Administrator, the State Survey Agency, and Adult Protective Services. However, the review of records and staff interviews confirmed that the required notifications were not made following the resident's report. The deficiency was identified through interviews, clinical record review, and examination of facility policies and procedures.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident who had intact cognition and multiple medical diagnoses, including myoneural disorder, toxic encephalopathy, dysphagia, ataxia, and post-traumatic stress disorder. The resident reported to police that an unknown male x-ray technician allegedly touched her breast while she was receiving medical care at the facility. The resident stated she informed a nurse at the facility about the incident, but there was no evidence that the facility initiated an internal investigation or reported the allegation as required. A review of facility records showed no documentation of a self-reported incident or a 5-day investigation report submitted to the State Agency regarding the alleged sexual abuse. Interviews with the resident’s former roommate confirmed that while a detective questioned her about the incident, facility staff did not approach her for information. Staff interviews revealed that the expected protocol in the event of an abuse allegation was to ensure resident safety and immediately notify the abuse coordinator or administrator, followed by a prompt investigation. However, the administrator and DON both stated they were unaware of any abuse allegations or investigations related to the resident in question, despite police involvement and requests for video footage. Facility policy required immediate reporting and thorough investigation of all abuse allegations, including interviews with all involved parties and preservation of evidence. Despite these requirements, the facility did not document any investigation or reporting of the alleged incident, nor did they interview potential witnesses or the alleged perpetrator. The lack of action and documentation directly contradicted the facility’s own policies and regulatory requirements for responding to abuse allegations.
Failure to Document Abuse Allegation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that an allegation of abuse and neglect involving a resident was completely documented in the clinical record. The resident in question had multiple complex diagnoses, including pathological fracture, muscle weakness, dysphagia, heart failure, metastatic cancer, anxiety disorder, and moderate cognitive impairment. Care plans indicated the resident was resistant to care and had a history of behavioral issues such as refusing care, yelling, hitting, and spitting at staff. Despite these factors and an allegation of abuse by a staff member, there was no evidence in the clinical record that the incident was documented as required. Interviews with nursing staff and the Director of Nursing confirmed that facility policy and their expectations required documentation of abuse allegations in the progress notes, including details such as the time of the incident, what was said, actions taken, and notifications made. The DON acknowledged that no progress note or specific documentation about the incident was entered into the clinical record, which did not meet facility expectations or policy. A review of the facility's documentation policy further confirmed the requirement for a complete account of resident care and incidents in the medical record.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was administered pain and psychotropic medications as per the physician's orders, leading to a deficiency in care. The resident, who had diagnoses including post-traumatic stress disorder, anxiety, major depression, low back pain, and chronic pain syndrome, was on a regimen of pain and anti-anxiety medications. On a particular day, the resident did not receive her scheduled doses of Alprazolam and Xtampza ER due to a disagreement with the nurse over the administration method. The nurse had provided the medications mixed in pudding, which the resident refused, leading to the medications being thrown on the floor and not administered. The nurse, identified as RN/staff #33, did not follow the proper protocol for medication administration and waste. He did not immediately contact the physician or the Assistant Director of Nursing (ADON) after the incident, which resulted in the resident missing her morning doses of critical medications. The nurse also failed to supervise the resident while taking her medications, which was necessary due to the resident's history of pocketing medications. This lack of supervision and failure to administer the medications as ordered contributed to the resident's agitation and refusal of care throughout the day. Interviews with staff and the resident revealed that the resident typically takes her medications with pudding due to swallowing difficulties, but she was not able to identify the medications when they were mixed. The Director of Nursing (DON) confirmed that the resident should not be allowed to take medications unsupervised and that the nurse should have followed the process for medication waste and notified the physician immediately. The facility's policies on professional standards and self-administration of medications were not adhered to, resulting in the deficiency.
Failure to Document and Communicate Change in Resident Condition
Penalty
Summary
The facility failed to provide services in accordance with professional standards of practice for a resident who was admitted with multiple diagnoses, including hemiplegia, hemiparesis, and coronary artery disease. The resident had orders for aspirin and ticagrelor for clotting prevention, but the care plan did not include a plan for hypertension, coronary artery disease, or the use of anticoagulants. On February 3, 2024, a licensed practical nurse (LPN) observed new bruising on the resident's left leg and communicated this to the physician, who ordered an X-ray and to hold the aspirin. However, the LPN did not report that the leg was cool to the touch, which was a significant observation indicating a potential change in the resident's condition. A registered nurse (RN) assessed the resident's lower extremities and noted a difference in temperature and color, with the left leg being cooler and blotchy. Despite these observations, the RN did not document the assessments in the progress notes, nor did she use a scale to assess the intensity of the pedal pulse, which could have indicated a change in condition. The RN reported her findings to the charge nurse, who then contacted the physician. However, the charge nurse did not document her assessment and relied on the RN to do so, leading to incomplete documentation of the resident's condition. The facility's policy required that all changes in resident condition be communicated to the physician and documented, but this was not fully adhered to in this case. The resident was later admitted to the hospital with a myocardial infarction, stroke, and blood clots in the lower extremity, and subsequently passed away. Interviews with staff revealed inconsistencies in the assessment and documentation of the resident's condition, contributing to the failure to provide appropriate care.
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Illustrative
What surveyors actually found near you
We read the 252 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chandler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sante Of Chandler | 0.4 mi | ★★★★★ | 3 | 0 |
| Archstone Care Center | 0.4 mi | ★★★★★ | 4 | 0 |
| Desert Cove Nursing Center | 0.6 mi | ★★★★★ | 18 | 0 |
| River Park Post Acute | 3.3 mi | ★★★★★ | 0 | 0 |
| Tempe Post Acute | 5.6 mi | ★★★★★ | 6 | 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 August 2026) and official state health department websites.