Chandler Nursing Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who enters the facility with/without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary for 2 of 2 residents (Resident #4 and #74) reviewed for indwelling catheters. The facility did not have an appropriate diagnosis for Residents #4's and #74's Foley catheter. This failure could place residents at risk for inappropriate placement of indwelling catheters, discomfort or injury, and urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 4 medication carts (MA Cart #1) and (Nurse Cart #1) observed for controlled medications storage, and failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals to ensure no medication errors and to meet the needs of each resident for 1 of 5 residents (Resident #70) for medication pass. * RN C was observed on 2/19/2026 signing the controlled substance count sheets for the end of their shift at the beginning of their shift on RN Cart #1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #4, #70, and #74) observed for Infection Control. * Residents #4 and #70 had incorrect isolation signage posted on their doors. * CNA A did not don PPE before entering Resident #70's room to deliver her lunch tray and did not wash her hands when leaving the room.* CNA A did not change gloves, sanitize/wash hands between glove changes, and touched clean items with dirty gloves while performing incontinent care on Resident #70 who was in Contact Isolation for ESBL of the urine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 24 residents reviewed for accuracy of assessments. (Resident #3) The facility did not accurately complete the MDS assessment to indicate Resident #3 did not use a ventilator (a type of breathing apparatus that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently). This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #70). * LVN B reconstituted Resident #70's Ertapenem Sodium Injection powered antibiotic with Lidocaine 1% Solution and administered IM to Resident #70. There was no physician order for the Lidocaine 1% Solution. This failure could place residents at risk for possible side effects pale, gray, or blue-colored skin, lips, or nails, confusion, headache, lightheadedness, fast heartbeat, or unusual tiredness or weakness of a medication administered without a physician order.

Inspectors wroteBased on interview and record review, the facility failed to provide notice as soon as practicable before transfer or discharge for 1 of 5 residents reviewed for admission, transfer, and discharge. (Resident #10)Resident #10's was transferred to another facility on 10/21/24 without required proper written documentation. This failure could place residents at risk of not receiving appropriate care and required notifications. Record review of Resident #10's face sheet indicated Resident #10, admitted to facility 06/09/24, was an [AGE] year-old female. Her diagnoses included dementia (An umbrella term for a group of conditions that cause a decline in mental ability severe enough to interfere with daily life affecting memory thinking and behavior) and generalized anxiety (a feeling of worry, nervousness, or unease about an uncertain outcome). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure the ice machine was properly cleaned. 2. The facility failed to ensure the designated scoop for ice was used. 3. The facility failed to ensure the spatula used for pureeing was kept on a clean, sanitary surface. 4. The facility failed to ensure gloves were used when prepping food products. 5. The facility failed to ensure foods stored in the refrigerators, were labeled and dated. 6. The facility failed to ensure the [NAME] effectively wore a hair net to cover all her hair. [NAME] had hair out on both sides of her head not covered by her hair net. 7. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 2 of 5 residents (Resident #13 and Resident #4) reviewed for medication administration. 1. The facility did not ensure medications were not stored at the bedside for Resident #13 on 12/2/2024 and 12/3/2024. 2. The facility did not ensure medications were not stored at the bedside for Resident #4 on 12/2/2024 This failure could place all residents at an increased risk of the potential for overmedications resulting in adverse health consequences.

Inspectors wroteBased on interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 2 of 5 staff (CNA B and CNA C) reviewed for staff qualifications. The facility failed to ensure CNA B was appropriately certified to practice and provide CNA care in the State of Texas when her certification expired on [DATE]. The facility failed to ensure CNA C was appropriately certified to practice and provide CNA care in the State of Texas when her certification expired on [DATE]. This failure could place residents at risk of not receiving care and services from staff who were properly trained.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #166 and Resident #44) and 2 of 5 staff (Treatment Nurse and CNA D) reviewed for infection control. Treatment Nurse did not sanitize or wash her hands between glove changes while performing wound care to Resident #166 on 12/3/2024. CNA D failed to wear a gown while performing incontinent care for Resident #44, who was on enhanced barrier precautions, and did not wash or sanitize her hands between glove changes on 12/4/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 16 residents (Resident # 57) observed for care in that: CNA A failed to sit while feeding Resident #57 in the dining room on 12/3/2024. This failure could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident was allowed the right to receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #24) reviewed for call lights. The facility failed to ensure the emergency call light in Resident #24's bathroom was accessible from the floor on 12/2/24. These failures could affect residents who used their call lights or desire to use the call lights and place them at risk of not being able to notify staff of their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for 1 of 8 residents (Resident #18) reviewed for care plans. The facility failed to develop a comprehensive care plan that included Resident #18's requirement of using a mechanical lift to transfer. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 of 8 residents (Resident #18 and Resident #217) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could place residents at risk of a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 3 residents (Resident #47) reviewed for pharmacy services. The facility failed to ensure Resident #47 received the correct dosage of Depakote (an anticonvulsant medication) on 12/3/24. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure recipes were followed to meet the nutritional needs of residents. The facility failed to ensure each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor and appearance for 2 of 2 observed recipe variations for meal accuracy. The facility failed to ensure recipes were followed during pureeing and approved liquid from the menu was used to preserve nutritive value of the food.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 4 trays reviewed for puree diets. The facility failed to prepare the Spanish rice and Enchiladas on the pureed test tray to a pudding like or smooth consistency on 12/03/2024. Findings Include: During Observation on 12/03/2024 at 11:30 AM [NAME] was observed pureeing of Spanish rice and enchiladas. The pureed for prepared for the residents was of appropriate smoothness and texture. During Observation on 12/03/2024 of a pureed test tray, the food was clumpy, sticky, with pieces of rice and chunks of enchiladas not blended to a smooth/pudding like consistency. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 3 days reviewed (12/2/2024 and 12/3/2024) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 12/2/2024 and 12/3/2024. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete Minimum Date Set (MDS) admission assessment was electronically transmitted to the CMS System for 14 of 14 residents' records reviewed for MDS assessments. (Resident #'s 1, 34, 26, 10, 2, 19, 22, 51, 33, 37, 44, 21, 49, and 32). The facility did not ensure the admission MDS assessment was completed and transmitted as required for Resident #'s 1, 34, 26, 10, 2, 19, 22, 51, 33, 37, 44, 21, 49, and 32. This failure could place residents at risk of not having their assessments transmitted timely.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 2 of 5 residents reviewed for PASRR (Resident's #15 and #20) The facility failed to ensure Resident #15 and Resident #20 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #37) of 2 residents reviewed for indwelling urinary catheters. The facility failed to ensure Resident #37's urinary (foley) catheter drainage collection bag was positioned to prevent contact with the floor. The facility failed to ensure Resident #37's catheter was anchored to the resident's thigh to prevent complications. This failure could place residents with urinary catheters at risk for damage to the bladder or urethra, dislodging of the catheter, and urinary tract infections.