Chandler Creek Post Acute

In the surveyor’s words

From the most serious findings on record at Chandler Creek Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 4, 2022

  Based 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. […]

• Immediate jeopardy, isolatedF760Feb 23, 2026

  Based 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). […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2026

  Based on observation, interviews and review of facility policy, the facility failed to follow professional food safety practices for preparation and service of resident meals. This deficiency potentially affected all residents receiving meal service from one main kitchen. This was evidenced by an observation of dirty equipment consisting of a counter mounted can opener; meat slicer, and the ice machine.Findings include: The undated facility's procedure titled, Cleaning Instructions: Slicer, read, Slicer will be cleaned and sanitized after each use.The undated facility's procedure titled, Cleaning Instructions: Ice Machine and Equipment, read, Ice machine and equipment will be kept clean and sanitized, according to the manufacturer's procedures (if available), or according to the following… […]

• No harm, potential for more than minimal, widespreadF880Jul 2, 2026

  Based on observation, interview, record review, and review of facility policy, the facility failed to implement and maintain an effective infection prevention and control program by failing to ensure Enhanced Barrier Precautions (EBP) were initiated and followed for three of three residents reviewed for EBP who had indwelling medical devices and/or wounds (Residents R135, R91, and R36). Specifically, the facility failed to ensure EBP signage was posted, personal protective equipment was readily available, and staff and contracted hospice personnel used gowns and gloves during high-contact resident care activities, including urinary catheter care, incontinence care, repositioning, transferring, feeding tube-related care, and wound/skin care. […]

• No harm, potential for more than minimal, widespreadF812May 20, 2025

  Based 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. Findings include: Review of the facility policy titled, Food and Nutritional Services Manual documented, 10. Food Receiving and Storage-All food and supplies received at [NAME] Creek Post Acute must be from approved sources and stored under conditions that prevent spoilage and contamination. Dry storage areas are clean, ventilated, and items are stored [greater than or equal to] 6 inches off the floor. […]