Every finding on record at Chandler Hall Health Services

Based on observation and staff interview, it was determined that the facility failed to maintain sanitary conditions in the kitchen.Findings include: Observations during the kitchen tour on June 30, 2026, at 11:46 a.m., revealed the following:A black substance was observed on the wall, the floor, and the drainpipe beneath the dishwasher. In an interview on June 30, 2026, at 11:55 a.m., the Culinary Director confirmed that there was black substance beneath the dishwasher that required mitigation. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to properly store medications on two of three hallways on the nursing unit. (100 hallway and 300 hallway) Review of the facility policy entitled, Security of Medication Cart, last reviewed February 24, 2025, revealed that medication carts must be securely locked at all times when out of the nurse's view. Observation on May 13, 2025, from 10:30 a.m. through 10:33 a.m., revealed the medication cart was unlocked and unattended on the 100 hallway. Observation on May 15, 2025, from 9:35 a.m. through 9:40 a.m., revealed the medication cart was unlocked and unattended on the 300 hallway. In an interview on May 15, 2025, at 9:40 a.m., Licensed Practical Nurse 1 confirmed that the medication carts should have been locked. In an interview on May 15, 2025, at 10:30 a.m., the Director of Nursing confirmed that the medication carts should have been locked. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and/or the resident's representative of their appeal rights and Ombudsman information in writing upon transfer from the facility for three of 12 sampled residents who were transferred to the hospital. (Residents 2, 33, and 37) Findings include: Clinical record review revealed that Resident 2 was transferred to the hospital on March 27, 2025, and April 25, 2025, after changes in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and Ombudsman information upon transfer to the hospital. Clinical record review revealed that Resident 33 was transferred to the hospital on May 7, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and Ombudsman information upon transfer to the hospital. Clinical record review revealed that Resident 37 was transferred to the hospital on April 14, 2025, after a change in condition. There was no documented evidence that the resident, the resident's responsible party, or the legal representative was provided information regarding appeal rights and Ombudsman information upon transfer to the hospital. In an interview on May 15, 2025, at 1:43 p.m., the Administrator confirmed that the identified residents and/or their representatives were not provided with transfer notices that included the required information.

Based on observation, facility policy review, and staff interview, it was determined that the facility failed to ensure that medications/biologicals were securely stored in one of one medication storage rooms. (Medication and Treatment Room) Findings include: Review of the facility policy entitled, Controlled Substances, last reviewed on February 25, 2024, revealed that controlled substances listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976 are to be separately locked in permanently affixed compartments. Observation on June 13, 2024, at 11:20 a.m., revealed the Medication and Treatment Room had controlled substances that were stored in a locked box inside a refrigerator. The locked box was not permanently affixed to the refrigerator and contained 35 doses of lorazepam suppositories. In an interview on June 13, 2024, at 12:23 p.m., the Director of Nursing confirmed that the medication box should have been permanently affixed in the locked refrigerator. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, review of policy and staff interview, it was determined that the facility failed to maintain sanitary conditions and store food properly in the kitchen. (Main Kitchen) Findings include: Review of the facility policy entitled, Food Storage, dated [DATE], revealed that products in storage were to be labeled with the date on delivery and once the product was opened the package was to be labeled with an opened and discard date. Observation during tour of the main kitchen dry storage room and refrigerator/freezers on [DATE], at 11:10 a.m., revealed an open unwrapped 25 pound bag of whole grain brown rice received [DATE], one open case of frozen egg rolls shipped [DATE], one open case breaded chicken tenderloin received [DATE], one jar of capers with no expiration date. The following items were past the expiration date: five boxes of grits, best by [DATE], two bottles of white truffle oil with expiration dates of [DATE], and [DATE], one open low fat cottage cheese use by [DATE], one low fat cottage cheese with best by date of [DATE], two plastic containers of dressing, use by [DATE], butter and chive mix use by [DATE], half gallon whole milk, expired [DATE], three wrapped beef packages, use by [DATE]. In the freezer there was a layer of frost on the outside of the food packages and boxes. Review of the policy entitled, Cleaning Instructions: Ovens, dated [DATE], revealed that ovens were to be cleaned as needed and according to the cleaning schedule at least once every two weeks. Spills and food particles were to be removed after each use. Observations on [DATE], at 11:10 a.m., and [DATE], at 11:05 a.m., revealed both ovens had a grease buildup on the inside walls, the inside of the doors, and on the oven racks. There were three stained oven racks stored on the floor behind a cookware rack and next to the ovens. Review of the policy entitled, Cleaning Instructions: Deep Fat Fryer, dated [DATE], revealed that the deep fat fryer oil was to be changed at least every 10 times the fryer was used. When the oil color changed to a dark brown, the oil should be changed. Food particles were to be removed from the oil after each use. Further, the baskets were to be cleaned by running them through the dish machine and wiping them dry prior to storage. Observations on [DATE], at 11:10 a.m., and [DATE], at 11:05 a.m., revealed the deep fat fryer oil was dark brown and contained debris. Two fryer baskets were coated with grease and were stored on a stainless steel shelf that had grease and debris on it. Observations on [DATE], at 11:10 a.m., and [DATE], at 11:05 a.m., revealed the table top under the grill was wet with brown liquid spillage and debris. In an interview on [DATE], at 11:10 a.m., the Food Service Director stated that food was to be dated prior to storage and disposed of when items expired. The Food Service Director stated there was no documentation to support that cleaning was scheduled or being completed per facility policy. 28 Pa.Code 201.18(b)(1)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on policy review, clinical record review and staff interview, it was determined that the facility failed to notify a resident's responsible party of a significant weight loss for one of two sampled residents with weight changes. (Residents 35) Findings include: Review of the facility policy entitled, Weight Policy, dated August 17, 2022, revealed that any unplanned significant weight changes were to be reported to the physician and the resident's representative. Clinical record review revealed that Resident 35 had diagnoses that included dysphagia following cerebral infarction and chronic kidney disease, stage 4. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had cognitive impairment and received tube feedings for his nutritional requirements. On April 26, 2023, the resident weighed 151 pounds (lbs). On May 25, 2023, Resident 35 weighed 138 lbs, an 8.61 percent weight loss in one month. There was no documented evidence that Resident 35's responsible party was notified of the significant weight loss. In an interview on July 7, 2023, at 12:18 p.m., the Director of Nursing stated there was no documented evidence that Resident 35's responsible party was notified of the significant weight loss. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to properly contain refuse in a sanitary manner. Findings include: Observation on July 5, 2023, at 11:10 a.m., revealed that there was trash and debris, including clear plastic bags and paper on the ground around the trash compactor. The recycling dumpster contained cardboard and the lid was open. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on observation, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment on three of three nursing units. (Nursing unit 1, 2 and 3) Findings include: Observation during all days of the survey revealed the following: On unit 100 hall, one sit to stand transfer lift had diry wheels. On unit 200 hall, a utility room accordion door panel was broken and a chair scale had dirty wheels. On unit 300 hall, two sit to stand transfer lifts and one transfer lift equipment had dirty wheels. In the dining area, the resident's refrigerator had dried spillage stains on the crisper drawer glass and in one crisper drawer. 28 Pa Code: 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident with pressure ulcers received the necessary care and services to promote healing for one of three sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], revealed that the resident was alert and oriented and had unhealed pressure ulcers. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On June 9, 2022, the physician ordered for staff to apply a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On June 9, 2022, the physician ordered for skin prep to be applied to his left heel twice a day. Review of treatment administration records for June 2022, revealed that there was no documentation to support that the Venelex treatment was completed as ordered to the sacral wound on three occasions, there was no documentation to support that the Santyl ointment was completed as ordered on three occasions, and the skin prep treatment to the left heel wound was not completed as ordered on two occasions. In an interview on August 26, 2022, at 2:30 p.m., the Director of Nursing stated she had no documented evidence to support that the treatments were completed as ordered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that orders by the physician were followed for one of four sampled residents. (Resident CR1) Findings include; Clinical record review revealed that Resident CR 1 had diagnoses that included Parkinson's disease (degenerative disorder of the nervous system) and dementia (disorder that affects memory). On June 2, 2022, a physician directed staff to obtain a urine specimen for analysis to determine the presence of a urinary tract infection. There was no documented evidence that the urine specimen was obtained and sent for analysis. In an interview on July 20, 2022, at 11:15 a.m., the Director of Nursing confirmed that the urine sample was not obtained and sent for analysis as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that medications were administered as prescribed by the physician for one of five sampled residents. (Resident CL1) Findings include: Resident CL1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On March 21, 2022, she had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on March 23, 2022, the Director of Nursing confirmed that there was no evidence to support that the medications were provided as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, policy and staff interview it was determined that the facility failed to ensure that all medications with the potential for abuse (controlled substances) were secured in a locked, permanently affixed compartment at all times in one of one medication storage rooms. Findings include: Review of the policy entitled, Medication Storage in the Facility, ID2: Controlled Substance Storage, dated July 12, 2021, revealed that controlled substances that require refrigeration were to be stored within a locked box within the refrigerator and that the box must be attached to the inside of the refrigerator. Observation on August 25, 2021, at 09:50 a.m., revealed that the refrigerator inside the medication storage room on the 100, 200, 300 halls nursing unit contained a Schedule IV controlled medication (lorazepam). The medication was not secured in a separate locked, permanently affixed box in the refrigerator. In an interview on August 26, 2021, at 10:19 a.m., the Director of Nursing stated that the narcotic medication should have been locked within the separate, locked, permanently affixed box in the refrigerator. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed accurately to reflect the resident's current status for one of 13 sampled residents. (Resident 19) Findings include: Clinical record review revealed that Resident 19 had an MDS assessment dated [DATE], which indicated in Section G there was no bathing activity under bathing self performance over the last seven days. In an interview on August 26, 2021, at 11:13 a.m., the Diretor of Nursing stated that the MDS assessment had been inaccurately coded under the Section G and failed to accurately reflect the resident's bathing activity for the seven day period of the assessment. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review, and interview, it was determined that the facility failed to ensure that showers were given to two of 13 sampled residents as per their preferred schedules. (Resident 7, 19) Findings include: Clinical record review revealed that Resident 7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required assistance from staff for most of her activities of daily living (ADL) care including bathing. Review of the resident's care plan identified that the resident was to have a shower three times a week, on Monday, Wednesday, and Saturday and needed assistance of one staff with bathing. Review of the resident bathing/shower schedule indicated that the resident was scheduled on Monday, Wednesday, and Saturday. Review of nursing documentation revealed that there was no documentation noted of any bathing for the month of August 2021. In an interview on August 26, 2021 at 10:45 a.m., the resident stated that, I don't always get my showers two times a week. In an interview on August 26, 2021, at 9:45 a.m., the Director of Nursing confirmed that there was no nursing documentation to show that any showers were being completed on Monday, Wednesday, and Saturday as care planned and per the resident's preference. Clinical record review revealed that Resident 19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE], indicated that the resident was alert and oriented and required assistance from staff for most of his ADL care including bathing. Review of the resident's current care plan revealed he required assistance with ADL care due to [CONDITION(S)]. Intervention was in place for staff to help with bathing. Review of the resident bathing/shower schedule revealed that Resident 19 was to receive a shower on Mondays and Thursdays. Review of nursing documentation dated July 26, 2021, revealed that the resident refused his shower because the staff person was running late and did not get to the facility until 7:30 a.m. The documentation further indicated that he likes to take his shower between 7:00 a.m. to 7:30 a.m. on his scheduled shower days. On this date, the note also indicated that the staff person assigned to assist him with his shower arrived after 7:30 a.m In an interview on August 25, 2021, at 1:15 p.m., the resident stated that he preferred his shower early in the morning on his scheduled shower days. He further stated that many times he does not get his scheduled shower because the staff is late and does not come until 7:30 a.m., and that is too late for me. 28 Pa. Code 201.29(j) Resident rights.

Based on review of facility policy, clinical record review and staff interview it was determined that the facility failed to initiate a bladder re-training program in order to restore bladder continence in a timely manner for one of one sampled resident who was incontinent of bladder. (Resident 88) Findings include: Review of the facility policy entitled , Prompted Toileting Protocol, dated July 12, 2021, indicated that on admission, each resident was to be assessed for incontinence. If the resident was deemed to have incontinence, a prompted toileting schedule was to be used as an individualized approach to help reduce incontinence. The prompted toileting was a program that included a toileting schedule. The goal of the prompted toileting schedule was to reduce the number of incontinence episodes. Clinical record review revealed that Resident 88 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a bowel and bladder assessment completed on August 14, 2021, revealed that the resident was alert, required limited assistance for mobility and that she was frequently incontinent of bladder. The recommendation was for a toileting schedule on the plan of care. Review of a second bowel and bladder assessment completed on August 19, 2021, revealed that the resident was alert, required limited assistance for mobility and was frequently incontinent of bladder. At this time, the recommendation was for an individualized bowel and bladder retraining program. Review of nursing documentation dated August 17, and 23, 2021, revealed that the resident was incontinent of bladder and was able to make her needs known. There was no documented evidence in the resident's clinical record that either recommendation to restore bladder incontinence had been implemented as per the facility policy. In an interview on August 26, 2021, at 12:00 p.m., the Director of Nursing stated that the recommendations for the toileting schedule nor the individualized bowel and bladder retraining program had not been implemented in a timely manner. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed properly contain refuse. Findings include: Observation of the compactor/dumpster area on August 24, 2021, at 10:00 a.m., located in the back of the facility revealed that there was an accumulation of trash and debris that included soda cans, used gloves, plastic utensils and other garbage on the ground on the left side of the compactor. 28 Pa.Code 207.2(a) Administrator's responsibility.

Based on observation, it was determined that the facility failed to provide a safe, sanitary and comfortable environment for residents on three of three nursing units. (Nursing unit 100, 200, 300) Findings include: Observation on August 24, 2021, at 12:42 a.m., on the 100 nursing unit revealed that the walls were marred and scratched in resident rooms 101, 108 and 110. The wall and bathroom door was scratched and marred in room 108. There was no towel rack in the bathroom in room 108 and there were towels observed draped over the toilet assist rail. In room 105 bathroom had a metal towel ring that was bolted to the wall that was separated and bent. The commode chair over the toilet in the bathroom of room 110 had cracked and missing paint on the front of the equipment with an area of rusty metal and bubbled paint. The bathroom wall in room 110 had two towel rack holders protruding from the wall and was missing the towel bar. Observation on August 24, 2021, 11:15 a.m., on the 200 nursing unit revealed that the walls were marred and scratched in resident rooms 207, 209, 210 and 211. Observation on August 24, 2021, at 10:10 a.m., on the 300 nursing unit revealed that the walls were marred and scratched in resident rooms 303, 308 and 309. The walls were scratched below the handrails throughout the hallway of the 300 nursing unit. In addition, observation on the same day at 12:18 p.m., revealed that the over the bed tables were soiled in resident rooms 302, 306, 307 and 309. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on clinical record review, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to notify the responsible party of a discontinued medication, chest x-ray results and a decline in condition, as required, for one of three records reviewed. (Resident CL2). Findings include: A review of Resident CL2's clinical record revealed that the resident was admitted from the hospital to the facility on [DATE], with [DIAGNOSES REDACTED].) The resident expired on [DATE], of acute [MEDICAL CONDITION] and dementia. Further review of Resident CL2's physician orders [REDACTED]. Further review of Resident CL2's clinical record revealed no documentation that the resident's responsible party was notified of the discontinuation of the resident's medication [MEDICATION NAME]. A review of a Nurse Practitioner (NP) noted dated [DATE], revealed that Resident CL2 was ordered a chest x-ray. X-ray results showed atelectasis (complete or partial collapse of a lung or a section of the lung), with possible pneumonia, right lower lobe as well as suggestion of left pleural effusion (a build up of fluid between the tissues that line the lungs and chest.) Further review of resident CL2's clinical record revealed no evidence that the resident's responsible party was notified of the results of the chest x-ray. Further review of nurse practitioner (NP) notes for resident CL2, dated [DATE], patient seen this a.m. at the request of staff for decreased blood pressure and lethargy. Staff reports from over the weekend, the resident in declining status. Additionally, Resident CL2's clinical record revealed no documented evidence that the residents' responsible party was notified of the resident's decline over the weekend. Telephone interview with the Nursing Home Administrator on [DATE], at 2:00 p.m. confirmed that there was no documentation available for review that the responsible party was notified of a discontinuation of medication, an chest x-ray and a decline of the resident's health status over a weekend. 28 Pa. 201.18 (b)(1) Management 28 Pa. Code 211.12 (d)(1) Nursing services

Based on interviews with residents and staff, it was determined that the facility failed to provide the residents an opportunity to vote in the (MONTH) 5, 2019 election for two of four residents interviewed. (Residents R18, R27 ). Findings include: On (MONTH) 6, 2019 at approximately 2:30 p.m., a group interview was held with three residents. When asked if that were given the opportunity to vote, Resident R18 replied, unable to vote yesterday. I was not reminded and did not receive an absentee ballot. Additionally, Resident R27 stated she received the absentee ballot too late therefore was unable to vote. Interview with the Administrator on (MONTH) 7, 2019 at approximately revealed that the Administrator was unaware that residents did not vote in the recent election. The facility failed to ensure that the residents were given the opportunity to vote for election officials. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/20/18 28 Pa. Code 201.18 (b)(3) Management Previously cited 12/20/18 28 Pa. Code 201.29(i) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/20/18

Based on interviews, review of clinical record and facility documentation, it was determine that the facility failed to accomodate residents preference related to frequency of showers for one of 22 residents reviewed. (Resident R18). Findings include: Interview with Resident R18 on (MONTH) 6, 2019 at 12:00 p.m. revealed that the resident prefers to take a shower more than twice a week. The resident further stated that she requested to take a shower three times a week at her care conference but that nothing has changed. Further interview with Resident R18 on (MONTH) 6, 2019 at 2:30 p.m. revealed that there has been no response regarding her request to provide showers more than twice a week. Resident R27, who was present at the time of the interview, confirmed that the subject was presented to administration at the resident council meeting 4-6 weeks ago. Review of Resident Council Minutes dated (MONTH) 18, 2019. recorded under old business, Resident R18 requested three showers a week. She brought the issue to the staff during her family meeting. The staff were able to accommodate this request, informed other residents to voice any requests to staff, in meetings, etc. Review of nurse aide's documentation regarding full bath/showers for the month of (MONTH) 2019 revealed Resident R18 received showers twice a week, every week. The Director of Nursing verified nurse aides documentation on (MONTH) 8, 2019 at approximately 8:21 a.m Review of facility's bath schedule on (MONTH) 12, 2019 at approximately 10:41 a.m. revealed that Resident R18 was scheduled for full bath/shower twice a week, Wednesdays and Saturdays on 7-3 shift. Review of Resident R18's plan of care revealed that it did not address the number of showers or when the showers were to be offered to the resident. Interview Employee E3, nurse's aide, on (MONTH) 12, 2019 at 10:41 a.m. regarding resident shower schedule. Employee E3 stated that the Unit Manager communicates in writing who is due for a shower and a shower list is posted in the nursing office. Interview with the Administrator and Director of Nursing on (MONTH) 7, 2019 at approximately 2:30 p.m. regarding Resident R18's request for a shower three times a week revealed that the resident's family said they were going to hire someone to provide the third shower. The facility failed to ensure that one resident's needs were accommodated relating to bathing preferences. 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/20/18 28 Pa. Code: 211.12(d)(5) Nursing services Previously cited 12/20/18

Based on review of clinical records, facility policy, facility documentation, and hospital records and interviews with staff, it was determined that the facility failed to protect residents from neglect by not providing the necessary services for one of 18 residents reviewed which resulted in actual harm, related to multiple fractures which required surgical treatment and admission into an intensive care unit for one resident (Residents R16). Findings include: Review of facility policy Abuse Prohibition, dated effective (MONTH) 26, (YEAR), stated, Each resident will be free from abuse. It further stated, No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Additionally, investigation of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse. Review of Resident R16's record revealed a Minimum Data Set (MDS- periodic assessment of resident needs) dated (MONTH) 30, (YEAR), which indicated that Resident R16 was admitted to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. The MDS further indicated that the resident was moderately cognitively impaired, required extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, hygiene, used a walker or wheelchair for mobility and was frequently incontinent of bowel and bladder. Review of facility documentation revealed that during morning care on (MONTH) 28, (YEAR), Resident R16 was noted with a bruise on the left shoulder, complained of pain, had slurred speech and disorganized conversation. The physician was notified and ordered that the resident go to the emergency room . Continued review of facility documentation revealed a written statement dated (MONTH) 28, (YEAR), by Employee E5, nurse's aide, revealed that when she started helping Resident R16 get ready for breakfast the resident was screaming it hurts, everything hurts, and that the resident was not able to roll over side to side as she usually does, when getting washed (personal care and hygiene). Employee E5 further stated, she tried to help her sit by the side of the bed to stand, the Resident could not stand at all and she put the resident back to bed using a complete lifting, and transferred the resident into the wheelchair. She removed the resident's pajama top and saw a bruise on her left shoulder. Additionally, Employee E5 stated, She was screaming it hurts while I was taking her top off and while I was putting her clothes on as well. The nurse was notified of the resident's bruising. While assisting the resident with her meal, Resident R16 told Employee E5 I fell really hard out of bed. Review of facility Face to Face documentation revealed that the nurse practioner had examined the resident on (MONTH) 28, (YEAR), at 2:30 p.m. Upon examination of the left upper arm the resident was found to have purplish discoloration to the back of the arm, had pain with movement and had a weak hand grip, had slurred speech and did not follow commands. The resident was sent to the emergency room for further evaluation. Review of hospital X-ray of left shoulder dated (MONTH) 28, (YEAR), at 3:22 p.m. revealed [DIAGNOSES REDACTED]. Further review of Resident R16's hospital records revealed a left hip X-ray dated (MONTH) 28, (YEAR), at 7:41 p.m. which revealed an acute displaced and angulated left femoral neck fracture (left hip) and left inferior pubic ramus fracture (pelvis). Resident R16's hospital records further indicated that the resident had been admitted to the hospital on (MONTH) 28, (YEAR), had required surgery to repair a left [MEDICAL CONDITION] and a left humerus fracture, had [MEDICAL CONDITION] which required a blood transfusion and had been subsequently admitted into the Intensive Care Unit. Review of a written statement by Employee E4, nurse aide, on the 3:00 p.m. to 11:00 p.m. nursing shift on (MONTH) 27, (YEAR), confirmed that she had cared for the resident that evening. Employee E4 further stated that she had assisted the resident with dinner, returned her to her room after dinner at 6:00 p.m., assisted the resident to the bathroom, helped her to get cleaned up and ready for bed, placed her into bed, saw the resident again at 9:30 p.m. and changed her brief. Continued review of facility documentation revealed a verbal statement obtained from the roommate of Resident R16 (Resident R27) on (MONTH) 28, (YEAR), at 1:30 p.m. which noted that Resident R16 fell the night before in front Resident R27's television, that someone came in and picked her up. Additionally, the facility investigation noted that it had been determined that Employee E4, nurse aide, had assisted Resident R16 using her walker out of the bathroom. Employee E4 had then instructed Resident R16 to walk to her bed (on the other side of the room), that the employee then exited the room, leaving the resident to walk back to her bed alone. When Employee E4 returned to the room, the resident was lying on the floor. Review of documentation submitted by the facility related to Resident R16's fall in the evening of (MONTH) 27, (YEAR), confirmed that the resident had been care planned for the assistance of one staff person for supervision while ambulating (walking) with a rolling walker (assistive device). Interview with the Director of Nursing on (MONTH) 19, (YEAR), at approximately 1:00 p.m. revealed that Employee E4 had put the resident into bed after she found her on the floor and did not report it and had been subsequently terminated. The facility failed to provide the resident with the necessary staff assistance while ambulating, resulting in actual harm to the resident who fell . The resident sustained [REDACTED]. The resident required surgical treatment for [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/08/16 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 12/08/16 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 201.29(j) Resident rights Previously cited 12/08/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/08/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/08/16

Based on clinical record review, review of hospital documentation, staff interview and facility document it was determined that the facility failed to implement physician's orders [REDACTED]. Findings include: Resident CL1's closed clinical record revealed Physician admission orders [REDACTED]. The hospital's discharge instructions included that the Resident had surgery for [REDACTED]. (International Normalized Ratio-test to measure time it takes for blood to clot) on [DATE] was noted to be 4.0, that the [MEDICATION NAME] was not to be given on [DATE] , that staff should recheck the INR on [DATE] and restart the [MEDICATION NAME] when the INR was between 2.0 and 3.0 (usual target range). Physician admission orders [REDACTED]. Additionally, the staff were to obtain vitals signs on every shift for 9 shifts, then weekly. A review of documentation available at the time of the survey revealed no vital signs were avilable to review for the 3:00 p.m. to 11:00 p.m. nursing shift on [DATE] and 11, 2015. Documentation by the Nurse Practitioner for [DATE], time unknown, stated that the Resident's Left Lower Quadrant stoma(opening in the abdomen for [MEDICAL CONDITION]) was intact, the abdomen was soft, with mild tenderness with palpation, that the Resident had a positive history of [MEDICAL CONDITION], that the INR had been previously been elevated at 5.5, 4.8, 4.0 A physician/Nurse Practitioner order was written [DATE], no time indicated, stating that the INR for that day was 2.8, to restart previous dose of [MEDICATION NAME] 6 milligrams by mouth daily and to recheck the INR on [DATE]. Review of nursing documentation for [DATE], at 2:00 p.m. stated that the Resident had complained of nausea in the morning after receiving the medications, that the Resident had a poor appetite, that the Resident was advised not to take mediication on empty stomach. There was no indication if the Resident's nausea had been reassessed or if the Resident had been medicated for the nausea. A nutrition assessment completed on [DATE](no time indicated) stated that the Resident stated that the Resident was very tired, not feeling good. There was no evidence available for review at the time of the survey that this information was passed on to the nursing staff at that time. Nursing documentation for [DATE], at 3:00 p.m. stated that the Resident was noted to have red blood in the [MEDICAL CONDITION] bag, appears as if mixed with liquid, that the Resident reported nausea, that the general surgeons office had been notified, that at 3:30 p.m. his office called back to notify the facility that the surgeon was not available for the next 4 hours. There was no evidence available for review at the time of the survey that vital signs or physical assessment were obtained at that time. A Nurse Practitioner progress note dated [DATE], (no time noted), stated the Resident was assessed, that the blood pressure was ,[DATE] mmHg(millimeters of mercury), that staff were unable to obtain oxygen saturation level (the amount of oxygen in the blood), that bright red blood was noted in Resident CL1's [MEDICAL CONDITION] bag, that the Resident was on [MEDICATION NAME] 6 milligrams by mouth daily, that the last INR was 2.8 on [DATE], that the Resident was being sent to the emergency room (ER). Review of hospital records dated [DATE], revealed that Resident CL1 had been seen in the ER at approximately 6:00 p.m An assessment documented by the Nursing Home prior to being sent to the ER revealed that the Resident was reporting pain, had significant diffuse tenderness associated with nausea and large amount of blood in the [MEDICAL CONDITION] bag. At 5:00 p.m. documentation reported that the Resident continued to bleed bright red blood into the [MEDICAL CONDITION] bag and that they were unable to get INR by fingerstick at 5:30 p.m. the Resident was transferred to the ER via 911. emergency room physician documentation at approximately 6:40 p.m. stated that Resident CL1 reported onset of pain that morning and had a large amount of bloody stool. It stated further that the physician had spoken with the nurse at the facility who reported that Resident had arrived at the facility on Monday ([DATE]) and received 6 milligrams of [MEDICATION NAME] on Tuesday and Wednesday ([DATE] and 11, 2015) after having elevated INR levels. Hospital documentation noted that during the first 2 hours after arrival the Residents blood pressure ranged from ,[DATE] to ,[DATE] (normal range approximately ,[DATE]). The Resident's INR was also noted to be 15.6 on arrival. emergency room records noted that the Resident was transfused in the emergency room with 2 units of blood and was medicated with [MEDICATION NAME] 2 milligrams intravenous for pain, [MEDICATION NAME] 4 milligrams intravenous for nausea, Kcentra (a blood clotting factor) intravenous infusion for urgent reversal of the blood's inability to clot, myphyton(Vitamin K) 5 milligrams by mouth for reversals of anticoagulant medication ([MEDICATION NAME]). Resident CL1 was transferred to critical care at 11:00 p.m. that evening. Facility documentation dated [DATE] at 1:30 p.m. stated that the Resident had expired in the hospital that morning. The Director of Nursing stated in an interview on [DATE], at approximately 9:10 a.m. that staff had neglected to notify the laboratory of the physician order, that the [MEDICAL CONDITION] bag had filled up with blood twice, confirmed that the vital signs had not been obtained, that the nurse neglected to put it in the book, that it was human error. The facility failed to follow physician orders [REDACTED]. In addition, the facility failed to adequately assess and monitor a Resident with recent abdominal surgery, complicated medical needs and an urgent change in condition resulting in hospitalization and actual harm to Resident CL1. 28 Pa. Code: 211.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited [DATE] & [DATE].