Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 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.
Antihypertensive Given Despite Hold Parameter: A resident with HTN, COPD, OSA, UTI, and CVA history had a Losartan order to hold if SBP was below 130, but the medication was administered even though the resident’s BP was below the ordered parameter. There was no documentation explaining the override or that the provider was notified. Later that morning, the resident developed severe hypotension with hallucinations and altered mental status and was sent to the hospital.
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.
Infection control practices were not followed during care for multiple residents. A resident with an indwelling urinary catheter had the drainage bag in contact with the floor, a wound care nurse placed dressing supplies on an unsanitized tray table and did not wear a gown during part of a dressing change, and staff caring for a resident on EBP for a PEG tube used gloves improperly, wore a gown that did not fully cover clothing, and failed to perform hand hygiene during repositioning and other resident contact.
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 PEG tube dependence, dementia, and severe cognitive impairment was placed in an abdominal binder, bilateral mitts, and a seatbelt restraint, but the chart did not consistently show that the resident or representative was informed of the risks and benefits before use. The record contained restraint evaluations and a consent form, but the listed risks and benefits did not match across documents, and staff interviews indicated there was no documentation that the family was educated before consent was obtained. The POA was also not present for an IDT care plan review, yet the record stated agreement with the plan of care.
A resident with a G-tube, anoxic brain damage, anxiety, and dementia was observed in a reclining wheelchair with bilateral mitts, an abdominal binder, and a seatbelt in place. The record showed repeated restraint use to prevent pulling at medical devices, but restraint evaluations did not document attempted alternatives, and progress notes showed no evidence of resident or representative consent for the mitts, binder, or seatbelt. IDT care plan reviews addressed restraint use, but did not document specific changes or less restrictive measures.
A resident with severe cognitive impairment, anoxic brain injury, dementia, and behavioral issues developed a left distal radius fracture after repeated unsafe movements in a geri chair and around the room. The facility interviewed nursing staff during the investigation, but no resident witnesses were interviewed and the investigation did not determine where or how the fracture occurred, despite policy language calling for interviews with the person reporting the incident and resident(s).
Inaccurate MDS Restraint Assessment: A resident with gastrotomy, anoxic brain damage, anxiety, and dementia had bilateral soft mitts, an abdominal binder, and a wheelchair seatbelt documented in the chart, care plan, physician orders, TAR, and direct observations. However, the quarterly MDS marked no restraint use for trunk or limb restraints, and the MDS Coordinator confirmed the assessment was inaccurate.
Failure to Notify State Mental Health Authority of Significant Mental Status Change: A resident with bipolar disorder was initially exempt from Level 2 PASARR while on hospice, but after hospice discharge the resident developed worsening behavioral symptoms, medication refusal, tearfulness, false accusations, and delusional statements. The chart showed a significant change in condition MDS and psychiatric involvement, yet there was no evidence that an updated Level 1 PASARR was submitted for a new Level 2 determination after the change in mental status.
Food items were found improperly stored and dated in the kitchen and unit refrigerator. Opened and exposed foods, unlabeled juice cups, uncovered cake pans, and foods on the tray line were observed at temperatures above the Dietary Supervisor’s stated limits. Staff also placed personal items in food prep and unit refrigerator areas, and the unit refrigerator had spills and was not cleaned per the posted schedule.
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.
Antihypertensive Given Despite Hold Parameter
Penalty
Summary
The facility failed to ensure that Losartan was administered according to the physician-ordered hold parameter for one resident. The resident was admitted with a history of UTI, COPD, OSA, hypertension, and CVA. The admission progress note stated the resident was alert, oriented x4, awake, and able to make needs known. The care plan included administering medications and treatments as ordered, monitoring and documenting side effects and effectiveness, and reporting occurrences to the physician. A physician order dated November 10, 2025 directed Losartan Potassium 50 mg, two tablets by mouth daily for hypertension, with instructions to hold if systolic blood pressure was less than 130. The order was transcribed to the MAR and scheduled for 8:00 a.m. Blood pressure documentation showed a reading of 90/55 at 7:04 a.m. on November 11, 2025, and the MAR documented a blood pressure of 103/65 at 8:00 a.m. Despite the systolic blood pressure being below the ordered hold parameter, Losartan was administered at the scheduled time. There was no documentation explaining why the medication was given outside the ordered parameters or that the physician was notified. Later that morning, the resident’s condition worsened. At 9:27 a.m., therapy documentation noted a blood pressure of 63/39 with visual and auditory hallucinations, and the therapist immediately notified the RN. Nursing documentation at 9:46 a.m. recorded a blood pressure of 69/45, hallucinations, anxiety, altered orientation, inability to answer questions, sweaty skin, and difficulty keeping eyes open or moving from a supine position. The record also stated the resident reported feeling "yucky" and had cramps on the left side. The provider and family were notified, 911 was called, and the resident was transported to the hospital for hypotension.
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.
Infection Control Failures During Catheter Care, Wound Care, and Resident Contact
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during care for a resident with an indwelling urinary catheter. Resident #71 was admitted with multiple conditions including orthopedic aftercare following surgical amputation, acquired absence of the right leg above the knee, generalized muscle weakness, cognitive communication deficit, hypertension, wound infection, diabetes mellitus, and an indwelling catheter. During observation, the resident’s catheter drainage bag was found in direct contact with the floor while the resident was sleeping in bed. Staff interviews confirmed that the bag should not touch the floor and should be kept below bladder level, and that floor contact was considered contaminated. The facility also failed to maintain infection control measures during a wound dressing change for Resident #166, who was admitted with diagnoses including encephalopathy, generalized muscle weakness, and abdominal aortic aneurysm. The resident had an active order for daily care of a right lower arm skin tear using normal saline, xeroform, and a hydrogel dressing. During the observed dressing change, the wound care nurse placed supplies on a tray table without first cleaning or sanitizing the surface, and the supplies were set on a folded absorbent pad. The old dressing was removed while the nurse wore gloves but no protective gown, and the nurse later washed hands and donned a gown and fresh gloves before completing the procedure. The nurse stated that several steps were missed and acknowledged that the table was not disinfected before supplies were placed on it. The facility further failed to ensure hand hygiene and PPE use during care for Resident #9, who had severe cognitive impairment, a feeding tube, and a care plan and physician order for enhanced barrier precautions related to the PEG tube. During incontinence care, an LPN used the same gloves from brief change to put on the resident’s shirt, and a CNA’s gown was not completely covering the pants and contacted the resident’s mattress. During another observation, a CNA repositioned the resident without wearing a gown and was not observed performing hand hygiene before or after the repositioning. The CNA later touched another resident’s wheelchair before sanitizing her hands. Staff interviews and the facility’s infection control policy stated that hand hygiene and gown and glove use were expected for resident care involving contact with the resident or the resident environment, including enhanced barrier precautions for feeding tubes and other indwelling devices.
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 Inform Resident Representative of Restraint Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident with gastrostomy, anoxic brain damage, anxiety, dementia, and severely impaired cognitive skills was fully informed of the risks and benefits of restraints before abdominal binder, waist/seat belt, and bilateral mitt restraints were used. The record showed that a binder was first placed over the resident’s PEG tube to prevent tube removal, and later the care plan identified physical restraints related to pulling at the PEG tube and a history of removing the PEG tube and PICC line. However, progress notes from the earlier periods reviewed did not show consent from the resident’s representative or documentation that the risks and benefits of the binder were explained. The record also showed that an abdominal support garment was recommended as a restraint to protect the feeding tube and prevent dislodgement, and that consent was obtained from a family member. Later, the resident had a new abdominal binder placed after the G-tube was replaced, and bilateral soft mitts were added. Review of the chart from February 2024 through August 2025 did not show resident or representative consent for the bilateral soft mitts, abdominal binder, or seatbelt restraints, and a behavior note documented the use of posey mitts and an abdominal binder to protect the G-tube site. An Assistive Device consent dated July 15, 2025 listed an abdominal binder, bilateral soft mitts, and a seatbelt, but the risks and benefits on that form did not match the risks and benefits documented in the restraint evaluations. The evaluations described the devices as restraints and noted benefits such as protecting the resident from injury and allowing medical treatment to proceed, but they did not include specific risks such as increased agitation, pressure ulcers, accidental injury, loss of independent mobility, withdrawal/depression, death by strangulation, or suffocation. The record also showed that the POA was not present for an annual IDT care plan review, yet the documentation stated that the resident and/or representative agreed with the plan of care. Interviews with staff further indicated that the family had not been documented as informed or educated before consent was obtained, and the DON stated the family was aware of the Assistive Device form.
Failure to Evaluate and Document Least Restrictive Restraint Use
Penalty
Summary
The facility failed to ensure that monitoring and evaluation were conducted for the least restrictive alternatives for the least amount of time and failed to conduct ongoing evaluations of the need for physical restraints for one resident. Resident #9 was admitted and re-admitted with diagnoses including gastrostomy, anoxic brain damage, anxiety, and dementia. The record showed repeated use of bilateral soft mitts, an abdominal binder, and a seatbelt while the resident was in a reclining wheelchair, with documentation that the resident had a G-tube and had a history of pulling at medical devices. The record review showed multiple restraint-related entries, including behavior notes stating that a binder was placed over the PEG tube to prevent the resident from pulling it out, that the resident tried to pull out a PICC line and tube feeding, and that mitts and a binder were placed after the G-tube was replaced. Physician documentation also noted an abdominal binder in place. However, review of progress notes from February 2024 through August 2025 revealed no evidence of resident or resident representative consent for the bilateral soft mitts, abdominal binder, or seatbelt restraints. Restraint/enabling device evaluations dated May 21, 2025, July 15, 2025, August 26, 2025, and November 25, 2025 identified the devices as restraints and stated they were used because the resident unintentionally removed the feeding tube, had impaired safety awareness, and could not sit still related to traumatic brain injury, but the evaluations did not show that alternatives were attempted before use. The care plan and IDT reviews documented restraint-related care planning, but the reviews did not include specific changes to the resident's current restraints or implementation of less restrictive restraints. During observations on December 9 and December 11, 2025, the resident was seen reclining in a wheelchair with bilateral mitts, an abdominal binder, and a seatbelt in place. An LPN stated that the mitts were started because the resident tends to pull the G-tube and that there had not been any other alternatives to minimize the use of the abdominal binder and mitts. The DON stated that the IDT reviews the need for restraints and acknowledged that no alternative measures were documented in the restraint evaluations.
Incomplete Investigation of Resident Fracture and Alleged Neglect
Penalty
Summary
The facility failed to ensure a thorough investigation of an allegation of neglect involving a resident with gastrotomy, anoxic brain damage, anxiety, and dementia. The resident’s MDS assessment showed no BIMS score and indicated severely impaired cognitive skills for daily decision-making. Clinical notes documented repeated attempts to put himself on the ground from a geri chair, rolling around on mats, crawling around the room, and restlessness while in the behavioral unit. The resident later had swelling of the left hand and an X-ray showed a left distal radius fracture. The facility’s investigation documented interviews with seven nursing staff members, but no resident interviews were conducted as potential witnesses, and the investigation did not identify where or how the fracture occurred. The Administrator stated that the facility’s process is to interview witnesses, residents, and the person affected, and acknowledged that the policy states interviews with the person reporting the incident and resident(s) should be completed.
Inaccurate MDS Restraint Assessment
Penalty
Summary
The facility failed to ensure that Resident #9’s MDS assessment was accurate regarding restraint use. The resident was admitted and re-admitted with diagnoses including gastrotomy, anoxic brain damage, anxiety, and dementia. Clinical documentation showed that the resident had a G-tube replaced, was placed in hand mitts and an abdominal binder, and later had ongoing care plan focus areas for physical restraints, including bilateral soft wrist mittens related to traumatic brain injury, a fastened seatbelt in a wheelchair, and abdominal support to secure the feeding tube and prevent dislodgement. Physician orders also directed use of a seatbelt while in a wheelchair and removal of bilateral soft wrist mittens every 2 hours for skin checks, circulation, and ROM. Despite this documentation and repeated observations showing the resident in a reclining wheelchair with bilateral soft mitts, an abdominal binder, and a fastened seatbelt, the quarterly MDS dated [DATE] indicated no evidence of restraint use in chair or out of bed for trunk restraints and limb restraints, and no evidence of a trunk restraint used in bed. The MDS Coordinator stated that the MDS was inaccurately completed regarding the abdominal binder and bilateral soft mitts. The DON stated that the resident had bilateral mitts and an abdominal binder because he pulled out his G-tube and had a seatbelt in the wheelchair so he would not harm himself, and that the MDS was expected to be accurate.
Failure to Notify State Mental Health Authority of Significant Mental Status Change
Penalty
Summary
The facility failed to ensure that the state mental health authority was notified when a resident with bipolar disorder had a significant change in mental condition. Resident #37 was admitted with diagnoses including atherosclerotic heart disease, bipolar disorder, and colostomy status. A Level 1 PASARR completed in February 2025 did not include the bipolar diagnosis, and an April 2025 Level 1 PASARR included bipolar disorder but was followed by an email from the state mental health authority stating the resident met the terminal illness exemption and did not require a Level 2 PASARR because of hospice status and a life expectancy of less than 6 months. The resident later had a hospice discharge-transfer summary showing hospice services ended on July 18, 2025 due to extended prognosis. After hospice discharge, nursing documentation on August 3, 2025 described medication refusal, tearfulness, refusal of some meals, and crying while asking why staff treated her that way, with staff noting another person was present because the resident made false accusations. The care plan was updated on August 4, 2025 to address behavior problems related to bipolar disorder, resistive to care, and false accusations. A significant change of condition MDS later documented active bipolar disorder, no psychological services, and no hospice care. On August 13, 2025, multiple medication administration notes documented continued refusal of medications, with the resident stating, "If the Holy Spirit wants to heal me he will or I will go home." The primary care physician and psychological services were notified, and a psychiatric note on the same date stated a urinary tract infection could be contributing to the recent behavior change and delusional thinking. Another psychiatric note on August 22, 2025 recommended a mood stabilizer, which the resident declined. The clinical record contained no evidence of an updated Level 1 PASARR after hospice discharge or after the significant change in mental condition, and staff interviews confirmed that the PASARR should have been resubmitted for a change of condition determination.
Food Items Left Open, Undated, and Improperly Stored
Penalty
Summary
The facility failed to ensure that food items were properly stored and dated in accordance with its food storage and date marking policy. During an initial kitchen observation, the Dietary Supervisor observed multiple items in the walk-in refrigerator that were opened or exposed to air, including a salad bag with open and use-by dates of 12/6-12/12, 1 lb of ground beef without an open or use-by date, an employee lunch bag, boiled eggs in an opened container, 9 unlabeled and undated juice cups, 1 lb bag of green beans opened to air, and a bag of lettuce opened to air. During a later kitchen observation, two sheet cake pans were left uncovered on the prep counter. A tray line temperature check showed several foods above the temperatures identified by the Dietary Supervisor, including cake desserts, milk, apple juice, diced peaches, applesauce, watermelon, and mechanical soft/moist pears. A Dietary Aide was also observed placing a personal water bottle on the bottom shelf of the food prep table. In addition, the unit refrigerator was found with a posted cleaning schedule showing it was not cleaned on the prior day, and it contained a half-eaten employee sandwich, which the Dietary Supervisor identified as an employee lunch. Juice spills were also observed on the shelves and bottom of the unit refrigerator. The Dietary Supervisor stated that food items should be labeled, dated, and properly closed, that staff lunches should be kept in the designated staff refrigerator, and that there was no set schedule for conducting refrigerator, freezer, and dry storage observations.
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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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 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 | ★★★★★ | 7 | 0 |
| Desert Cove Nursing Center | 0.6 mi | ★★★★★ | 17 | 0 |
| River Park Post Acute | 3.3 mi | ★★★★★ | 0 | 0 |
| Tempe Post Acute | 5.6 mi | ★★★★★ | 8 | 0 |
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