Inspection Reports for
Chandler Post Acute and Rehabilitation

The facility was found deficient in properly administering medications as ordered, specifically Metformin to a diabetic resident, and in ensuring working call systems were available in residents' bathrooms and rooms, potentially placing residents' safety at risk.

The complaint involved an allegation that Resident #8 hit Resident #10 on October 31, 2025. Multiple staff interviews confirmed the incident, but the facility failed to properly assess, document, report, and investigate the abuse in a timely manner. The facility was disputing the citation. The investigation was ongoing at the time of the report.

The facility failed to protect Resident #10 from physical abuse by Resident #8, failed to develop and implement adequate policies and procedures to prevent abuse, failed to timely report the abuse allegation to mandated entities within 2 hours, and failed to appropriately assess and investigate the incident according to facility policy. The investigation and interviews were ongoing at the time of the report.

The complaint involved an allegation that an unknown male x-ray technician sexually abused Resident #10 by touching her breast during medical care. The facility did not report the allegation within 2 hours as required and failed to investigate properly. Police involvement occurred, but requested video footage was unavailable due to non-functioning cameras. The facility had no record of self-reporting or investigation of the allegation. Interviews with staff revealed lack of awareness and failure to follow reporting protocols. The facility corrected the deficiencies by November 17, 2025.

The facility failed to report an allegation of sexual abuse within the required 2-hour timeframe and failed to investigate the allegation properly. Past non-compliance was identified but corrected by the time of the survey. The facility conducted in-service training and resident questionnaires to ensure safety and compliance.

The complaint investigation revealed that resident #34 was not administered medications as ordered on October 27, 2024, including pain and anti-anxiety medications. The resident became agitated and refused care after medications were given in pudding without separation, and medications were thrown on the floor. Staff failed to follow proper medication wastage procedures and delayed notifying the physician. The resident was not allowed to self-administer medications unsupervised due to a history of pocketing medications.

The facility failed to ensure that resident #34 received pain and anti-anxiety medications as ordered, resulting in missed doses and agitation. Staff did not follow proper procedures for wasted medications, and the resident was allowed to have medications unsupervised despite a history of pocketing medications. The resident refused medications after a dispute over medication administration in pudding, leading to further care refusal and distress.

Complaint survey from October 31 to November 1, 2024 for intake AZ00217464 with one deficiency cited.

The visit was complaint-related, investigating failure to provide appropriate care for resident #1. The complaint was substantiated as the facility did not properly assess or document the resident's condition, and failed to notify the physician timely about critical changes. The resident was admitted to the hospital with myocardial infarction, stroke, and blood clots, and later died.

The facility failed to identify and provide appropriate services for resident #1, who had new bruising and blood clots in the left lower extremity. Staff did not adequately assess or document the resident's condition, including failure to use a pulse intensity scale and failure to notify the physician promptly about the coolness and discoloration of the leg. The resident was hospitalized and subsequently passed away.

Complaint survey April 1-2, 2024 for complaint #AZ00207957 with two deficiencies cited related to physical health services and quality of care.

The complaint investigation focused on whether the facility properly notified the physician of resident #491's elevated blood pressure and irregular pulse. The investigation found no evidence that the physician was notified of these critical changes, despite facility policy requiring such notification. The resident was found unresponsive and deceased shortly after these events.

The facility failed to notify the resident's physician of significant changes in vital signs, including a high blood pressure reading of 168/110 and a new onset irregular pulse rate of 115 beats per minute. The resident was later found unresponsive and deceased. Interviews with staff revealed gaps in communication and notification processes despite facility policies requiring prompt physician notification of condition changes.

Recertification survey combined with complaint investigations citing two deficiencies related to quality of care and care plan compliance.

The facility failed to ensure that staff implemented infection control standard precautions during incontinence care, posing a potential risk of contamination among residents. Observations and interviews revealed improper glove use and hand hygiene practices by staff.

The complaint investigation found that resident #1 was subjected to family abuse. The resident exhibited severe cognitive impairment and combative behavior. An incident on March 30, 2023 involved the resident biting a family member's inner forearm, leading to the family member being escorted out. Staff interviews confirmed the resident required two-person assist for safety and that family presence often agitated the resident. The family member was not counted as part of the two-person assist. The complaint was substantiated with findings of minimal harm.

The facility failed to protect resident #1 from family abuse, as documented by multiple progress notes and staff interviews describing the resident's combative behavior and an incident where a family member was bitten by the resident. The resident required two or more staff for care due to aggressive behaviors, and family presence often increased agitation. Facility policies on abuse prevention and resident rights were reviewed.

The facility was found deficient in multiple areas including medication administration, honoring advance directives, notification of physician for vital sign changes, medication administration standards, accident hazard prevention, hot water temperature safety, and nutritional monitoring. Deficiencies were generally of minimal harm or potential for actual harm affecting a few residents.

The facility was found deficient in multiple areas including failure to complete required PASRR screening for a resident with mental disorders, failure to develop a baseline care plan for a resident on hemodialysis within 48 hours of admission, failure to provide respiratory care consistent with physician orders for a resident on oxygen therapy, and failure to properly manage medication storage including expired and undated medications.