Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Chandler Nursing Center during CMS and state inspections, most recent first.
Missing Diagnosis for Foley Catheter Orders: Two residents had Foley catheter orders without a documented diagnosis supporting the indication for the catheter. One resident had multiple chronic conditions and an indwelling catheter with no related diagnosis in the order or care plan, while the other resident had quadriplegia, kidney failure, and obstructive uropathy, but the Foley order still lacked a catheter indication. The TX Nurse stated the catheters were used due to pressure wounds and urinary retention, and the DON acknowledged the missing diagnosis on the orders.
Staff on two med carts signed controlled substance count sheets for both shift change entries at the same time instead of at the actual coming-on and going-off times, despite knowing the process. In a separate medication pass, an LPN reconstituted an antibiotic for a resident with Lidocaine 1% liquid without an order for that solution; the resident had an order for the antibiotic and a separate topical Lidocaine order only.
Infection control failures were observed for multiple residents with isolation needs, including a resident on strict contact isolation for C. difficile, a resident on strict contact isolation for ESBL in urine, and a resident with an indwelling catheter and wound care needs. CNA A entered one isolated resident’s room without PPE to deliver a meal and left without hand hygiene, then later performed incontinent care without changing gloves or sanitizing hands between dirty and clean tasks while handling a clean brief. The TX Nurse also failed to change gloves or perform hand hygiene between dirty and clean procedures during incontinent care, and leadership stated staff were expected to follow glove-changing and hand hygiene practices.
Inaccurate MDS Assessment for Respiratory Treatment: A resident with COPD, respiratory failure, and OSA was incorrectly coded on the MDS as receiving an invasive mechanical ventilator even though the chart showed no trach or ventilator use and the resident had only a CPAP order. Surveyors observed the resident on O2 via NC with a CPAP at bedside, and the resident stated she did not use a ventilator. The MDS Nurse said she marked the wrong box, while the DON and Administrator said they expected the record to be completed accurately.
Medication Error: Antibiotic Reconstituted With Unordered Lidocaine. An LVN reconstituted and administered an IM dose of Ertapenem Sodium using Lidocaine 1% solution for a resident with a UTI and femur fracture, but there was no physician order for the Lidocaine used to prepare the medication. The LVN said she believed an order existed, while the DON and Administrator stated staff should have an order for any medication needed for reconstitution.
A resident with dementia and severe cognitive impairment was transferred to a memory care unit without the required written notice to the resident or her representative, and without notifying the local ombudsman. The facility's records lacked documentation of the transfer notice, reasons for the move, signed consent, and a discharge summary, and the family was not informed in advance.
The facility failed to maintain professional standards for food service safety, with deficiencies in kitchen sanitation and food handling. Observations revealed an unclean ice machine, improper use of ice scoops, and inadequate labeling of food items. The oven and steam table had significant buildup, and the food processor was not sanitized between uses. Staff interviews highlighted a lack of formal training and documentation, with the Dietary Manager and other staff acknowledging the need for improved practices and teamwork.
Two residents in the facility were found with medications at their bedside without physician orders or permission to self-administer. One resident had zinc oxide, nasal spray, and mentholatum ointment, while another had Aspercream, all brought by family members without notifying the facility. The facility's policy required medications to be stored securely, and no residents were deemed safe to self-administer, highlighting a lapse in monitoring and control procedures.
The facility failed to ensure two CNAs maintained their certifications, allowing them to work with expired credentials. CNA B and CNA C's certifications expired, and despite being informed, CNA C continued to work. The ADON and Administrator acknowledged the issue, and both CNAs were removed from the schedule until renewal. The facility lacked a policy on staff qualifications, potentially risking resident care.
A facility failed to maintain proper infection control practices, as a Treatment Nurse did not sanitize hands between glove changes during wound care, and a CNA did not wear a gown or sanitize hands between glove changes while providing care to a resident on Enhanced Barrier Precautions. Staff interviews confirmed the risk of infection due to these lapses.
A facility failed to ensure a resident's emergency call light was accessible from the floor, as the string was wrapped around a grab bar, making it difficult to use in case of a fall. The resident, who was cognitively intact and independent with toileting, had a history of falls. Staff interviews revealed a lack of awareness about the importance of keeping the call light accessible, despite facility policies emphasizing the need to respond to residents' requests and needs.
A facility failed to include the use of a mechanical lift in a resident's care plan, despite the resident's severe cognitive impairment and dependence on staff for all ADLs. The resident was observed with a faded mechanical lift sling, and interviews with the DON and Administrator highlighted the risk of staff being unaware of the resident's needs, potentially leading to falls and injuries.
The facility failed to follow recipe guidelines for pureed meals, using unapproved liquids during preparation, which could affect the nutritive value and quality of meals. Staff interviews revealed a lack of formal training and reliance on verbal instructions, contributing to the deficiency.
The facility failed to provide food of the correct consistency for residents on puree diets, as observed with clumpy and sticky Spanish rice and enchiladas. The Dietary Manager and cook acknowledged the inconsistency, attributing it to a mistake and lack of formal training. Interviews revealed a need for improved documentation and structured training for kitchen staff to ensure compliance with dietary guidelines.
A CNA at an LTC facility was observed standing while feeding a resident, contrary to training that staff should sit at eye level to maintain dignity. The resident, dependent on staff due to quadriplegia, was fed by the CNA who had been employed for a week. Facility staff confirmed the expectation to sit during feeding, but no formal policy on dignity was in place.
The facility failed to remove worn and damaged mechanical lift slings from service, posing a risk to residents. Two residents with severe cognitive impairment were observed using slings with faded colors and unreadable labels, which could lead to improper use and potential injury. Interviews revealed that while the facility had protocols for inspecting slings, these were not effectively followed, resulting in the continued use of unsafe equipment.
A resident with a history of stroke, dementia, and hypertension was administered an incorrect dosage of Depakote due to a discrepancy between the MAR and the medication card. The resident was supposed to receive 500mg twice daily but was given only 250mg in the morning. The error was identified when an LVN compared the medication card to the MAR and realized the mistake.
The facility failed to post daily nurse staffing information in a prominent location, placing it on a wall in B hall instead of at the front entrance or nurse's station. This oversight was observed over two days, with the ADON responsible for the postings and trained to place them in B hall. The Administrator was aware of the location but had not been informed of any issues with accessibility. The facility lacked a policy for staff postings, leading to potential risks of uninformed residents, families, and visitors.
Missing Diagnosis for Foley Catheter Orders
Penalty
Summary
The facility failed to ensure that two residents with indwelling Foley catheters had an appropriate diagnosis documented to support the catheter orders. Resident #4, a female with diagnoses including myocardial infarction, osteomyelitis, hypertension, encephalopathy, and atrial fibrillation, had a physician order for a Foley catheter with monthly changes, but the record did not include a related diagnosis indicating why the catheter was needed. Her MDS showed moderately impaired cognition, an indwelling catheter, and no renal insufficiency, neurogenic bladder, obstructive uropathy, or recent UTI. Her care plan listed altered bladder/bowel elimination related to the Foley catheter, but still did not identify a diagnosis for the catheter indication. Resident #74, a male with diagnoses including quadriplegia, kidney failure, and obstructive uropathy, also had a physician order for a Foley catheter with monthly changes and no related diagnosis documented for the catheter indication. His MDS showed moderately impaired cognition, an indwelling catheter, obstructive uropathy, and no UTI in the last 30 days. His care plan identified the indwelling catheter as related to a pressure ulcer. During interviews, the TX Nurse stated Resident #4’s Foley had been inserted due to pressure wounds on her bottom and urinary retention, and stated Resident #74’s catheter was in place because of a healing Stage 4 wound to his bottom. The DON said she had not realized the Foley orders lacked a related diagnosis, and the Administrator said she expected nursing staff to have a diagnosis for catheter use.
Controlled Drug Count Documentation and Medication Order Error
Penalty
Summary
The facility failed to maintain an accurate system for controlled drug receipt, disposition, and reconciliation for two medication carts. During observation, RN C and MA D were seen signing the controlled substance count sheets for both the end of their shift and the beginning of their shift at the same time on RN Cart #1 and MA Cart #1. The narcotic count verification sheet stated that staff were acknowledging they had counted the controlled drugs on hand and found the quantities in agreement with the record. In interviews, RN C and MA D each stated they knew they should not sign both the coming and going slots at the same time, and the ADON and DON stated staff were supposed to sign the controlled drug count record when coming on duty and when going off duty. The ADON said she had in-serviced nurses and MAs on the procedure and was responsible for monitoring compliance. The facility also failed to ensure accurate medication administration for one resident during a medication pass. During observation, LVN B reconstituted Ertapenem Sodium Injection powder with Lidocaine 1% liquid 5cc for Resident #70. Record review showed the resident had an order for Ertapenem Sodium Injection 1 gram intramuscularly daily, and a separate order for Lidocaine HCl External Pad 4% applied topically to the right knee as needed, but there was no order for Lidocaine 1% liquid 5cc to reconstitute the injection. LVN B stated she did not realize there was no order for the Lidocaine and said she should clarify the order with the physician. The DON stated there should be an order for the Lidocaine or any injectable solution used to reconstitute a powdered antibiotic, and the Administrator stated she expected staff to ensure they had an order for medications needed.
Infection Control Failures During Isolation and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 of 4 residents observed for infection control. Resident #4 had diagnoses including myocardial infarction, osteomyelitis, hypertension, encephalopathy, and atrial fibrillation, with moderately impaired cognition, an indwelling catheter, and a wound. Her record showed strict contact isolation for C. difficile, and during observation she had PPE set up outside her room and isolation signage on the door. Resident #70 had diagnoses including myocardial infarction, osteomyelitis, hypertension, encephalopathy, and atrial fibrillation, with severely impaired cognition, an indwelling catheter, and a care plan for ESBL in the urine requiring strict contact isolation and single room occupancy. During observation, CNA A entered the resident’s room to deliver a lunch tray without putting on PPE and left without washing her hands. During a later incontinent care observation, CNA A removed a dirty brief and then, without doffing dirty gloves, sanitizing her hands, or donning clean gloves, opened the closet, obtained a clean brief, and continued care while touching clean items with dirty gloves. Resident #74 had diagnoses including quadriplegia, kidney failure, and obstructive uropathy, with moderately impaired cognition, an indwelling catheter, and a wound. During wound care and incontinent care, CNA A and the TX Nurse removed a dirty brief and then, without doffing dirty gloves, sanitizing their hands, or donning clean gloves, obtained a clean brief from the closet and continued care. The ADON, DON, and Administrator stated staff were expected to change gloves and perform hand hygiene between dirty and clean procedures and to follow policy and standards of practice.
Inaccurate MDS Assessment for Respiratory Treatment
Penalty
Summary
The facility failed to ensure an accurate assessment for Resident #3 by incorrectly completing the MDS to show that the resident received an invasive mechanical ventilator. Record review showed the resident was admitted with diagnoses including COPD, respiratory failure, and obstructive sleep apnea. The chart did not indicate a tracheostomy or ventilator use, and the resident had an order for CPAP at bedtime. Surveyors reviewed the quarterly MDS assessments and found that section O0110, Special Treatments, Procedures, and Programs, marked invasive mechanical ventilator as received. During observation, Resident #3 was seen sitting in a recliner with oxygen via nasal cannula and a CPAP machine at bedside, and later was observed in a wheelchair with portable oxygen via nasal cannula. The resident stated she did not use a ventilator, only CPAP when needed. The MDS Nurse stated she marked the wrong box and that the resident had CPAP, not a ventilator/respirator. The DON said she only checked MDS completion and expected staff to ensure the information was correct, and the Administrator stated she expected staff to complete the clinical record accurately.
Medication Error: Antibiotic Reconstituted With Unordered Lidocaine
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed, Resident #70. During an observation, LVN B reconstituted Ertapenem Sodium Injection powder with Lidocaine 1% solution and administered it intramuscularly to the resident. Record review showed an order for Ertapenem Sodium Injection 1 gram IM daily for a urinary tract infection, but there was no physician order for Lidocaine 1% liquid 5 cc to be used to reconstitute the medication. The resident’s face sheet identified her as a [AGE] year-old female admitted on 04/22/25 with diagnoses including fracture of the right femur and urinary tract infection. During interview, LVN B stated she thought there was an order for the Lidocaine injectable and did not realize there was no order for the Lidocaine used to reconstitute the antibiotic. She stated she should have clarified the order with the physician and acknowledged the resident could have a reaction to the medication requiring further medical intervention since it was injected. The DON stated there should be an order for the Lidocaine or any injectable solution used to reconstitute a powdered antibiotic, and the Administrator stated staff were expected to ensure they had an order for medications needed. The facility’s IM injection policy stated to verify that there is a physician’s medication order for the procedure.
Failure to Provide Required Transfer/Discharge Notification and Documentation
Penalty
Summary
The facility failed to provide the required written notice and documentation prior to the transfer of a resident with dementia and severe cognitive impairment to another facility. The resident, who exhibited wandering and exit-seeking behaviors, was transferred to a memory care unit without written notification to the resident or her representative, and without notifying the local ombudsman. The clinical records did not contain evidence of a transfer or discharge notice, the reasons for the move, or a signed consent from the resident's representative. Additionally, there was no documentation of a discharge summary or a recapitulation of the resident's stay. Interviews and record reviews revealed that the resident's family member was not informed of the transfer in advance and only learned of the planned admission while visiting the receiving facility. The social worker confirmed that neither a 5-day nor a 30-day discharge notice was provided, and the ombudsman reported not being notified of the transfer. The facility's own discharge policy requires involvement of the resident and family in the discharge planning process and proper notification, which was not followed in this case.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in the kitchen's sanitation and food handling practices. Observations revealed that the ice machine was not properly cleaned, with black and brown substances present on the inside walls. Additionally, the designated scoop for ice was not used, as a water pitcher was employed instead. The spatula used for pureeing was not kept on a clean, sanitary surface, and gloves were not used during food preparation, increasing the risk of cross-contamination. Further deficiencies were noted in the labeling and dating of food items. Pre-prepared glasses of liquids in the cooler were not labeled or dated, and the facility's cleaning and sanitation standards were not followed. The oven and steam table had significant brown and black baked-on buildup, indicating a lack of regular cleaning. The food processor was not properly sanitized between uses, and the three-compartment sink was not set up with wash, sanitizing, or rinse water, as required by the facility's standards. Interviews with staff members, including the Dietary Manager (DM), cook, dishwasher, and others, highlighted a lack of formal training and documentation of in-services. The DM acknowledged the need for improvement in cleaning practices and staff training. The cook admitted to not properly sterilizing equipment and expressed a desire for better teamwork in the kitchen. The dishwasher and other staff members also noted the absence of written training and the need for updated equipment. The facility's Administrator and Director of Nursing (DON) recognized the deficiencies and the potential risk of foodborne illnesses due to inadequate sanitation practices.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, leading to medications being stored at the bedside for two residents. Resident #13, who had diagnoses including age-related osteoporosis, hypertension, COPD, and candidiasis, was found to have zinc oxide ointment, nasal spray, and mentholatum ointment on her overbed table without any physician orders for these medications or permission to self-administer. These medications were brought in by her family without notifying the facility, and the resident used them for various personal health issues. Similarly, Resident #4, diagnosed with osteoarthritis, unspecified dementia, hypertension, senile degeneration of the brain, and cerebral ischemia, was found with a bottle of Aspercream on her dresser. There were no physician orders for this medication, nor was the resident care planned to self-administer medications. The resident mentioned that her family brought the Aspercream to her, but she did not specify the frequency or amount of use, and the staff was unaware of its presence. The facility's policy required medications to be stored securely in a medication room or cart, and no residents were deemed safe to self-administer medications. The ADON and DON were unaware of the medications at the bedside until the survey, indicating a lapse in the facility's procedures for monitoring and controlling medication storage. The presence of these medications at the bedside posed a risk of overmedication or misuse by the residents or others.
Expired CNA Certifications
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), identified as CNA B and CNA C, maintained their certifications in accordance with state laws. CNA B's certification expired, and there was no evidence of renewal. Similarly, CNA C's certification expired, and she was unaware of the expiration until informed by the Assistant Director of Nursing (ADON). Despite being notified, CNA C continued to work without a valid certification. The ADON acknowledged awareness of the expired certifications and stated that both CNAs had been removed from the schedule until their certifications were renewed. The Administrator confirmed that the facility had been conducting in-service training on the TULIP certification system and had encountered issues with the system. Despite these efforts, CNA B and CNA C were allowed to work under previous waivers, but their certifications remained expired after the waivers ended. The facility did not have a policy on staff qualifications, and the Administrator emphasized that staff were responsible for maintaining their certifications. The lack of a policy and the expired certifications could potentially place residents at risk of receiving care from unqualified staff.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and personal protective equipment (PPE) use by staff members. Specifically, a Treatment Nurse did not sanitize or wash her hands between glove changes while performing wound care on a resident with a pressure ulcer. The nurse admitted to not having sanitizer available during the procedure and acknowledged the risk of infection due to inadequate hand hygiene. Another incident involved a Certified Nursing Assistant (CNA) who failed to wear a gown while providing incontinent care to a resident on Enhanced Barrier Precautions (EBP) due to an ileostomy. The CNA did not sanitize her hands between glove changes during the care process. Despite the presence of an EBP sign on the resident's door, the CNA did not use a gown, citing the absence of PPE outside the room. The CNA was unaware of her failure to sanitize hands between glove changes, which could increase the risk of infection. Interviews with facility staff, including the Infection Preventionist/Assistant Director of Nursing (IP/ADON) and the Director of Nursing (DON), confirmed that the facility's policy required the use of gowns and gloves for residents on EBP. The staff acknowledged the risk of infection if proper hand hygiene and PPE protocols were not followed. The facility's policies on hand hygiene and EBP were reviewed, indicating the necessity of following CDC guidelines and using PPE for high-contact resident activities.
Inaccessible Call Light in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that the emergency call light in a resident's bathroom was accessible from the floor, which is a necessary accommodation for resident safety. The resident, who was cognitively intact and independent with toileting, had wrapped the call light string around the grab bar in the bathroom. This action made the call light inaccessible in the event of a fall, which could prevent the resident from notifying staff of their needs. The resident had a history of falls, although she had not fallen recently. Staff interviews revealed a lack of awareness regarding the importance of keeping the call light string unwrapped and accessible. A medical assistant was unaware of the reason for not wrapping the string around the grab bar, while a CNA acknowledged that wrapping the string could prevent a resident from calling for help if they fell. The Director of Nursing confirmed that the resident had wrapped the string herself and had been educated on the issue. The facility's policy emphasizes the importance of responding to residents' requests and needs, highlighting the deficiency in ensuring the call light was accessible.
Failure to Include Mechanical Lift in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included the necessary use of a mechanical lift for transfers. The resident, an elderly male with diagnoses of parkinsonism, hemiplegia, and Alzheimer's, was observed in a wheelchair with a mechanical lift sling that was faded and had an unreadable label. The care plan, dated several months prior, did not address the use of a mechanical lift, despite the resident's severe cognitive impairment and dependence on staff for all activities of daily living (ADLs). Interviews with the Director of Nursing (DON) and the Administrator revealed that the MDS nurse was responsible for care plans but was unavailable at the time. The DON acknowledged that without a proper care plan, staff might not be aware of the resident's need for a mechanical lift, potentially putting the resident at risk for falls and injuries. The Administrator confirmed that care plans should address residents' needs to ensure they receive the proper assistance.
Failure to Follow Recipe Guidelines for Pureed Meals
Penalty
Summary
The facility failed to ensure that recipes were followed to meet the nutritional needs of residents, specifically during the preparation of pureed meals. Observations revealed that the cook used water, an unapproved liquid, to dilute Spanish rice and enchiladas for pureeing, which was not in accordance with the recipe guidelines. The cook admitted to not consulting the recipe during preparation, relying instead on memory from past experience. This deviation from the recipe could potentially affect the nutritive value, flavor, and appearance of the meals provided to residents. Interviews with staff, including the Dietary Manager (DM), cook, and other personnel, highlighted a lack of formal, documented training and in-services on food preparation and pureeing techniques. The DM acknowledged the oversight and the need for more structured training, while the cook admitted to not having received training on pureeing in several years. The absence of written training materials and reliance on verbal instructions contributed to the deficiency, as staff were not adequately informed or reminded of the correct procedures to follow, potentially impacting the quality of care provided to residents.
Inadequate Puree Food Consistency for Residents
Penalty
Summary
The facility failed to ensure that food prepared for residents on puree diets met the required consistency standards. During an observation, it was noted that the pureed Spanish rice and enchiladas on a test tray were clumpy and sticky, with pieces of rice and chunks of enchiladas not blended to a smooth, pudding-like consistency. The Dietary Manager (DM) acknowledged the inconsistency and attributed it to a possible mistake by the cook, who was observed to be nervous and admitted to forgetting some steps in the pureeing process. The cook speculated that the food might have thickened due to sitting on the hot steam table. Interviews with various staff members, including the DM, Assistant Director of Nursing (ADON), and Registered Dietitian (RD), revealed a lack of formal, documented training and in-services for kitchen staff on food preparation. The DM admitted to not intervening when she noticed the cook making a mistake and acknowledged the need for more structured training. The ADON and RD also recognized the need for improved training and documentation to ensure compliance with dietary guidelines and state regulations. The Administrator emphasized the importance of following menus and checking food consistency per doctor's orders and care plans before serving.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during meal assistance. A CNA was observed standing while feeding a resident in the dining room, contrary to the facility's training and expectations that staff should sit at eye level with residents during feeding. The resident, who was dependent on staff for all activities of daily living due to quadriplegia and other medical conditions, was fed by the CNA who had been employed at the facility for only a week. The CNA acknowledged awareness of the facility's preference for sitting while feeding but did not adhere to this practice. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that staff were trained to sit while feeding residents to avoid making them feel insecure or intimidated. The facility's training records indicated that the CNA had attended an in-service training on dignity issues related to feeding. Despite this, the facility did not have a formal policy on dignity, which may have contributed to the oversight in ensuring consistent adherence to the expected feeding practices.
Failure to Remove Damaged Lift Slings Poses Hazard
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service. Two residents, one with severe cognitive impairment and dependent on assistance for all activities of daily living, were observed using mechanical lift slings that were faded and had unreadable labels. The slings were noted to have faded colors, which could lead to confusion about which loops to use during transfers, posing a risk of tearing and potential injury. Interviews with the Director of Nursing (DON) and the Laundry Supervisor revealed that the facility's protocol required slings to be inspected for wear and tear, including color fading, before use. However, the Laundry Supervisor admitted to not noticing the faded coloring on the straps, focusing instead on stitching. The DON acknowledged that all staff should inspect slings before use, but the facility had not effectively ensured this practice was followed, leading to the continued use of unsafe slings.
Medication Error: Incorrect Depakote Dosage Administered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Depakote, an anticonvulsant medication. The resident, a male with a history of cerebral infarction, dementia, and hypertension, was supposed to receive 500mg of Depakote twice daily. However, on the date in question, the resident was administered only 250mg in the morning due to a discrepancy between the medication administration record (MAR) and the medication card. The MAR indicated the correct dosage of 500mg, but the medication card incorrectly instructed the administration of 250mg in the morning and 500mg in the evening. The error was observed when an LVN administered the incorrect dosage and later realized the mistake upon reviewing the medication card and MAR. The pharmacy representative confirmed that their system had the incorrect instructions, which had been followed since the previous year. The facility's policy requires verification of the MAR against the pharmacy label and the manufacturer's identification system, and discrepancies should be clarified before administering medication. This protocol was not followed, leading to the medication error.
Failure to Post Nurse Staffing Information Prominently
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent and accessible location for residents, families, and visitors. On two of the three days reviewed, the staffing information was not posted at the front entrance or the nurse's station, which are considered prominent locations. Instead, the postings were found on a wall in B hall, which was not easily accessible to all individuals entering the facility. This oversight was observed on 12/2/2024 and 12/3/2024, with the posting for 12/3/2024 still being displayed on 12/4/2024. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) was responsible for posting the staffing information and had been trained to place it on B hall, where other facility postings were located. The Administrator acknowledged awareness of the posting location but stated that no one had previously raised concerns about its accessibility. The facility did not have a policy in place for staff postings, which contributed to the oversight and potential risk of residents, families, and visitors not being informed of the staffing levels for each day.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 159 citations issued within 25 miles in the last 12 months — including the 10 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Greenbrier Nursing & Rehabilitation Center Of Tyle | 8.8 mi | ★★★★★ | 22 | 0 |
| The Heights Of Tyler | 8.8 mi | ★★★★★ | 7 | 0 |
| Briarcliff Health Center | 9.5 mi | ★★★★★ | 0 | 0 |
| Reunion Plaza Healthcare & Rehabilitation | 9.6 mi | ★★★★★ | 0 | 0 |
| Avir At Azalea Heights | 9.6 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Chandler Nursing Center.
100% money-back within 48 hours.
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.