Health inspection·December 9, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility documentation, it was determined that the facility failed to ensure a resident safe, comfortable and home like environment for 9 out of 9 residents reviewed (Resident R1, R2, R3, R4, R5,R6, R7, R8, and R9). Finding include: Review of the facility policy, Environment of Care, with a revision date of September 2024 indicated that the purpose of the policy is to ensure that the facility's building and equipment are repaired in an effect and efficient manner and to ensure a safe and healthful workplace, and to ensure that facility work orders are completed in order of their priority. Review of the policy also indicated that work request should be placed in TELS (a computer system used by facility staff to input repair/replacement request, etc within the facility), and hat a detailed description of the request should be written as well as ensuring that staff assign the appropriate priority to that request (e.g. Low, Medium, Critical). Continued review of the policy indicated that the Environmental Services Director, Maintenance Supervisor or designee will review work order request daily and that emergency work order request will be given priority for making necessary repairs. Review of information received by the State Survey Agency on November 22, 2024, indicated that requested repairs/replacements inputted in the facility's maintenance computer system were not being addressed in a timely manner. Review of several work orders with the facility Maintenance Director (Employee E3) on December 9, 2024 at 12:15 p.m. that were submitted by facility staff indicated that the orders that impacted residents care, services and safety, were not addressed in a timely manner: Review of a work order request with the Maintenance Director on December 9, 2024 at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on November 16, 2024, at 7:16 a.m. for room [ROOM NUMBER], where Resident R1 and Resident R2 resided reporting that the toilet in the room was not flushing properly and that it was overflowing. The work order for the toilet was documented as being Open, indicating that the repair had not been made. During a tour with the Maintenance Director on December 9, 2024 that began 12:45 p.m. following observations were made regarding the following work order request: In room [ROOM NUMBER], the Maintenance Director reported that work request that was submitted on November 16, 2024 regarding the inoperable toilet for Resident R1 was addressed last week. The Page 1 of 3 395346 395346 12/09/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Maintenance Director reported that the tank needs to be replaced. The Maintenance Director also reported that the resident had a concern about his bed was also addressed last week. During an interview with Resident R1 on December 9, 2024, at 11:29 a.m., the resident reported that his toilet was not working, and he was told that he could use the shower bathroom. Resident reported that he needed help from staff to use this bathroom. During the above referenced interview, the resident reported that his bed quit working and that it would not move up and down and explained that he told multiple people about the toilet and his bed and that it had not been addressed by maintenance staff so his room was moved sometime last week. A work order request was submitted to the maintenance department by facility staff on December 3, 2024 at 1:47 p.m. reporting that the bed mattress for Resident R9 in room [ROOM NUMBER] was not staying in in place. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In room [ROOM NUMBER], Resident R9 reported that someone came in and asked him about his mattress. It was found during the investigation that a maintenance staff member addressed the work order that was submitted on December 3, 2024 regarding the resident's mattress was updated by the Maintenance Director as Completed on December 9, 2024 at 1:32 p.m., 6 days after the request was made. Review of a work order request with the Maintenance Director on December 9, 2024 at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on December 3, 2024 at 1:51 p.m. reporting that the call bell for room [ROOM NUMBER] where Resident R7 and R8 resided was on outside their room, and cannot be turned off. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In room [ROOM NUMBER], the call bell light indicator outside the room was on. Resident R8 entered the room and stated that the call bell for their room had not been working and that both she and her roommate, Resident R7 just got hand-held bells today. Resident R8 entered her room with a hand-held bell for herself and a 2nd one for Resident R7. Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on August 29, 2024 at 8:01 a.m. reporting that the shower room located on the north side of the 2nd floor needed a new toilet. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In the north 2nd floor shower room, the Maintenance Director reported that the whole toilet has to be replaced and that one will be ordered, but had not been ordered yet. Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on September 16, 2024 at 8:18 a.m. indicating that the there was water leaking towards the window in front of Resident R5's bed in room [ROOM NUMBER]. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. In room [ROOM NUMBER], the ceiling tile was removed from the resident's room leaving the ceiling exposed. Pointing to the ceiling, Resident R5 stated no one has done anything about this. The 395346 Page 2 of 3 395346 12/09/2024 Onyx Wellness Center 205 East Johnson Highway Norristown, PA 19401

F 0584 Maintenance Director reported that a plumber will need to come out and make repairs. Level of Harm - Minimal harm or potential for actual harm Review of a work order request with the Maintenance Director on December 9, 2024, at 12:15 p.m. indicated that a work order request was submitted to the maintenance department by facility staff on November 15, 2024 at 6:40 a.m. indicating that the call light in the room is not working in room [ROOM NUMBER] where Resident R3 and R4 resided. The work order was marked as Open, indicating that it had not been addressed by maintenance staff. Residents Affected - Some The call light outside room [ROOM NUMBER] was one. Resident R3 and Resident R4 reported that their call bells have been broken and that once she was using the bathroom and had to yell for staff to come ad help her. Resident R3 and Resident R4 reported that they just received hand held call bells, today. During an interview with the Maintenance Director on December 9, 2024 at 1:30 p.m. it was confirmed that the work orders were not addressed/resolved in a timely manner. 28 Pa. Code 201.18(a) Management 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 201.29 (a) Resident Rights 395346 Page 3 of 3