Chandler Post Acute and Rehabilitation

Inspectors wroteBased on record review, staff interviews, review of facility documents and policy, the facility failed to ensure that a medication was administered following the physician ordered parameters for one resident (#135). The deficient practice resulted in hospitalization due to lowered blood pressure.

Inspectors wroteBased on the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure hand hygiene was performed and PPE was appropriately applied for one resident (Resident #9) , and infection control measures were implemented for a resident with a urinary catheter (Resident #71) and during a dressing change (Resident #166). This deficient practice can result in contamination and spread of infection.

Inspectors wroteBased on observation, staff interviews, facility documents, and policy, the facility failed to ensure several residents' rooms were equipped with a working communication system to call for staff assistance. The deficient practice could place residents' safety at risk.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#9) and/or the resident representative were informed of the risks and benefits of restraints prior to usage of abdominal binder, waist/seat belt restraint and bilateral mitt restraints. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and risks of restraints. The census was 109.

Inspectors wroteBased on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation were conducted for the least restrictive alternatives for the least amount of time and conduct ongoing evaluations of the need for physical restraints for one resident (Resident #9). The deficient practice could result in the resident not able to use a less restrictive alternative. The census was 109.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure review, the facility failed to ensure a thorough investigation of an allegation of neglect was completed for one resident (#9). The census was 109. The deficient practice could result in incomplete investigations of allegations of abuse.

Inspectors wroteBased on clinical record review, staff interview, the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that on residents Minimum Data Set (MDS) assessment regarding restraints was accurate. The deficient practice could result in inaccurate documentation of the resident's medical history and needs. The census was 109.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the state mental health authority was notified of a resident's change in mental condition for one resident (#37). The deficient practice could result in residents not receiving the proper level of care to meet their needs. Findings Include:Resident #37 was admitted to the facility on [DATE] with diagnosis that included atherosclerotic heart disease, bipolar disorder, and colostomy status. A Level 1 Pre-admission Screening and Resident Review (PASARR) dated February 25, 2025 was completed with no referral was necessary for PASARR Level 2. Further review of the PASRR revealed that the Bipolar Diagnosis was not included. [...]

Inspectors wroteNumber of residents sampled:Number of residents cited: 1Based on observations, record review, staff interviews, review of facility documents, policy, [NAME] Nursing Drug Book, and Medlineplus.gov website, the facility failed to ensure medications for one resident (#14) were administered as ordered by the physician and according to accepted standards of clinical practice. The deficient practice could place residents' safety at risk.

Inspectors wroteBased on observations, staff interviews, and the facility's policy and procedures, the facility failed to ensure that food items were properly stored and dated to meet safety standards. The deficient practice could result in loss of nutritive value and increase the risk of foodborne illness.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#10) right to be free from physical abuse from another resident (#8). The deficient practice could result in physical and psychosocial harm.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment. [...]

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to report an allegation of physical abuse of a resident (#10) immediately and within 2 hours to mandated entities. The deficient practice could lead to ongoing abuse of a resident resulting in physical and psychosocial harm.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment. [...]

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to immediately assess residents (#8 and #10) after an allegation of physical abuse, and failed to investigate the allegation according to facility policy. The deficient practice could result in physical and psychosocial harm of a resident.-Regarding Resident #10 (alleged victim): Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included contracture of right and left hands, need for assistance with personal care, personal history of traumatic brain injury, and anoxic brain damage. A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #10 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognition impairment. [...]

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to report an allegation of sexual abuse of one resident (#10) to mandated entities within 2 hours. The deficient practice could result in ongoing abuse, leading to physical and/or psychosocial harm of a resident. Past non-compliance was identified for this citation:These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of November 17, 2025 and three were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction. [...]

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to investigate an allegation of sexual abuse of one resident (#10). The deficient practice could result in ongoing abuse, leading to physical and/or psychosocial harm of a resident. Past non-compliance was identified for this citation:These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of November 17, 2025 and three were no other occurrences of the same deficient practice. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and, therefore, does not require a plan of correction. [...]

Inspectors wroteBase on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to monitor and ensure that resident (#34) was administered pain and psychotropic medications as per the orders and medications were left with the resident unsupervised. The deficient practice could result in the pain and anxiety not being managed.

Inspectors wroteBased on review of documentation, photographs, staff interviews, and the facility policy and procedure, the facility failed to provide services in accordance with professional standards of practice for one resident (#1). The deficient practice could result in appropriate services not being identified and provided to residents.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that changes in resident #491 condition will be communicated to the physician. The deficient practice could result in delayed treatment.

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure infection control standard precautions was implemented by staff during incontinence care. The deficient practice has the potential of contamination among other residents in the facility.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#192) was assessed to determine clinical appropriateness to self-administer medications. The deficient practice could result in medications not being taken as ordered.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to implement their policy to ensure one sample resident's (#190) advance directive was implemented. The deficient practice could result in other residents' wishes not being honored.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure the physician was notified of change in vital signs for one resident (#48). The sample size was 2. The deficient practice could result in delayed treatment for residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure administration of medications met professional standards of quality for one resident (#76). The deficient practice could result in delayed treatment and adverse effects for residents.

Inspectors wrote-Resident #33 was admitted to the facility on [DATE] with diagnoses that included personal history of traumatic brain injury, schizoaffective disorder (bipolar type) and borderline personality disorder. During initial observation and interview with resident #33 on October 17, 2022 at 9:57 a.m., resident #33 was observed sitting in the wheelchair. The resident inquired about the purpose of the survey and held out an item that appeared to be a sewing needle (two inches long, sharp on one end, and silver in color) and uttered, I have this and I know you like to look at this. One male resident was observed wandering in the hallway. The resident showed a device (threaded in between two rods with beads threaded in) which the needle was being used for and proceeded to thread the needle through his garment. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#24) was evaluated timely after a significant weight loss. The sample size was 3. The deficient practice could result in delayed interventions for residents experiencing weight loss.