Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to fully investigate an incident with injury in a timely manner for one of 10 residents reviewed (Residents R78). Findings include: Review of a facility policy entitled Abuse Policy of the Transitional Care Unit dated 11/08/2024, revealed that, all investigations shall be comprehensive and responsive and shall occur promptly after notification of an alleged abuse . Review of facility policy entitled Accidents and Incident Reports dated 11/08/24, revealed a written report shall be made of any accident or incident in which a resident is involved in the facility . Review of Resident R78's clinical record revealed an admission date of 6/25/2024, with diagnoses that included arthritis, pain in right hip, and infection and inflammatory reaction due to internal right hip prosthesis (artificial hip joint). Review of Resident R78's clinical record revealed a progress note dated 7/07/2024, that indicated Resident R78 was sitting on his/her buttocks in front of wheelchair. It was reported by a Nurse Aide that Resident R78 had stood up and was attempting to transfer into bed independently with the call bell alarming. The Nurse Aide in response to the call bell, assisted Resident R78 and their knees buckled causing the resident to fall to the floor. Resident R78 was assessed with complaint of pain to the left lower leg. An order was received from the physician to transfer Resident R78 to the hospital. Resident R78 returned from the hospital with a diagnosis of fractured left femur. Review of Resident R78's clinical record and incident documentation revealed a lack of evidence that an investigation was completed. Further review of the clinical record and facility documentation lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff of the incident investigation to ensure the resident was free from abuse and/or neglect. During an interview on 11/14/2024, at 10:40 a.m. the Nursing Home Administrator (NHA) confirmed that there was a lack of a thorough investigation completed on Resident R78's incident with injury. The NHA also confirmed that all incidents should be investigated which included obtaining written statements. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of position description and job duties and facility documentation, and staff interviews, it was determined that the facility failed to ensure that a registered nurse was employed as the Director of Nursing on a full-time basis since October 26, 2023. Findings include: Review of the position description section for the Director of Nursing - (DON) revealed that the role of the DON includes to coordinate total nursing care for residents using nursing standards and the nursing process in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern the Long Tern Care Facility to assure that the highest degree of quality care can be provided to our residents at all times. The Job Duties for the DON included to promote an environment in which the resident care team can work cooperatively toward objectives, directs, supervises, delegates and evaluates all nursing care provided to the residents by using professional skills and judgements. Functions as clinical and managerial resource to guide and validate the independent decision making of staff. Review of information submitted by the facility regarding a change in the DON position revealed that Employee EI began as the DON on November 6, 2023. During an interview on December 13, 2023, at 10:30 a.m. DON Employee E1 reported he/she was serving as the temporary DON while they work to fulfill the job with a permanent employee. Employee E1 reported that they also work as the Nursing Supervisor in the acute care hospital two to three days a week. During an interview on December 13, 2023, at 10:30 a.m. the Nursing Home Administrator confirmed that Employee E1 assumed the DON role on November 6, 2023, and the former DON's last day worked was on October 26, 2023. The NHA also confirmed that the current DON does not work on a full-time basis as they also work as the Nursing Supervisor in the acute care hospital two to three days a week. 28 Pa Code 201.14 (a) Responsibility of license 28 Pa Code 211.12 (b) Nursing Services

Based on review of manufacturer's guidelines, facility records, observations, and staff interviews, it was determined the facility failed to maintain safe storage of ice for residents for one of one ice machines located in the kitchen. Findings include: Review of the manufacturer's guidelines for the Kold-Draft GT & GB Models (ice machine) revealed that Individual drains must never be directly connected to a common manifold, drain, or standpipe. If individual drains are to be discharged into a common manifold, drain, or standpipe, a minimum one and half-inch air gap must be provided at each connection. This is to prevent any backflow or back-siphoning of drain water into the ice maker or ice bin. Review of ice machine maintenance records provided by the facility on 12/12/23, indicated that the ice machine was last serviced and cleaned on 9/25/23. Observation on 12/11/23, at 11:14 a.m. revealed a black, slimy substance on the outside of the white plastic drainpipe from the bottom of the ice bin. The bottom edge of the pipe was resting against the top edge of the drainpipe to the floor, and there was black, slimy substance on the inside edge of the drainpipe to the floor, and there was no one and half-inch air gap. During an interview on 12/11/23, at 11:14 a.m. the Dietary Manager confirmed the presence of the black, slimy substance on both pipes and that the pipes were resting together. During an interview on 12/12/23, at 1:30 p.m. the Nursing Home Administrator confirmed the presence of the black, slimy substance; the edges of the pipes were touching; the ice machine was last cleaned on 9/25/23; and that the ice machine piping was dirty and should have been cleaned and measures taken to prevent the development of the black, slimy substance. 28 Pa. Code 201.14(a) Responsibility of licensee