Chandler Nursing Center moved Resident #10 to a sister facility without providing the federally required discharge notices to the family, according to a November inspection report. The resident's family member had no idea the transfer was happening until staff at the destination facility mentioned the planned admission during an unrelated visit.
"She was visiting other facilities to seek placement and while at the sister facility, she was informed of the planned admission for that day to new facility," inspectors wrote after interviewing the family member on November 18.
The social worker confirmed during interviews that Resident #10 "had not been given a 5-day nor a 30-day discharge notice." She told inspectors she couldn't recall all the details because she wasn't a full-time employee when the transfer occurred and was off work that day.
Federal regulations require nursing homes to involve residents and their representatives in discharge planning and provide proper notice before transfers. The facility's own policy states that discharge plans must be developed with "the assistance of the resident and his or her family" and that "the resident/representative will be involved in the discharge planning process and informed of the final discharge plan."
None of that happened.
The ombudsman assigned to the facility also had no record of the transfer. During an email exchange on November 21, she told inspectors "she did not recall being notified of Resident #10's transfer to sister facility and she did not have any documentation regarding transfer."
The current administrator, who wasn't employed at the facility during the incident, outlined what should have happened. She told inspectors her expectations would be to place an exit-seeking resident on one-to-one supervision and, if necessary, initiate proper discharge notices to find "a safer environment such as a memory care unit."
The administrator said all required documentation should be completed and given to appropriate entities. That documentation never materialized for Resident #10's case.
Inspectors found the facility's discharge policy clearly spelled out requirements that weren't followed. The policy mandates that discharge plans include where the resident plans to live, arrangements for follow-up care, and how the interdisciplinary team will support the transition to post-discharge care.
The social worker's absence during the actual transfer highlighted another problem: continuity of care planning. As a part-time employee who was off work when the resident was moved, she couldn't provide inspectors with basic details about what should have been a carefully coordinated process.
The family member's accidental discovery of the transfer exposed the complete breakdown in communication. While actively searching for appropriate placement options, they found themselves learning about their loved one's location from staff at the receiving facility rather than from Chandler Nursing Center itself.
The violation demonstrates how facilities can circumvent discharge protections by simply moving residents without proper notification. Federal rules exist specifically to prevent families from being blindsided by transfers and to ensure they can participate in decisions about their loved one's care.
The case also raises questions about the relationship between Chandler Nursing Center and its sister facility. The seamless transfer suggests coordination between the facilities, yet neither the family nor the ombudsman received any advance notice of the planned move.
For Resident #10's family, the discovery came too late to influence the discharge planning process they were legally entitled to join. They learned about the completed transfer while trying to find better care options, only to discover the decision had already been made without them.
The administrator's description of proper procedures highlighted exactly what didn't happen. Exit-seeking residents should receive increased supervision and proper discharge planning, not secret transfers to sister facilities.
The ombudsman's lack of documentation further underscores the facility's failure to follow required notification procedures. Ombudsmen serve as advocates for nursing home residents and typically receive notice of significant changes in a resident's status or placement.
Instead, Resident #10 disappeared from Chandler Nursing Center's records and reappeared at the sister facility without the paper trail or family involvement that federal regulations demand. The family's search for better care options led them to accidentally stumble upon their own loved one's new location.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chandler Nursing Center from 2025-11-18 including all violations, facility responses, and corrective action plans.