Chandler Hall Health Services, Inc. - Hicks.

“Glucometer readings were not accurately documented on the medication administration record for Resident #3. On 1/3/2026, the glucometer reading was 120 but 123 was documented, and on 1/1/2026, the reading was 119 but 118 was documented.”

“Staff persons did not receive required training on meeting the needs of residents as described in preadmission screening forms, assessment tools, medical evaluations and support plans, and care for residents with mental illness or intellectual disability.”

“Staff persons A and B did not receive training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert during the 2025 training year.”

“The commercial dryer in the laundry room was not operable for approximately two weeks. Additionally, the carbon monoxide detector in the main kitchen was hanging off the ceiling.”

“Residents #4 and #5 were not educated about their right to refuse medication if they believed there may be a medication error, and signed documentation of this education was not provided.”

“The home does not have written approval from the Department of Labor and Industry, Department of Health or local building authority for the keypad and electronic card operated systems used on the exit doors from the SDCU.”

“The home's record of direct care staff training does not include the date and length of each course as required.”

“Two large sections of fencing were missing from the secured unit patio area, covered only with a black tarp that could be easily lifted. The area beyond posed a tripping hazard with pinecones, branches, and loose dirt.”

“Resident assessment and support plans were not signed by the residents and do not indicate if the residents declined or were unable to participate in the development of the support plans.”

“A resident admitted to the Secure Dementia Care Unit did not have a written cognitive preadmission screening completed within 72 hours prior to admission as required. This is a repeat violation.”

“Directions for operating the home's key-locking mechanism were not conspicuously posted near the main dining room exit door to the Secure Dementia Care Unit.”

“A resident admitted to the Secure Dementia Care Unit did not have an initial support plan developed and documented within 72 hours of admission or prior to admission as required.”

“Resident requiring total physical assistance with toileting was left unattended on the toilet by staff member who went to assist another resident. Resident fell to the floor, remained unattended, and sustained a closed head injury requiring emergency room treatment.”

“Three resident-home contracts were not signed by the residents as required.”

“Three resident records did not contain statements signed by residents acknowledging receipt of a copy of resident rights and complaint procedures.”

“Resident requiring total physical assistance with toileting was left unattended on the toilet by staff member. Resident fell and sustained a closed head injury. This constitutes neglect of a vulnerable resident.”

“Three residents admitted to the facility were not educated regarding their right to question or refuse a medication if they believed there may be a medication error, and documentation was not maintained.”

“Resident was found with a large skin tear on the right leg requiring 8 sutures. While the injury was reported to staff at 10:00am, the allegation of abuse was not reported to the local area agency on aging as required by the Older Adult Protective Services Act.”

“Resident was found with a large skin tear on the right leg requiring 8 sutures at 1:30am. The home did not report this incident to the department until 10:00am, failing to meet the 24-hour reporting requirement.”

“A resident whose assessment and support plan indicated the need for assistance with eating did not receive required assistance during breakfast; the resident waited 15 minutes for staff assistance.”

“Colgate toothpaste and Listerine mouthwash, both labeled as poisonous, were found unlocked, unattended, and accessible to residents. Not all residents have been assessed as capable of safely recognizing and using poisonous materials.”

“Staff person A did not receive required annual training in emergency preparedness procedures and recognition and response to crises and emergency situations during training year 2024.”

“An uncovered, unsealed bag of herbs was stored in the walk-in refrigerator, allowing potential contamination of food.”

“A tray of peeled bananas and a black trash bag containing loaves of bread were stored in the walk-in freezer unlabeled and undated, making it impossible to determine if they were outdated or spoiled.”

“Not all residents evacuated to a designated meeting place during fire drills: on 9/20/2024, 16 of 22 residents evacuated; on 11/20/2024, 9 of 18 residents evacuated. Some hospice residents did not meet requirements to remain in place during drills.”

“Guaifenesin Oral Solution and Milk of Magnesia prescribed for resident 1 were in the medication cart but not listed on the resident's current medication orders. This is a repeat violation from 2/15/2024.”

“Multiple medications were stored improperly: Insulin Glargine Pen for resident 2 had no open date indicated (should be discarded after 28 days); Olopatadine 0.1% eye drops for resident 3 had an open date of 12/20/2024 (should be discarded 4 weeks after opening); Latanoprost solution 0.005% eye drops for resident 3 had an open date of 12/20/2024 (should be discarded 6 weeks after opening).”

“Acetaminophen 325 mg tablets prescribed for resident 2 (to be taken as 2 tablets every 6 hours as needed) were not available in the home on 3/6/2025 at 1:55 p.m.”

“The resident-home contract for resident #1 was not signed by the resident or payor, violating the requirement that contracts be signed by the administrator or designee, resident, and payer.”

“Resident #1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.”

“Bathroom cabinets in resident rooms #409 and #600 containing toothpaste and skin protectant with poison warning labels were unlocked, unattended, and accessible to residents. Not all residents have been assessed as capable of recognizing and using poisons safely.”

“The bathroom in resident room #409 does not have an operable outside window and the ventilation exhaust fan is inoperable, violating the requirement for ventilation in bathrooms without operable windows.”

“Resident #2's medical evaluation did not include documentation of special health or dietary needs of the resident, specifically the need for the Secured Dementia Care Unit.”