Health inspection·November 18, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Record review of Resident #10's Quarterly MDS, dated [DATE], indicated a BIMS score of 05 (indicating a severe impairment of cognitive abilities). Resident #10 used a wheelchair to propel self and had a wander guard bracelet. Record review of Resident #10's Care Plan dated 08/23/24, indicated Resident #10 had wandering behaviors related to dementia. Interventions include freedom of movement throughout facility/unit; always wear a wander guard bracelet; redirect from exit doors; re-direct if attempting to enter areas that are inappropriate; and use diversion and redirection. In addition, (dated 09/16/24) Resident #10 was unable to adjust to placement due to confusion and agitation. Unable to be distracted from agitation or confusion. Interventions included assisting with phone calls to family member. Record review of Resident #10's progress notes, dated 10/17/24 at 04:43 p.m., entered by the SW, read this SW informed that resident is having increasing confusion and exit seeking behavior. This SW contacted resident [family member] and discussed with her the concern and that resident would benefit from a memory care unit. Resident [family member] voiced understanding and that this SW could send referral to (sister facility). Referral sent to sister facility. This SW will follow up. Record review of Resident #10's progress notes, dated 10/21/24 at 2:15 p.m., entered by nursing, read late entry: Received report that resident was discharging to memory care unit. Medications and belongings packed by previous shift. Driver in facility for pickup. At 2:30 PM noted resident belongings left in room, but they did take medication. Notified receiving facility of belongings being left. Was informed that belongings would get picked up 10/22/24.Record review of a Referral packet sent to the sister facility on 10/17/24 at 3:49 p.m. and provided by the SW, contained the following for Resident #10:- face sheet,10/17/24;- physician note dated 09/23/24;-physician order report dated 09/17/24 - 10/17/24; and-nurse progress notes dated 07/23/24 - 10/12/24.Record review of Resident #10's clinical records from 09/17/24 - 10/21/24 did not document the following:-notification to resident or resident representative of transfer or discharge and the reasons for the move in writing;-notification of transfer or discharge notice to local ombudsman;-notice of transfer or discharge at least 5 days or 30 days before being transferred or discharged ;-signed consent from resident representative for transfer/discharge;-a discharge summary with a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455910 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chandler Nursing Center 300 Cherry St Chandler, TX 75758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)