Chandler Creek Post Acute

Inspectors wroteBased on review of facility policy, resident records, hospital records, and interviews, the facility failed to protect Resident (R)2 from a significant medication error for 1 of 2 residents reviewed. Specifically, on 12/04/25, Licensed Practical Nurse (LPN)1 administered medications prescribed for R3 to R2, including Oxycodone thirty milligrams (mg) (a pain medication), Amlodipine 5 mg (a blood pressure medication), Losartan 50 mg (a blood pressure and heart medication), Dofetilide 250 micrograms (mcg) (a heart rhythm medication), Gabapentin 600 mg (a nerve pain medication), and Metoprolol 50 mg (a heart rate and blood pressure medication). This failure resulted in R2 being sent out to the hospital. [...]

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to report a significant medication error that resulted in serious bodily injury to the Administrator and the State Agency within 2 hours, for 1 of 2 residents reviewed, Resident (R)2. Specifically, on 12/04/25, Licensed Practical Nurse (LPN)1 administered medications prescribed for R3, to R2. Following the medication error, R2 was hospitalized . Findings Include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating last revised in September 2022, states, Policy Statement: [...]

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to ensure proper food safety practices related to the maintenance and documentation of refrigerator and freezer temperatures, these failures had the potential to affect all residents who eat from the kitchen.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to provide regular dishware during meal service, in order to promote a homelike environment for all residents in the facility.

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to provide privacy during Resident Council meeting for 5 residents who attended, Resident (R)13, R46, R20, R60, R21.

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure medications were free of expiration, failed to ensure narcotic boxes were permanently affixed, failed to discard medication after discontinuation of medication, failed to ensure treatment carts were locked when unattended, and failed to sign narcotics out from narcotics sheet for 2 of 3 unit medication rooms and 2 of 3 medication carts.

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to ensure the call light was within reach for Resident (R)107, for 1 of 1 resident reviewed.

Inspectors wroteBased on review of facility policy, observation, interview and record review, the facility failed to ensure a clean, sanitary homelike environment was provided for Resident (R)30, for 1 of 1 residents reviewed for homelike environment.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to identify and assess Resident (R)43's skin wounds located on the bilateral lower extremities, for 1 of 2 resident reviewed.

Inspectors wroteBased on review of facility policy, record review, observation, and interview, the facility failed to assess Resident (R)26 and R270 for self administration of medication, for 2 of 3 residents reviewed.

Inspectors wroteBased on review of the facility policy, record review, observation, and interview, the facility failed to follow Physician Order for the administration of oxygen to Resident (R)95, for 1 of 3 residents reviewed for oxygen therapy.

Inspectors wroteBased on review of facility policy, observation, interview and record review, the facility failed to ensure the medication error rate was less than 5 percent (%) on 1 of 3 units reviewed for medication administration. The medication error rate was 12.12% with 33 opportunities, for 1 of 5 residents observed for medication administration.

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to administer ordered medication to Resident (R) 2 for 1 of 1 residents reviewed for medication administration.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure that a resident was assessed for self-administration of medications prior to medications being left at bedside and that the correct dose was given for one of five residents (Resident (R) 8) reviewed for medication administration of 23 sampled residents.

Inspectors wroteBased on record review and interview, and facility policy review, the facility failed to issue one of three residents (Resident (R) 123) or their responsible party out of 23 sampled residents a bed hold notice when R123 was sent to the emergency room. This had the potential to affect the resident's return to the facility.

Inspectors wroteBased on observation, staff interview, resident interview, and review of the facility policy, the facility failed to maintain safe hot water temperatures within non-hazardous ranges for 12 of 121 (R) residents (R31, R272, R52, R75, R22, R9, R74, R55, R93, R103, R81, R100). The assistance of the facility's Maintenance Director was requested and on 02/28/22 at 8:28 PM, water temperatures were measured by the Maintenance Director, utilizing the facility's Raytek noncontact thermometer. Temperatures above 120 degrees Fahrenheit (F) were discovered for the following resident conjoined bathrooms: 131-133 degrees F in rooms [ROOM NUMBERS], 131 degrees F in rooms [ROOM NUMBERS] (where steam was observed rising from the sink), 132 degrees F in rooms [ROOM NUMBERS], and 132 degrees F in rooms [ROOM NUMBERS] (steam was observed rising from the sink). [...]

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to develop and implement a comprehensive person-centered care plan for 3 out of 3 Residents (R) 93, 27 and 9 reviewed in a total sample of 37 residents. The facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised 12/2016, revealed that this facility's policy is to develop and implement a comprehensive, person-centered care plan that includes measurable objective to meet the resident's physical, psychosocial and functional needs that is developed and implemented for each resident. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/13/22, reveled the facility admitted R93 to the facility 01/11/22. R 93 was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure Resident (R) 113 was properly screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility. The facility's failure to ensure R113 was screened properly prior to admission places the residents with a serious mental illness at risk for inadequate care and inappropriate healthcare placement for one of three sampled residents reviewed for preadmission screening and resident review (PASRR).

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review it was determined the facility failed to assure catheter care for one resident (R) 9 out of a sample of 24 residents. R9 had an indwelling catheter that was not secured to his leg to prevent potential dislodgement during his daily episodes of restlessness. This failure placed the resident at risk of improper removal of the catheter during erratic movements and possible injury related to the accidental removal resulting in potential urethral damage.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure Resident (R) 12's oxygen nasal cannula and humidifier bottle were dated. In addition, the facility failed to ensure the humidifier bottle contained water and that the oximeter's filter was properly cleaned. The oxygen nasal cannula and humidifier bottle are be changed weekly as per the facility policy. This failure placed the resident at risk for infection and increases the likelihood of bacterial growth.

Inspectors wroteThe facility failed to assure the physician documented a rationale for not following the pharmacy consultants' recommendations related to PRN (as needed) psychotropic medications, for one resident (R) 9 out of a sample of five residents reviewed for unnecessary medications. The consultant pharmacist recommended R9's physician follow the Centers for Medicare and Medicaid Services (CMS) guidelines for a 14 day stop date when prescribing PRN psychotropic's. The guidelines required an evaluation after 14 days, then a decision as to whether to re-order the medication for another 14 days and subsequent re-evaluation. This failure potentially placed the resident at risk for possible adverse reactions from the medication.

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to assure as needed (PRN) psychotropic medications were not ordered for more than 14 days, without an evaluation of the resident and a restart of another 14 days, if necessary, for one resident (R9) out of five residents reviewed for unnecessary medications. Failure to follow these guidelines placed elderly residents at possible risk for adverse side effects up to and including death.

Inspectors wroteBased on observations, record reviews, and facility policy review, the facility failed to ensure staff followed infection control procedures to prevent potential cross contamination for one (R9) of one resident observed during catheter care. Staff failed to wash hands prior to assisting with the resident's catheter tubing. This failure had the potential to result in cross contamination of bacteria, causing potential infections.