Health inspection·January 31, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility documentation, review of clinical records, review of video footage and interviews with staff, it was determined that the facility failed to ensure that one of six residents reviewed were free from physical abuse from nursing staff. This failure resulted in an Immediate Jeopardy situation with Resident R2 who was struck twice, and rough handled sustaining left upper arm bruising. (Resident R2). Findings Include: Review of facility policy on Abuse Prevention Program dated August 2020 states, The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Abuse-Includes Verbal, Physical, Sexual, and Mental/Emotional. Abuse- willful infliction of injury, unreasonable confinement/Involuntary seclusion. Separation of a resident from other residents, or from their room or other area, against the resident's will or the will of the resident's representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Corporal punishment and any physical or chemical restraint not required to treat the resident's symptoms. Instances of abuse of residents, irrespective of any mental or physical condition, that causes physical harm, pain, or mental anguish to include verbal, sexual, physical, & mental abuse. Abuse that includes that which is facilitated or enabled using technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that he individual must have intended to inflict injury or harm. Verbal abuse includes oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families to describe the resident within hearing distance, regardless of their age &/or ability to comprehend or disability. Physical abuse includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. Review of facility policy on Catastrophic Crisis Management dated October 2021 states, The staff will strive to safely manage a behavior crisis when the resident poses immediate danger to themselves or others. If the behavior cannot be managed and the crisis continues, the resident will be transferred to an acute care facility. The procedure reads, 1. Implement immediate protective interventions Page 1 of 9 395346 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0600 Level of Harm - Immediate jeopardy to resident health or safety for the resident (s) and staff. 2. Remain calm and speak to the resident in a calm, firm voice. A. Respond to the resident's voiced concerns. B. Reassure the resident. 3. Analyze situation for immediate actions that will promote safety of resident and/or others. 4. Summon additional staff as needed by paging (Code CATCatastrophic) with the location. 5. Initiate the following interventions which may include but are not limited to: a. Remove resident from the situation to a safe, supervised environment. b. Identify and reduce/remove triggers of behavior. c. Remove others from the area. Residents Affected - Few Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Further review of Resident R2's clinical record revealed that Resident R2 had a diagnosis of Hemiplegia (weakness on one side of the body), Urinary Tract Infection, Muscle Weakness, Major Depressive Disorder, Generalized Anxiety Disorder, Dysphagia (difficulty swallowing), Lack of Coordination, Abnormalities of Gait and Mobility, Unspecified Lack of Coordination, and Weakness. Review of Resident R2's quarterly Minimum Data Set (MDS-assessment of resident's care needs) dated November 6, 2023, revealed the resident was assessed with a BIMS (Brief Interview for Mental Status) with no score which suggested that the resident had difficulty completing the assessment due to not being able to be understood due to her language barrier. Continued review of the assessment revealed that the resident did not demonstrate any physical or verbal behavioral symptoms. Review of nursing progress note from January 15, 2024 time stamped at 11:19 a.m. revealed Resident observed with a bruise to LUE (left upper extremely) this AM, call was placed to MD'S office message left . pain management in progress, resident indicated the arm hurts a little bit, nursing to monitor and assess for changes, resident speaks very little English and has not voiced how she got the bruise. Review of nursing progress notes from January 15, 2023, time stamped at 11:22 p.m. reads Resident on 1:1 for safety. Tolerated medication well. No complaints of pain or discomfort. Safety precautions maintained. Review of information submitted to the Department of Health from January 15, 2024 states On 1/15/24 is was reported at 10:30 by [licensed nurse, Employee E8] that Resident R2 was observed with a discolored area to left forearm. She did a hand gesture of as if she was hit, no additional information provided. Observation of the facility's video footage of Unit one was conducted on January 31, 2023, at 11:11 a.m. with the Director of Nursing, Employee E2 allowing access. The video footage revealed two camera angles camera #1 of the Resident R2's hallway to her bedroom and camera #2 was an angle of the nurse's station and right hallway. Both were reviewed through the timeframe the incident occurred on January 14, 2024. The video revealed Resident R2 in camera 2 view sitting alongside the wall next on to the right of the camera view at 2:40 p.m. At 2:41 p.m. nurse aide, Employee E6 walked past the resident, to the end of the nurse's station and Resident R2 began yelling at her and using hand gestures in her direction. At 2:42 p.m. nurse aide, Employee E6 was standing at the end of the nurse's station and began to use hand gestures and yelled back at the resident. At 2:43 p.m. Resident R2 began to wheel herself towards the nurse's station and tried to knock down a water bottle and a computer. Nurse aide, Employee E6 moved the water bottle and held the computer and then sat down at the nurse's station at the 395346 Page 2 of 9 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few end of the right side. At 2:44 p.m. Resident R2 wheeled herself closer to the end of the nurse's station and attempted to hit nurse aide, Employee E6. Employee E6 pulled her hand out of the way, and it was not struck by the resident. Resident R2 then attempted to pull charts off of the filing cabinet and nurse aide, Employee E6 lifted her hand up and struck it down making contact with the resident's hand for the first time. Employee E4 at this point looked at Resident R2 and Employee E6 but continued typing on the computer. Resident R2 then attempted to grab file folders again and was struck in the hand by Employee E6 for the second time. At 2:45 p.m. nurse aide, Employee E4 interrupted the altercation and moved resident back to space by the wall where she was prior to the altercation. At 2:46 p.m. Resident R2 started moving away from the wall. Nurse aide, Employee E6 gestured with her hand pointing towards the wall for her to go back by the wall and then walked into the day room. At 2:47 p.m. Resident R2 wheeled herself away from the wall and went into day room. At 2:49 p.m. nurse aide, Employee E6 exited the day room. At 2:52 p.m. Resident R2 left the day room and sat back by the wall. Continued review of the video footage revealed that at 3:33 p.m. Resident R2 wheeled herself to the nurse's station and attempted to throw a phone off of the nurse's station and nurse aide, Employee E5 placed the phone out of reach of the resident. After placing the phone out of reach nurse aide, Employee E5 was seen pulling the resident away from the counter while her hand was still on the counter, she pulled at her upper left shoulder to remove her arm from the nurse's station. Nurse aide, Employee E5 then attempts to wheel her into the day room when the resident grabbed onto the grab bars in the hallway while attempting to swat at nurse aide, Employee E5. Employee E5 was seen holding the right side of her wheelchair for forty-five seconds restricting her movement. At this time, the resident was swatting at nurse aide, Employee E5. Employee E5 then went to the nurse's station and checks her phone. At 3:55 p.m. Employees E5, E7, and E9 were all seen at the nurse's station. At 4:01 p.m. Resident R2 was seen on the left camera coming out of her room. Resident R2 wheeled herself and sat alongside the wall. At 4:12 p.m. Resident R2 wheeled herself to the nurse's station and tried grabbing something of the nurse's station. Nurse aide, Employee E7 point towards her room. At 4:14 p.m. the resident wheeled herself back to the same spot along the wall. At 4:15 p.m. before Resident R2 stopped wheeling herself, nurse aide, Employee E7 walked away from the nurse's station and turned the resident around and wheeled the resident to her bedroom. At 4:15 p.m. nurse aide, Employee E7 was seen walking out of Resident R2's room dancing and putting her hands in front of her and behind her back. Review of facility documentation revealed an interview held on January 17, 2024, with Nursing Home Administrator, Employee E1 and Nurse aide, Employee E4. Employee E1 asked nurse aide, Employee E4, is she had ever seen any staff or resident hit Resident R2, nurse aide, Employee E4 said no, not that she can recall, no. Further review of facility documentation revealed, Ten minutes later [Employee E4] calls the [Nursing Home Administrator Employee E1] and states: that she doesn't want to blame anyone or get anyone fired, but [Resident R2] was coming after [nurse aide, Employee E6] on Saturday or Sunday while she was charting (could not recall the time) [Resident R2] was near the nursing station as she tried to grab on papers that were there and [nurse aide Employee E6] made a hand motion at Resident R2 to show that she should go away. Nursing Home Administrator Employee E1 asked [Employee E4] to come in the next day and reenact what happened to assist with better understanding. 395346 Page 3 of 9 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of facility investigation documentation revealed on January 18, 2024, Resident Physical Abuse reportable investigation: Bruise found on resident left arm below the shoulder. Resident informed family that someone wheeled her into her room and hit her. Dark and light skinned with long hair. Investigation initiated. Review of facility investigation documentation revealed observations made through the video cameras located on the unit. On Sunday 1/14/24 at 2:43 p.m. camera #1 at the first-floor nurse's station Resident R2 sitting near nursing desk goes to the nursing desk and tried to knock down a water bottle. Nurse aide, Employee E6 immediately grabbed the water bottle and closed it Resident R2 tries to knock down the desktop monitor. Employee E6 held it down. Resident R2 then come around the nursing station and tried to grab at Employee E6, Employee E6 moved her hand away. Resident R2 then grabbed a chart and as she is about to knock it down Employee E6 slapped her hand down. Employee E4 sitting at the nurse's station then come around and wheeled Resident R2 away from the nursing station. At 3:40 p.m. Resident R2 was seen on camera #1 at the nursing station knocking down the phone. Coming out of the activities room was nurse aide, Employee E5 who had witnessed this and come towards the nursing station, in front of Resident R2, and placed the phone back up. Resident R2 then hits Employee E5. Without any reaction. Employee E5 went behind Resident R2, placed her left hand away from the nursing desk and wheeled her back. At 4:00 p.m., Resident R2 on camera #1 was seen sitting at the nursing station then began throwing things at nurse aide, Employee E7, who was sitting behind the nursing desk. Nurse aide, Employee E7 then went around the nursing station and wheeled Resident R2 into her room, after a minute come out of her room with towels. (Resident R2 is known to store towels at the side of her wheelchair). Camera continues to show Employee E7 going back to the nursing station sitting down. In some time, Resident R2 starts to come out of her room sitting near her room facing the wall puts her head down on the railing. She then slowly makes it back to the nursing station and sits in her usual spot. Employee E7 then goes around the nursing station to Resident R2 and wheels her back to her room. Review of facility investigation documentation revealed on January 22, 2024, the Nursing Home Administrator Employee E1 called nurse aide, Employee E6 to notify her of her termination of employment related to the facility sustaining resident abuse. While letting nurse aide, Employee E6 know the specific actions that the employee performed, Employee E6 said I did do that, in relation to each action. Interview held with the Director of Nursing revealed upon completion of the investigation nurse aide, Employee E6 was terminated and nurse aide, Employee E7 was also terminated. Nurse aide, Employee E5 was educated but it still employed at the facility. the Director of Nursing revealed that nurse aide, Employee E4 was given a discharge warning for not reporting immediately but is still employed at the facility. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that a resident was free from physical abuse from nursing staff. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on January 31, 2024, at 1:17 p.m. The facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following: 395346 Page 4 of 9 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0600 On January 31, 2024 at 5:11 p.m. the facility provided the following corrective active plan: Level of Harm - Immediate jeopardy to resident health or safety 1. [Resident R2] was immediately assessed by the Director of Nursing. Resident was immediately placed on 1:1 on 1/15/2023 for emotional support and to feel safe. The 1:1 was educated prior to the start of 1:1. Responsible Party, Physician and Risk Manager notified. Pain and skin assessment completed. Resident remains at her behavioral baseline with no signs nor symptoms of distress. The physician examined the resident on 1/16/2024. The resident displayed no signs of distress. The resident remained on 1:1 until IDT (Interdisciplinary Team) team made the decision that it was safe for the resident 1:1 to be removed on 1/19/2024. Residents Affected - Few 2. The facility reported an event to the DOH on 1/15/2024. The three staff members that were identified during this investigation were suspended pending results. 3. A Licensed Nurse conducted skin assessments of all patients to determine if any other patient may have been impacted by abuse or neglect. The Unit Manager on duty provided supervision and oversight of this assessment. This assessment was completed on 1/20/24 with no findings of physical or psychosocial signs of abuse and neglect. 4. The Risk Management Consultant provided education to the Administrator and Director of Nursing on the facility abuse, neglect and misappropriation policy and procedure with an emphasis on the immediate reporting of potential or witnessed abuse, neglect, or misappropriation. This education was completed on 1/19/24. 5. The Administrator, Director of Nursing, and Social Services Director educated all staff on the facility abuse, neglect, and misappropriation policy with an emphasis on the immediate reporting of potential or witnessed abuse, neglect, or misappropriation and rough handling of patients. This education included the execution of the employee attestation of commitment. 100% of all staff received this training by 1/29/24. 6. The Administrator, Director of Nursing, Social Service Director, and Executive Director reviewed the facility policy on abuse, neglect, and misappropriation. No need for changes was identified at the time. The Administrator/DON/Designee will monitor residents for signs and symptoms of abuse and/or neglect weekly times 4 weeks, monthly times 4 months. Findings will be taken to QA weekly times 4 weeks, then monthly. Facility documentation was reviewed, and residents skin assessments were completed on January 16, 2024 on every resident. The immediate implementation of the action plan was verified on January 30, 2023. Interviews were conducted with facility staff from various departments, and all reported that they had been in-serviced by the facility on resident abuse, and the importance of immediate reporting any allegation or suspected abuse. On January 31, 2024, twenty staff members were interviewed. All staff interviewed were able to verbalize what constitute abuse, methods to de-escalate a resident who is agitated. and who and when to report resident abuse. The Immediate Jeopardy was lifted on January 31, 2024 at 5:32 p.m. 395346 Page 5 of 9 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0600 28 Pa. Code 201.14(a) Responsibility of Licensee Level of Harm - Immediate jeopardy to resident health or safety 28 Pa. Code 201.18(b)(1) Management Residents Affected - Few 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(c) Resident Rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1) Nursing Services 395346 Page 6 of 9 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to make certain that residents were protected from physical abuse from a nursing staff for one of six residents reviewed. (Resident R1) This failure resulted in an Immediate Jeopardy situation for Resident R2. Residents Affected - Few Findings include: Review of the job description for the Nursing Home Administrator (NHA) stated that the Nursing Home Administrator as a member of The Board of Managers of Operator is responsible and accountable for the Facility Quality Assurance Performance Improvement (QAPI) for all aspects of the Facility including but not limited to; establishing and implementing policies and procedures, quality of care, quality of life, regulatory compliance, compliance/ethics, business development and financial stewardship. Leads the facility Ethics and Compliance Program, acting as the Ethics and Compliance Officer. Enacts, implements and enforces the facility policies regarding the management and operation of the facility. Provides supervision either directly or indirectly to all facility employees including the selection, hiring, orientation, training and coaching of employees. Responsible establishing and implementing policies regarding the operation of the facility. Review of the job description for the Director of Nursing (DON) stated that the DON is appointed to the Facility Board of Managers and is responsible for developing, organizing, evaluating, and administering patient care programs and services. The DON has twenty-four (24) hour responsibility for the overall delivery of nursing services and ensures the implementation of all clinical policies and procedures. Makes rounds to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards. Ensures that each resident ' s right to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to lodge a complaint, are strictly enforced. Supervises nursing staff whether directly or indirectly in accordance with facility policies and procedures. Responsible for hiring, selection, training and coaching employees. Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE]. Further review of Resident R2's clinical record revealed that Resident R2 had a diagnosis of Hemiplegia (weakness on one side of the body), Urinary Tract Infection, Muscle Weakness, Major Depressive Disorder, Generalized Anxiety Disorder, Dysphagia (difficulty swallowing), Lack of Coordination, Abnormalities of Gait and Mobility, Unspecified Lack of Coordination, and Weakness. Review of nursing progress note from January 15, 2024 time stamped at 11:19 a.m. revealed Resident observed with a bruise to LUE (left upper extremely) this AM, call was placed to MD'S office message left . pain management in progress, resident indicated the arm hurts a little bit, nursing to monitor and assess for changes, resident speaks very little English and has not voiced how she got the bruise. The video revealed Resident R2 in camera 2 view sitting alongside the wall next on to the right of the camera view at 2:40 p.m. At 2:41 p.m. nurse aide, Employee E6 walked past the resident, to the 395346 Page 7 of 9 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few end of the nurse's station and Resident R2 began yelling at her and using hand gestures in her direction. At 2:42 p.m. nurse aide, Employee E6 was standing at the end of the nurse's station and began to use hand gestures and yelled back at the resident. At 2:44 p.m. Resident R2 wheeled herself closer to the end of the nurse's station and attempted to hit nurse aide, Employee E6. Employee E6 pulled her hand out of the way, and it was not struck by the resident. Resident R2 then attempted to pull charts off of the filing cabinet and nurse aide, Employee E6 lifted her hand up and struck it down making contact with the resident's hand for the first time. Employee E4 at this point looked at Resident R2 and Employee E6 but continued typing on the computer. Resident R2 then attempted to grab file folders again and was struck in the hand by Employee E6 for the second time. At 2:45 p.m. nurse aide, Employee E4 interrupted the altercation and moved resident back to space by the wall where she was prior to the altercation. Review of facility investigation documentation revealed on January 18, 2024, Resident Physical Abuse reportable investigation: Bruise found on resident left arm below the shoulder. Resident informed family that someone wheeled her into her room and hit her. Dark and light skinned with long hair. Investigation initiated. Review of facility investigation documentation revealed on January 22, 2024, the Nursing Home Administrator Employee E1 called nurse aide, Employee E6 to notify her of her termination of employment related to the facility sustaining resident abuse. While letting nurse aide, Employee E6 know the specific actions that the employee performed, Employee E6 said I did do that, in relation to each action. Interview held with the Director of Nursing revealed upon completion of the investigation nurse aide, Employee E6 was terminated and nurse aide, Employee E7 was also terminated. Nurse aide, Employee E5 was educated but it still employed at the facility. the Director of Nursing revealed that nurse aide, Employee E4 was given a discharge warning for not reporting immediately but is still employed at the facility. Based on the deficiencies identified in this report, the NHA and DON failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation. Refer to F600. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 395346 Page 8 of 9 395346 01/31/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0835 28 Pa. Code 211.12(d)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395346 Page 9 of 9