Health inspection·January 22, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on the review of clinical records, facility investigation, review of facility policy and interviews with resident and staff, it was determined that the facility failed to treat residents with respect and dignity for one of 20 residents reviewed. (Resident R22) Findings Include: Review of an updated facility policy Resident Rights-Resident [NAME] of Rights revealed that No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law . Every resident of a facility shall have the right to: Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. Retain and use his or her own clothes and other personal property in his or her immediate living quarters, so as to maintain individuality and personal dignity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. Interview with Resident R22 on January 16, 2024, at 11:32 a.m. stated couple months ago, he was sexually assaulted by three staff members who came to his room and pinned him down to the bed. One staff held his right hand, and one staff removed his brief and took a cigarette lighter from which was inside his brief. Resident stated staff touched his private area without permission. He stated he was very upset and complained to the staff. Police was called and he was transferred to the hospital for evaluation. Resident also stated he did not consent to search his room or search his body and staff invaded his privacy. Review of facility investigation dated October 14, 2023, revealed that Resident R22 reported an allegation of sexual abuse. According to the staff, resident was smoking in his room. Staff went to his room and asked Resident R22 to hand over his cigarettes and lighter, which resident refused and placed it behind his back. Out of concern, staff removed the cigarette and lighter. However resident became combative towards the staff and used derogatory language towards the staff. Review of statement from Employee E31, Nursing Assistant dated October 14, 2023, revealed that she smelled cigarette when she was in Resident R22's room, she reported to the two nurses on the floor. Three of them went into the resident's room and confiscated the cigarette. Resident was fighting all three of the staff. Review of statement from Employee 32, Registered Nurse, dated October 14, 2023, revealed that Nursing Assistant reported that Resident R22 was smoking in his room, upon entering his room nurse perceived smoke odor all over the room. Resident was on his bed, cursed staff and asked them to leave. Charge nurse took an unfinished cigarette and lighter to the nurse which they got from the resident. Page 1 of 39 395446 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0557 Level of Harm - Minimal harm or potential for actual harm Review of statement from Employee 33, Licensed Practical Nurse, dated October 14, 2023, revealed that the Nursing Assistant reported that Resident R22 was smoking in his room. Staff asked the resident where was the lighter and resident stated it was none of their business. Resident R22 stated, I am not giving out my lighter and you won't get it The nurse rolled the resident, he tried to fight. The staff found the cigarette at the edge of the brief. Residents Affected - Few Interview with Nursing Home Administrator and Director of Nursing on January 17, 2024, at 5:00 p.m., stated staff should have asked resident for permission before searching his room and body. If resident denies for search staff should place resident on 1:1 supervision and notify the police. Administrator confirmed that the staff on October 14, 2023, did not ask Resident R22's permission before they searched his body and removed the lighter which was inside his brief. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 201.29(c) Resident rights 395446 Page 2 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to provide written notice, including reason for transfer before a resident's room was changed for one of 20 residents reviewed (Residents R77). Findings Include: A review of facility policy titled, Room Change Notification dated February 2021, indicated that the facility must contact the resident/ resident representative when a room change is being considered and must document the reason for room change. Review of Resident R77's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated November 13, 2023, revealed Resident R77 was admitted to the facility on [DATE]. Continued review of Resident's MDS revealed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment; and had a POA (a power of attorney). Review of facility investigation dated July 2, 2023, revealed that Resident R77 was moved to another room after a resident-to-resident altercation. Interview conducted with the Social Worker, Employee E11, on January 18, 2024, revealed that a written notice, including reason for Resident R77's room change, was not provided to the resident and resident representative. Further interview revealed that the facility did not have a procedure in place regarding providing resident representatives with a written notice, including reason for transfer before a resident's room was changed. Interview with the Director of Nursing on January 22, 2024, at 11:57 a.m. confirmed the above-mentioned findings and that the resident and resident's representative should have been notified with a written notice. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(d) Resident rights 29 Pa. Code 201.29(j) Resident rights 395446 Page 3 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel records, interviews with staff and reviews of facility policies and procedures, it was determined that the facility failed to initiate and complete a federal criminal background check four of six employee records reviewed (Employees E14, E16, E21, and E22) and failed to initiate and complete abuse training for one of six employee records (Employee E22). Residents Affected - Few Finding include: A review of the policy titled Abuse, Neglect and Misappropriation the facility strives to reduce the risk of resident abuse, neglect, and misappropriation. The policy also indicated that Potential employees are screened for a history of abuse, neglect, or mistreatment of residents. Screening will consist of, but may not be limited to, inquiry to state licensing authorities if applicable, inquiry into state nurse registry, references checks and criminal background checks. A review of personnel files revealed Employee E14, nurse aide was hired on December 13, 2023; Employee E16, Licensed nurse, was hired on October 10, 2023; Employee E21, nursing aide, was hired on December 15, 2023, and Employee E22, licensed nurse, was hired on November 30, 2023. Personnel records revealed that these employees were hired without documented criminal background checks initiated or completed prior to hire. A review of the Employee E22 license nurse personnel record revealed that this employee was hired without abuse training. Interview with the Director of Nursing, Employee E2, at 3:07 p.m., on January 22, 2024, confirmed the lack of documentation to indicate that a federal criminal background check and abuse training had not been done for Employees E14, E16, E21, and E22 as part of the screening process for newly hired employees. 28 Pa. Code 201.18(b)(1)(3)(d) Management 28 Pa. Code 201.19(8)(9)(10) Personnel policies and procedures 28 Pa. Code 201.29(a)(b)(c)(c.3) Resident rights 395446 Page 4 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for two of 20 residents reviewed (Resident R77 and R30). Findings include: Review of Resident R77's clinical record revealed that the resident was transferred to the hospital on July 2, 2023, after a resident-to-resident altercation which occurred on July 2, 2023. Further review of Resident R77's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to Resident R77's responsible party and the Office of the State Long-Term Ombudsman. Review of Resident R30's clinical record revealed that the resident was transferred to the hospital on April 12, 2023, related to change in condition. Further review of Resident R30's clinical record failed to reveal documented evidence of a written hospital transfer notice provided by the facility to Resident R30's responsible party and the Office of the State Long-Term Ombudsman. Interview with the Director of Nursing, Employee E2, on January 18, 2024, at 3:38 p.m. confirmed that Residents R77 and R30 representatives were not notified in writing of the reasons for the transfer, and in a language and manner they understood. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights 395446 Page 5 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for two of 20 residents reviewed. (Resident R77 and R30) Findings include: Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R77 dated November 13, 2023, revealed Resident R77 was admitted to the facility on [DATE]. Continued review of Resident's MDS revealed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment; and had a POA (a power of attorney). Review of Resident R77's clinical record revealed that the resident was transferred to the hospital on July 2, 2023, after a resident-to-resident altercation which occurred on July 2, 2023. Further review of Resident R77's clinical record revealed that there was no documented evidence that resident's representative was provided a written notice of the facility bed-hold policy at the time of the resident's facility-initiated transfer to the hospital. Review of Resident R30's MDS dated [DATE], revealed Resident R30 was admitted to the facility on [DATE]. Continued review of Resident's MDS revealed a BIMS (Brief Interview for Mental Status) score of 99, indicating severe cognitive impairment. Review of Resident R30's clinical record revealed that the resident was transferred to the hospital on April 12, 2023, related to change in condition. Further review of Resident R30's clinical record revealed that there was no documented evidence that the resident's representative was provided a written notice of the facility bed-hold policy at the time of the resident's facility-initiated transfer to the hospital. Interview with the Director of Nursing, Employee E2, on January 18, 2024, at 3:38 p.m. confirmed that the Resident representatives for both, Residents R77 and R30, were not provided with the bed hold policy upon transfer. 28 Pa Code 201.14(a) Responsibility of licensee 395446 Page 6 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that the State mental health authority and/or the State intellectual disability authority was notified of a significant change in resident's mental health status which required admission into a psychiatric facility for 2 out of 22 residents reviewed (Resident R197 and Resident R85). Findings include: Review of the June 2023 physician orders for Resident R197 include the following diagnosis: chronic kidney disease (a gradual loss of kidney function over time); hypertension (high blood pressure); diabetes (a disease that occurs when your blood sugar, is too high) intellectual disabilities (a term for when a person has limited mental abilities and skills for daily life), and schizophrenia (a mental disorder in which people interpret reality abnormally). Review of a nursing note dated April 10, 2023 at 10:44 p.m. revealed that Resident R197 was hospitalized and sent out for changes in her behavior and escalated aggression. Resident R197 was subsequently admitted into a psychiatric treatment facility and was readmitted into the facility on May 11, 2023. Review of the resident's clinical record did not show evidence that the facility notified the State mental health authority and/or the State intellectual disability authority regarding the resident's change in the mental status, and her admission into the psychiatric treatment facility. During an interview with the Director of Social Worker, Employee E11 on January 22, 2024 at 2:32 p.m. it was confirmed that there was no information to produce to show evidence that the facility notified that State mental health authority and/or the State intellectual disability authority regarding the resident's change in mental condition and her admission into a psychiatric treatment facility. Review of the January 2024 physician orders for Resident R85 included the diagnoses of congestive heart failure (a long-term condition in which an individual's heart can't pump blood well enough to meet their body's needs); alcohol abuse; bipolar disorder (a mental illness that causes extreme mood swings, from high to low, that affect your energy, thinking, and behavior). Review of a nursing note dated June 20, 2023 at 4:38 p.m. documented that Resident R85 was sent out to the hospital due to change in mental status and aggressive behaviors. Review of a nursing note dated June 21, 2023 at 7:24 p.m. documented that the resident was admitted into a psychiatric treatment facility for aggressive behaviors and paranoia. Continued review of the nursing notes indicated that Resident R85 was readmitted into the facility on July 5, 2023. During an interview with the Director of Social Worker (Employee E11) on January 18, 2024, at 10:46 a.m. it was confirmed that there was no information to produce to show evidence that the facility notified that State mental health authority and/or the State intellectual disability authority regarding the resident's change in mental status and his admission into a psychiatric treatment facility. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 395446 Page 7 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, observations, facility policies and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for Resident R27 with documented history of behavioral issues and suicidal ideation to prevent resident access to potentially hazardous materials. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident which placed Resident R27 and the other residents at risk for serious harm and resulted in immediate jeopardy situation. One of 25 residents reviewed. (Resident R27). Findings Include: Review of a facility policy Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, dated September 2023, revealed that The facility shall support that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Managing risk factors to the extent possible or indicating the limits of such interventions. Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. Applying current standards of practice in the care planning process. Evaluating treatment of measurable objectives, timetables and outcomes of care. Respecting the resident's right to choose to decline treatment, request treatment or discontinue treatment. Review of an undated facility policy Suicidal Ideation Identification and Guidance revealed that Evaluate resident environment for safety; remove and store objects which could be used for self-harm. Objects to consider for removal may include but not be limited to: a. Ligatures - belts, neckties, call light cords, shower hose, oxygen tubing, tube feeding tubing, IV tubing, cables to the TV or other electronics, wire coat hangers etc. b. Sharp objects such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. c. Personal care supplies that may be poisonous if ingested 395446 Page 8 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0656 d. Level of Harm - Immediate jeopardy to resident health or safety Educate resident/resident representatives about reviewing new personal items with staff upon receipt in facility. Residents Affected - Few When the resident has been deemed safe and enhanced monitoring is no longer required; if the resident is ambulatory, regardless of the mode of ambulation, throughout the facility, the following prevention activities shall occur: a. Educate staff to continue to confirm location and well-being during routine care rounds, b. Educate staff regarding security of sharps, medications, hazardous chemicals, or other potentially dangerous objects in the facility, c. Educate staff regarding the locking of storage closets, monitoring and removing any hazardous objects on carts in patient care areas, shower rooms, or other rooms utilized by residents, and d. Management rounds to observe for compliance to prevention activities. When the resident has been deemed safe and enhanced monitoring is no longer required, if the resident is non-ambulatory, the following prevention activities shall occur: a. Care plan interventions updated and implemented, b. Management rounds to observe for compliance to prevention activities. Emergency Services or inpatient psychiatric stay should be utilized as appropriate. Contact the National Suicide Prevention Lifeline for additional assistance, if indicated. Review PASRR for accuracy and submit for review if required for changes. Update care plan and [NAME] if needed, communicate changes to staff. Review of Resident R27's clinical record revealed that the resident was admitted to the facility with diagnosis including schizoaffective disorder, severe intellectual disabilities, suicidal ideations, and auditory hallucinations. 395446 Page 9 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of MDS (Minimum Data Set-Assessment of Resident care Needs) for Resident R27 dated November 27, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9 which indicated that the cognitive status of the resident was moderately impaired. MDS mood assessment indicated that the resident sometimes had social isolation. Review of care plan for Resident R27 dated August 25, 2023, revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times, Review of hospital record for Resident R27 dated August 5, 2023, revealed that the resident was hospitalized for homicidal ideation and resident was on 1:1 monitoring and followed by video monitoring in the hospital. Resident was admitted as involuntary 305 admission (A 305 hearing also requires the treating psychiatrist to testify about the consumer's mental health status, at which time the mental health review officer can order treatment for a period not to exceed an additional 180 days). Resident had been hospitalized 24 times for 302 admissions (An involuntary commitment is an application for emergency evaluation and treatment for persons who are a danger to themselves or others due to a mental illness) since 1999 and have ongoing suicidal ideation and homicidal ideation. Review of a psychiatric progress note dated October 9, 2023, revealed that Currently patient presents as concrete and repetitive. Related to the altercation, patient states There was a dog and cat fight to describe the incident. They was talking about me and I don't like it- there was a dog and cat fight- I threw a bottle of soda on her Focus of encounter on emphasizing concrete, simple coping strategies; pt encouraged to back away from confrontations and ask for help from staff nearby if she feels that she might get into an argument with a peer. Review of progress note for Resident R27 dated October 9, 2023, revealed that the resident threw a bottle of soda at a female resident when the other resident asked her to move from the table. Review of progress note for Resident R27 dated October 28, 2023, at 8:51 p.m. revealed that the resident was wheeling up and down the hallway, very angry, resident then started banging her head and hand on the fire extinguisher door. Staff was able to calm the resident down. Resident then went to the dining area and started throwing the glass vases on the floor. Review of progress note for Resident R27 dated October 28, 2023, at 9:55 p.m. revealed that the resident continued with destructive behaviors. After breaking the glass vases, she flipped over the treatment cart. Review of progress note for Resident R27 dated November 29, 2023, revealed that the resident threw a plastic bag with items in it at another female resident. Resident was separated and placed on 1:1 supervision. Resident stated she heard voices from her mother and threw the plastic bag in the air. Review of a psychiatric progress note dated December 7, 2023, revealed that the resident was Patient seen today for suicidal ideation statements. She is seen sitting in her wheelchair. Patient reports [a male resident] and everyone else gets more attention than me, I want more attention, I am going 395446 Page 10 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to commit suicide. When asked if she had a plan, she said no. She was calm, pleasant and cooperative for exam, she was jovial and said her moods have been okay since last visit. She denies auditory hallucinations but can be heard having conversations with herself sometimes. She states, I just talk to myself and talk to the sky. She has disorganized thinking, labile moods. No delusions or paranoia. Does not appear to be a threat to self or others at this time. Emotional support provided. Followed by Psychology. Plan included, - Monitor for worsening behaviors or self-harm behaviors. -Does not appear to be a threat to self or others at this time. -Monitor/document changes in mood/behavior to assist with psychotropic med management. -Monitor for s/s of threatening or suicidal behaviors or actions. -Plastic silverware for precaution. -No long cords in room. -Offer emotional support. -Continue to utilize nonpharmacologic interventions, supportive care when needed. -Redirect and reorient. Observation of the resident on January 17, 2024, at 11:25 a.m. on the second-floor dining room revealed that Resident R27 was screaming and swinging a blue razor at surround residents. It was observed that there were other residents within 2-3 feet of the resident while she was swinging the resident. There were approximately 10 residents nearby resident. Interview with Employee E23, Nursing assistant, on January 17, 2024, at 11:25 a.m. stated that the resident should not be having a razor and that she must have taken it off the cart. Employee E23 stated sometimes she holds utensils in her hands says I got weapons. Employee E23 stated the razors were kept in the medication cart or in the locked supply room. Interview with Employee E24, Licensed Practical Nurse, on January 17, 2024, at 11:45 a.m. stated resident steals a lot, and she did not know [NAME] resident got hold of that razor. Employee E24 stated resident should only get plasticware for meals. Observation of second floor medication cart 2 revealed that there was unopened twin blade razor, similar razor, Resident R27 observed swinging, in the cart. Observation of the second-floor supply room revealed that the room was unlocked with a broken keypad lock. There were resident care supplies inside the room. Interview with Employee E2, Director of Nursing, on January 17, 2024, at 1:44 p.m. stated resident had a history of hoarding, she clutches all kind of items, such as spoons. She had a history of suicidal ideation. Employee E2 stated resident shows the items and says she uses as a weapon; she swings the fork and anything she gets. An interview with Resident R27 was attempted on January 17, 2024, at 12:00 p.m., resident was observed visibly upset and was saying things to herself. It was not clear what she was saying but could hear repeatedly saying weapon, that is my weapon. Review of care plan for Resident R27 dated August 25, 2023, revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times. 395446 Page 11 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Further review of resident care plan revealed no evidence that the resident's care plan interventions included measures such as evaluation of resident environment for safety and removal of objects which could be used for self-harm. Care plan interventions did not include psychiatric recommendation of no long cord in the room. Continued review of resident's care plan revealed that the care plan did not include interventions to prevent resident access to hazardous materials such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. Review of Resident R27's care plan also revealed that the care plan interventions did not include interventions to prevent resident-to-resident altercations including physical aggression towards other residents. Interview with Employee E2, Director of Nursing, on January 17, 2024, at 3:19 p.m. stated resident was swinging an unused razor which should have kept in the locked treatment cart. When asked Resident R27 was saying she got it off the cart. Employee E2 also facility did not know how resident got the razor and Resident R27 should not have anything sharp or hazardous materials due to her behavior and history. Employee E2 confirmed that resident's care plan interventions for suicidal ideation and aggressive behavior only included providing plastic utensils and did not include interventions to prevent resident access to hazardous materials such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. Interview with Director of Nursing and Administrator on January 17, 2024, at 3:39 p.m. stated residents with diagnosis of dementia, behavioral aggression or suicidal ideation should not have access to hazardous material such as razors or sharp objects and residents plan of care should reflect such interventions. Review of facility record revealed that there were 30 residents with diagnosis of dementia on second floor. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 17, 2024, at 5:35 p.m. for the facility's failure to develop and implement a comprehensive person-centered care plan for Resident R27 with documented history of behavioral issues and suicidal ideation to prevent resident access to potentially hazardous materials. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident which placed Resident R27 and the other residents at risk for serious harm, An IJ Template was presented to the facility on January 17, 2024 at 5:35 p.m The facility submitted a written plan of action on January 17, 2024, at 9:00 p.m. and implemented the plan of action which included: 1. Staff removed the razor from Resident R27 and was immediately placed on 1:1 supervision. Staff performing 1:1 supervision will be trained by the Administrator or designee regarding their responsibilities and documentation requirements prior to: starting their 1:1 assignment. The Interdisciplinary care plan team will review the care plan for R27 and update to ensure interventions to prevent. the resident from obtaining sharp objects, medications, hazardous chemicals, and other potentially 395446 Page 12 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few dangerous objects. This update will include any additional recommendations from the Behavioral Health Services Consultant. Date of completion will be 1/17/2024. 2. The Interdisciplinary care plan team will audit the diagnosis, care plans, incident reports, admission records, and behavior health notes to identify any resident at risk. Any identified resident will have their care plan updated to ensure interventions to prevent the resident from obtaining sharp objects, medications, 3. Administrator or designee will educate staff about the care plan interventions to prevent residents from obtaining sharp objects, medications, hazardous, chemicals, and other potentially dangerous objects. Staff will be educated before the start of their shift. Date of completion with 90% done by 1/18 and 100% by 1/24/2024. 4. IDT Team will conduct an audit of resident care plans who were identified as suicidal ideation and behavioral concerns to ensure care plans are updated and interventions are implemented to prevent the residents from obtaining sharp objects, medications, hazardous chemicals, and other potentially dangerous materials. Initial audit today, then weekly x 4, then monthly x 4. On January 18, 2024, at 5:40 p.m. the action plan was reviewed, observation was made of all nursing units, janitors closet and housekeeping carts, medication and treatment carts, interviews were conducted with staff to confirm that the in-service education was completed. Resident records and facility audits were reviewed to ensure care plan was updated. The NHA was notified that the I.J. was lifted on January 18, 2024, at 5:40 p.m. The Immediate Jeopardy was abated, and the scope/severity was lowered to an E. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management 395446 Page 13 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that a care plan was updated related to nutrition for one of two residents reviewed (Resident R30). Residents Affected - Few Findings include: Review of Resident R30's weight records indicated that on July 7, 2023, the resident weighed 105 pounds. On December 7, 2023, the resident weighed 93 pounds; indicating a 11.43% weight loss in five months. Review of physician orders revealed multiple orders for nutritional supplements, including Boost Plus; Prostat; and Magic Cup. Further review revealed Resident R30 was ordered a regular diet on May 5, 2023; regular texture, and regular (thin) consistency liquids. Review of nutrition notes revealed a note dated, December 15, 2023, which indicated that Resident R30's representative was aware of resident's weight loss and suggested that Resident R20 likes to have finger foods like sandwiches and rolls including chicken in a roll, peanut butter sandwiches, or ham sandwiches to prevent further weight loss. Review of Resident R30's current care plan, date-initiated February 14, 2023, revealed that the resident had a nutritional problem related to weight loss. Continued review revealed no indication that the resident preferred finger foods, including sandwiches and rolls as weight loss intervention. Lunch observations on Wednesday January 17, 2023, at approximately 1:00 p.m. revealed Resident R30 received beef stew with rice on his lunch tray. Interview with the Registered Dietitian, Employee E17, on January 22, 2024, at 9:05 a.m. confirmed that Resident R30's care plan was not updated to include resident preferences to aid in residents severe weight loss. 28 Pa Code 211.12(d)(3) Nursing services 395446 Page 14 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on the review of facility immediate jeopardy action plan, clinical records, facility policies, observations and interview with staff and residents, it was revealed that the facility failed to ensure that a resident received a care and services in accordance with the comprehensive person-centered care plan and facility immediate jeopardy action plan. (Resident R27) Residents Affected - Few Findings Include: Review of an undated facility policy Suicidal Ideation Identification and Guidance revealed that Evaluate resident environment for safety; remove and store objects which could be used for self-harm. Objects to consider for removal may include but not be limited to: a. Ligatures - belts, neckties, call light cords, shower hose, oxygen tubing, tube feeding tubing, IV tubing, cables to the TV or other electronics, wire coat hangers etc. b. Sharp objects such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. c. Personal care supplies that may be poisonous if ingested d. Educate resident/resident representatives about reviewing new personal items with staff upon receipt in facility. When the resident has been deemed safe and enhanced monitoring is no longer required; if the resident is ambulatory, regardless of the mode of ambulation, throughout the facility, the following prevention activities shall occur: a. Educate staff to continue to confirm location and well-being during routine care rounds, b. Educate staff regarding security of sharps, medications, hazardous chemicals, or other potentially dangerous objects in the facility, c. Educate staff regarding the locking of storage closets, monitoring and removing any hazardous objects on carts in patient care areas, shower rooms, or other rooms utilized by residents, and 395446 Page 15 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0684 d. Level of Harm - Minimal harm or potential for actual harm Management rounds to observe for compliance to prevention activities. Residents Affected - Few Review of Resident R27's clinical record revealed that the resident was admitted to the facility with diagnosis including schizoaffective disorder, severe intellectual disabilities, suicidal ideations, and auditory hallucinations. Review of MDS (Minimum Data Set-Assessment of Resident care Needs) for Resident R27 dated November 27, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9 which indicated that the cognitive status of the resident was moderately impaired. MDS mood assessment indicated that the resident sometimes had social isolation. Review of care plan for Resident R27 dated August 25, 2023, revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times, Review of care plan for Resident R27 updated on January 17, 2024, revealed that ensure that all hazardous materials such as sharp objects, medication, hazardous chemicals and or other potentially dangerous objects are stored in appropriate place in the facility. Provide plastic utensils with meals at all times. Resident placed on 1:1 immediately. Review of the facility plan of action dated January 17, 2024, at 9:00 p.m. revealed that Staff removed the razor from Resident R27 and was immediately placed on 1:1 supervision. Staff performing 1:1 supervision will be trained by the Administrator or designee regarding their / responsibilities and documentation requirements prior to starting their 1:1 assignment. The Interdisciplinary care plan team will review the care plan for R27 and update to ensure interventions to prevent the resident from obtaining sharp objects, medications, hazardous chemicals and other potentially dangerous objects. This update will include any additional recommendations from the Behavioral Health Services Consultant. Facility wide sweep was completed by 6pm on 1/17/2024 and all hazardous material was removed. All medication carts, housekeeping lacks check, and medication rooms were checked and secured effective today 1/17/2024 Date of completion will be 1/17/2024. Observation of second floor dining room on January 22, 2024, at 12:45 p.m. revealed that the Resident R27 was holding a metal fork in a fist. It was observed that Employee E23, Nurse Aide, was trying to remove it from resident's hand the resident was not letting the staff take. Eventually staff was able to remove the fork from resident's hand. Further observation revealed that the lunch tray for Resident R27 was on the table with a metal spoon on the tray. Interview with Employee E20, Licensed Nurse, on January 22, 2024, at 12:56 p.m. stated resident was on a 1:1 with a Nursing Assistant. Another staff who passed out the tray did not check the tray to ensure that the resident only received plastic utensils. Employee E20 also confirmed that the kitchen sent metal utensil instead of plastic utensils. 395446 Page 16 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0684 Level of Harm - Minimal harm or potential for actual harm Interview with Nursing Home Administrator and Director of Nursing on January 22, 2024, at 1:30 p.m., stated kitchen did not follow Resident R27's care plan for no metal utensils for safety and staff who passed the lunch tray for Resident R27 on January 22, 2024, did not ensure that the resident only received plastic utensils. Residents Affected - Few 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 395446 Page 17 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, observations, facility policies and interview with staff, it was determined that the facility failed to ensure that resident's environments were free of accident hazards, and failed to ensure that hazardous materials were not accessible to residents in one nursing unit. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident. The facility's failure placed Resident R27 who had a history of suicidal ideation and behavioral issues as well as other residents on the second floor at risk for serious injury and resulted in immediate jeopardy situation for one of 25 residents reviewed. (Resident R27). Findings Include: Review of an undated facility policy Suicidal Ideation Identification and Guidance revealed that Evaluate resident environment for safety; remove and store objects which could be used for self-harm. Objects to consider for removal may include but not be limited to: a. Ligatures - belts, neckties, call light cords, shower hose, oxygen tubing, tube feeding tubing, IV tubing, cables to the TV or other electronics, wire coat hangers etc. b. Sharp objects such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. c. Personal care supplies that may be poisonous if ingested d. Educate resident/resident representatives about reviewing new personal items with staff upon receipt in facility. When the resident has been deemed safe and enhanced monitoring is no longer required; if the resident is ambulatory, regardless of the mode of ambulation, throughout the facility, the following prevention activities shall occur: a. Educate staff to continue to confirm location and well-being during routine care rounds, b. Educate staff regarding security of sharps, medications, hazardous chemicals, or other potentially 395446 Page 18 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0689 dangerous objects in the facility, Level of Harm - Immediate jeopardy to resident health or safety c. Educate staff regarding the locking of storage closets, monitoring and removing any hazardous objects on carts in patient care areas, shower rooms, or other rooms utilized by residents, and Residents Affected - Few d. Management rounds to observe for compliance to prevention activities. Review of Resident R27's clinical record revealed that the resident was admitted to the facility with diagnoses including schizoaffective disorder, severe intellectual disabilities, suicidal ideations, and auditory hallucinations. Review of MDS (Minimum Data Set-Assessment of Resident care Needs) for Resident R27 dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9 which indicated that the cognitive status of the resident was moderately impaired. MDS mood assessment indicated that the resident sometimes had social isolation. Review of care plan for Resident R27 dated [DATE], revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times. Review of hospital record for Resident R27 dated [DATE], revealed that the resident was hospitalized for homicidal ideation and resident was on 1:1 monitoring and followed by video monitoring in the hospital. Resident was admitted as involuntary 305 admission (A 305 hearing also requires the treating psychiatrist to testify about the consumer's mental health status, at which time the mental health review officer can order treatment for a period not to exceed an additional 180 days). Resident had been hospitalized 24 times for 302 admissions (An involuntary commitment is an application for emergency evaluation and treatment for persons who are a danger to themselves or others due to a mental illness) since 1999 and have ongoing suicidal ideation and homicidal ideation. Review of a psychiatric progress note dated [DATE] revealed that Patient referred for assessment of mood, adjustment; patient is a recent skilled nursing facility admission with a history of schizoaffective disorder, bipolar disorder, seizure disorder and intellectual disability. Per staff, patient has been restless, indicating periods of confusion since her admission, has made statements about not having regular silverware so she won't hurt herself. Facility is giving pt plastic silverware as a precaution. Patient is on paired care as a precaution. Staff describe other unusual behavior such as dancing about the hall. Currently pt presents as hypomanic, somewhat disorganized, difficulty articulating/word-find during interview; has difficulty giving information related to psychosocial history. Patient denies depression, states she was previously in a psych hospital stay but was unable to provide details. Denies suicidal ideation currently. States she is anxious because I don't have my belongings-I don't have any clothes. Reports auditory hallucinations I hear my mother talking to me 395446 Page 19 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0689 Level of Harm - Immediate jeopardy to resident health or safety from outside the window Does not answer questions about the nature of hallucinations or whether the voices are giving her instructions or if they cause her to feel distressed. Focus of encounter on fostering therapeutic rapport and setting goals. Plan included, Suggest staff maintain high degree of routine and structure as able while patient adjusts to skilled nursing facility placement; redirect when anxious or irritable; continue to use plastic silverware and paired care as precautionary measures; maintain supportive and encouraging response. Residents Affected - Few Review of a psychiatric progress note dated [DATE]. revealed that History of threating statements, history of multiple suicidal ideation and homicidal ideation and attempts of oral ingestions, running into traffic, behaviors of placing knives to throat. Resident had auditory hallucinations and history of visual hallucinations. Plan included Monitor/document changes in mood/behavior to assist with psychotropic medication management. Monitor for signs and symptoms of threatening or suicidal behaviors or actions. Plastic silverware for precaution. Review of a psychiatric progress note dated [DATE], revealed that Currently patient presents as disorganized, mildly anxious. States I been hearing and seeing things in my mind- I see my father and he talks to me and he is dead- it's scary sometimes and I see my mother too- she holds a scary doll- I want some rubber snakes and a plastic knife with blood on it for Halloween to scare everybody- I need some guy-ish clothes and some girlish clothes. Focus of encounter on concrete coping strategies to deal with anxiety of seeing her deceased parents. Patient denies thoughts of self-harm. Review of a psychiatric progress note dated [DATE], revealed that Currently engages, endorses anxious thoughts, confusion, possible delusions; is perseverating about weapons, knives, using forks as weapons and Halloween. Is repetitive I turned in all my weapons my knives I hid in my pockets, I turned it in- I would never hurt anybody - I like Halloween. States He called my mother a bitch- my mother died- I went to the funeral but I couldn't send her off at the cemetery- the cemetery gives me the creeps- I am scared of that Focus of encounter on concrete strategies to reduce anxiety and fear; pt encouraged to focus on the positivity and safety that is around her and encouraged to know she does not have to think about things that frighten her. Review of a psychiatric progress note dated [DATE], revealed that Currently patient presents as concrete and repetitive. Related to the altercation, patient states There was a dog and cat fight to describe the incident. They was talking about me and I don't like it- there was a dog and cat fight- I threw a bottle of soda on her Focus of encounter on emphasizing concrete, simple coping strategies; pt encouraged to back away from confrontations and ask for help from staff nearby if she feels that she might get into an argument with a peer. Review of progress note for Resident R27 dated [DATE], revealed that the resident threw a bottle of soda at a female resident when the other resident asked her to move from the table. Review of progress note for Resident R27 dated [DATE], at 8:51 p.m. revealed that the resident was wheeling up and down the hallway, very angry, resident then started banging her head and hand on the fire extinguisher door. Staff was able to calm the resident down. Resident then went to the dining area and started throwing the glass vases on the floor. Review of progress note for Resident R27 dated [DATE], at 9:55 p.m. revealed that the resident continued with destructive behaviors. After breaking the glass vases, she flipped over the treatment cart. 395446 Page 20 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of progress note for Resident R27 dated [DATE], revealed that the resident threw a plastic bag with items in it at another female resident. Resident was separated and placed on 1:1 supervision. Resident stated she heard voices from her mother and threw the plastic bag in the air. Review of a psychiatric progress note dated [DATE], revealed that the resident was Patient seen today for suicidal ideation statements. She is seen sitting in her wheelchair. Patient reports [male resident] and everyone else gets more attention than me, I want more attention, I am going to commit suicide. When asked if she had a plan, she said no. She was calm, pleasant and cooperative for exam, she was jovial and said her moods have been okay since last visit. She denies auditory hallucinations, but can be heard having conversations with herself sometimes. She states, I just talk to myself and talk to the sky. She has disorganized thinking, labile moods. No delusions or paranoia. Does not appear to be a threat to self or others at this time. Emotional support provided. Followed by Psychology. Plan included, - Monitor for worsening behaviors or self-harm behaviors. -Does not appear to be a threat to self or others at this time. -Monitor/document changes in mood/behavior to assist with psychotropic med management. -Monitor for s/s of threatening or suicidal behaviors or actions. -Plastic silverware for precaution. -No long cords in room. -Offer emotional support. -Continue to utilize nonpharmacologic interventions, supportive care when needed. -Redirect and reorient as needed. -Encourage socializing and activities to support mood and cognition. Review of progress note for Resident R27 dated [DATE], revealed that the nursing assistant asked the resident to go back to her room, resident got mad at the nursing assistant and threw a bag at her and threw the Christmas tree down. Resident stated I am mad at her. Review of progress note for Resident R27 dated [DATE], revealed that the resident was seen in the dining area waving a razor around hollering. Staff removed the razor from the resident's hand and redirected her. A search of the resident's belonging were completed to see if resident had anymore weapons no other weapons observed. Observation of the resident on [DATE], at 11:25 a.m. on the second-floor dining room revealed that Resident R27 was screaming and swinging a blue razor at surrounding residents. It was observed that there were other residents within 2-3 feet of the resident while she was swinging the razor. There were approximately 10 residents nearby resident. Interview with Employee E23, Nursing assistant, on [DATE], at 11:25 a.m. stated that the resident should not be having a razor and that she must have taken it off the cart. Employee E23 stated sometimes she holds utensils in her hands says I got weapons. Employee E23 stated the razors were kept in the medication cart or in the locked supply room. Interview with Employee E24, Licensed Practical Nurse, on [DATE], at 11:45 a.m. stated resident steals a lot, and she did not know how resident got hold of that razor. Employee E24 stated resident should only get plasticware for meals. Observation of second floor medication cart 2 revealed that there was unopened twin blade razor, similar razor, Resident R27 observed swinging, in the cart. Observation of the second-floor supply room revealed that the room was unlocked with a broken keypad lock. There were resident care supplies inside the room. Interview with Employee E2, Director of Nursing, on [DATE], at 1:44 p.m. stated resident had a 395446 Page 21 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few history of hoarding, she clutches all kind of items, such as spoons. She had a history of suicidal ideation. Employee E2 stated resident shows the items and says she uses as a weapon; she swings the fork and anything she gets. An interview with Resident R27 was attempted on [DATE], at 12:00 p.m., resident was observed visibly upset and was saying things to herself. It was not clear what she was saying but could hear repeatedly saying weapon, that is my weapon. Interview with Employee E2, Director of Nursing, on [DATE], at 3:19 p.m. stated resident was swinging an unused razor which should have kept in the locked treatment cart. When asked Resident R27 was saying she got it off the cart. Resident R27 also stated she feels she has a right to hold it. Employee E2 stated possibly she got it off the cart. Employee E2 also facility did not know how resident got the razor and Resident R27 should not have anything sharp or hazardous materials due to her behavior and history. Review of facility audit report dated [DATE] revealed that the facility found 3 razors and 2 nail clippers unsecured from second floor resident rooms which were removed to securely label and store. Interview with Director of Nursing and Administrator on [DATE], at 3:39 p.m. stated residents with diagnosis of dementia, behavioral aggression or suicidal ideation should not have access to hazardous material such as razors or sharp objects. Review of facility record revealed that there were 30 residents with diagnosis of dementia on second floor. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 5:35 p.m. for the facility's failure to ensure resident's environment were free of accident hazards and failed to ensure that hazardous materials were not accessible to residents in one nursing unit. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident. The facility's failure placed Resident R27 who had a history of suicidal ideation and behavioral issues as well as other residents on the second floor at risk for serious injury. An IJ Template was presented to the facility on [DATE] at 5:35 p.m The facility submitted a written plan of action on [DATE], at 9:00 p.m. and implemented the plan of action which included: 1. Staff removed the razor from Resident R27 and was immediately placed on 1:1 supervision. Staff performing 1:1 supervision will be trained by the Administrator or designee regarding their / responsibilities and documentation requirements prior to starting their 1:1 assignment. The Interdisciplinary care plan team will review the care plan for R27 and update to ensure interventions to prevent the resident from obtaining sharp objects, medications, hazardous chemicals and other potentially dangerous objects. This update will include any additional recommendations from the Behavioral Health Services Consultant. Facility wide sweep was completed by 6pm on [DATE] and all hazardous material was removed. All medication carts, housekeeping locks check, and medication rooms were checked and secured effective today [DATE] Date of completion will be [DATE]. 2. The Interdisciplinary care plan team will audit the diagnosis, care plans, incident reports, admission records, and behavior health notes to identify any resident at risk: Any identified resident 395446 Page 22 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0689 Level of Harm - Immediate jeopardy to resident health or safety will have their care plan updated to ensure interventions to prevent the resident from obtaining sharp objects, medications, hazardous chemicals, and other potentially dangerous objects. Initial audit today, then weekly x4, then monthly x 4. Date of completion will be [DATE]. 3. Administrator or designee will educate staff about the care plan interventions to prevent residents from obtaining sharp objects, medications, hazardous, chemicals, and other potentially dangerous objects. Residents Affected - Few 4. Administrator, DON, and designee will conduct an inspection of the facility medication rooms, storage rooms, all carts, and remote storage rooms to identify any carts or storage areas that are not secured or have potentially hazardous materials not secured. Any room or cart identified as not being secure will be corrected immediately Initial audit today, then weekly x4, then monthly x 4. Date of completion with 90% done by 1/18 and 100% by [DATE]. 5. Administrator and DON will update the Facility Policy regarding the securing of sharp objects medications, hazardous chemicals, and other potentially dangerous objects. All staff will be educated on the new policies and procedures. Date of completion with 90% done by 1/19 and 100% by [DATE]. On [DATE], at 5:40 p.m. the action plan was reviewed, observation was made of all nursing units, janitors closet and housekeeping carts, medication and treatment carts, interviews were conducted with staff to confirm that the in-service education was completed. The NHA was notified that the I.J. was lifted on [DATE], at 5:40 p.m. The Immediate Jeopardy was abated, and the scope/severity was lowered to an E. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management 395446 Page 23 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record, and staff interview, it was determined that the facility failed to ensure the one of one resident ordered enteral feeding was properly position during care to prevent potential complications associated with tube feedings (Resident 47). Findings include: Review of Resident R30's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphasia (language disorder that affects the ability to produce and understand spoken language), hemiplegia (paralysis of one side of the body), and aphasia (comprehension ad communication disorder). Review of physician order dated December 21, 2023, revealed an Enteral feed order: Glucerna 1.2 Cal. Continuous via tube to infuse at a rate of 60 mL/hr. total volume of 1320 mL infused in 24 hours. May turn off for care/services . Observations conducted on January 17, 2024, at 11:54 a.m. reveled Nurse Aide, Employee E18 was providing care (bed bath) for Resident R47. Further observations revealed Resident R47 was in the Trendelenburg position (feet raised higher than their head causing the abdominal organs to move towards the head) while the continuous tube feeding was infusing at a rate of 60 mL/hr., with a total noted volume of 1320 ml. Nurse aide, Employee E18 confirmed the observation and reported that she should have asked the nurse to stop the tube feeding before she provided Resident R47 with a bed bath. Interview with the Director of Nursing, Employee E2, on January 22, 2024, at 10:58 a.m. confirmed that the continuous tube feeding should have been stopped by a qualified nurse before providing a bed bath to Resident R30 to prevent the risk of aspiration. 28 Pa. Code 211.12 (d)(1)(5) Nursing services 395446 Page 24 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of clinical record and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for one of 22 residents reviewed (Residents R61). Residents Affected - Few Findings include: Review of Resident R61's clinical record revealed the resident was diagnosed with tracheostomy status (procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Review of Resident R61's physician's orders dated March 29, 2023, revealed the tracheostomy size 6. Humidified Oxygen Per trach PRN (as needed) 2 liters. Change trach collar, mask, and oxygen weekly as well as PRN. Further review of Resident's R61's clinical record revealed a physician's assessment and plan dated on December 5, 2023, to start trach mask with humidifier. Observation of Resident R61 conducted on January 22, 2024, at 9:35 a.m. revealed that the trach /oxygen nasal cannula to the oxygen concentrator did not have a date affixed. Extra 6.5 and 7 tracheostomy was observed in the trach care station in resident's room. Resident R61 didn't have an oxygen concentrator and there was none the by resident's bedside. Interview with Resident R61 on January 22, 2024, at 9:45 a.m. revealed that she was not getting trach/ oxygen care at night. During observation, an interview was conducted with 1st floor unit manger, Registered nurse, Employee E12, in Resident's R61 room on January 22, 2024, at 10:08 a.m. confirmed that tubing was not dated, extra trach was wrong sizes and no oxygen was present by resident bedside as ordered by the physician. During interview with the 1st floor unit manger, Registered nurse, Employee E12, it was revealed and confirmed on January 22, 2024, at 11:29 a.m. that staff didn't clarify physician orders regarding the resident's respiratory care. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395446 Page 25 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm The facility failed to ensure that performance reviews for nursing assistants were completed annually to ensure that in-service education was based on the outcomes of the performance reviews for 1 out of 3 nursing assistants reviewed (Employee E30) and failed to ensure the completion of 12 hours of inservice for 3 out of 3 nurse aides reviewed (Employee E30, E31 and E32). Residents Affected - Few Findings include: Review of the documentation provided from the facility revealed there was no annual performance evaluation for Employee E30. Review of training records for Employee E30, E31 and E32 did not show evidence that nurse aides were provided with 12 hours of training per year was conducted, as required. During an interview with the Director of Nursing on January 22 at 2:15 p.m. the Director of Nursing confirmed that she could not provide documentation to show evidence that the facility completed the required annual performance reviews for the above referenced nursing assistant, or the annual 12 hours of inservice training for the above referenced nursing assistants. 28. Pa. Code 201.19(d)(1) Personnel policies and procedures 395446 Page 26 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility policy, observation, review of clinical records, interview with staff and residents it was determined that the facility failed to ensure that medications were administered in accordance with professional standards for one of 25 residents reviewed. (Resident R56) Findings include: Review of facility policy on Medication Administration dated September 2018, revealed that Medications are administered as prescribed in accordance with manufacturers specification, good nursing principles, and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the prescriber. Review of physician order for Resident R56 dated September 8, 2023, revealed an order for Simethicone 80 (milligrams mg) tablet every 6 hours as needed for gas pain. Interview with Resident R56 on January 16, 2024, at 12:00 p.m., stated, she had stomach pain due to gas and she requested as needed medications to the nurse. She stated she requested the medication after the breakfast around 9:00 a.m. Resident also stated she asked the nursing assistant to let the nurse know to give her the medication, but she did not receive the medications yet. Interview with the Nursing Aide, Employee E33, on January 16, 2024, at 12:10 p.m., confirmed that the resident requested as needed gas pill to her. Employee E33 stated she informed the Unit Manager, Employee E26 who was on the medication cart at that time. Interview with the Unit Manager, Employee E26, on January 16, 2024, at 12:15 p.m., stated resident refused her regular medications in the morning but she was not aware of the request for gas pill. When asked if nursing assistant notified about Resident R56's request for medication, Employee E26 did not respond and stated she was busy and walked away. Review with the Medication Administration Record for Resident R56 for January 2024 revealed that the resident did not receive the medication until 1:58 p.m. on January 16, 2024. Interview with the Director of Nursing, Employee E2, on January 16, 2024, at 1:08 p.m., stated residents have the right to refuse medications and treatments. Residents could also request for as needed medications and staff was expected to administer the medications according to the symptoms, parameters and physician order. 28 Pa. Code 211.12(d)(1) Nursing services 395446 Page 27 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one of two medication carts and two of one medication storage rooms observed (first floor cart A and second floor medication storage room). Findings include: Review of facility policy Storage of Medication, dated [DATE], revealed that The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. Observation of the first-floor cart A with Employee E35, Licensed Practical Nurse, revealed that the medication cart contained undated and expired insulin. There were two insulin glargine pens without open date or discard dates. There were one Trulicity pen with an expiration date on [DATE]. Observation of the second-floor medication storage room on [DATE], at 2:49 p.m., revealed that the storage room was open. The door had an automatic closure device which did not close the door properly preventing it from locking automatically. Review of facility record revealed that there were 30 residents with diagnosis of dementia on Second floor. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code. 211.12(c) Nursing services 28 Pa. Code 211.12 (d)(1) Nursing services. 395446 Page 28 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: A review of facility policy titled, Policy and Procedure under the heading, Storage, indicated that refrigerators are equipped with thermometers and checked by staff daily to ensure maintaining temperature at or less than 41 degrees Fahrenheit (F) and freezer at or less than 10 degrees F. A review of policy titled, Storage dated 2021, indicated that the refrigerator thermometer should be placed in the warmest area in the refrigerator unit, near the door. A tour of the Food Service Department was conducted on January 16, 2024, at 11:13 a.m. with the Food Service Director (FSD), Employee E19. Observations in the pantry refrigerator revealed the following items were expired, dated January 14, 2024: pureed sweet potatoes, pureed turkey, mashed potatoes, and mushrooms. Further observations revealed A container of cooked eggs and pancakes were unlabeled and undated. Observations of the main reach in refrigerator revealed temperature felt warm inside. FSD, Employee E19, attempted to locate a thermometer which was stored away from the door, behind food boxes, and not readily accessible. Observations of the thermometer reading revealed a registered temperature of -40 degrees F. Further inspection of the thermometer revealed that the thermometer was cracked and not working accurately. Interview with the FSD at the time of the observation confirmed that observation and further revealed that the thermometer must have been broken for months. A temperature check was performed by the FSD on several items stored in the main reach-in refrigerator and revealed the following: Italian dressing registered at 50.1 degrees F; mayonnaise dressing at 53 degrees F; two salad plates registered at 50.1- and 53.4-degrees F; and liquid eggs at 49.8 degrees F. Interview with the FSD confirmed that the tested items were above the acceptable temperature and in the temperature danger zone. Observations in the dish machine area revealed grime, dust, and crumbs on top of the dish machine. Further observation revealed mold on walls and paint was observed peeling off the walls, leaving physical paint contaminants around clean dishware. Interview with the FSD, employee E19 on January 16, 2024, at approximately 11:47 a.m. confirmed the above-mentioned findings. 28 Pa. Code 201.14(a) Responsibility of licensee 395446 Page 29 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road 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 Based on review of facility records, job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that proper procedures were followed in the facility related to ensuring that hazardous materials were not accessible to residents in one nursing unit. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident. The facility's failure placed Resident R27 who had a history of suicidal ideation and behavioral issues as well as other residents on the second floor at risk for serious injury and resulted in immediate jeopardy situation. Residents Affected - Few Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed 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. Review of the job description for the Director of Nursing (DON) revealed that he Director of Nursing (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. ESSENTIAL DUTIES AND RESPONSIBILITIES (To be completed without harming or injuring the resident/patient, co-worker, self, or others): Participates in the Board of Managers reporting and responsibilities. Leads, organizes, evaluates, and manages nursing and clinical personnel through sound management practices and delegation. 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. Ensures compliance with applicable local, state, federal and other regulatory agencies and quality assurance standards, certifications and licensure requirements. Participates in the clinical admission process Attends regularly conducted staff meetings and participates regularly in continuing education 395446 Page 30 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0835 training programs Level of Harm - Minimal harm or potential for actual harm Handles on-call responsibilities as required. Residents Affected - Few Accountable for adherence by staff to policies, procedures and standards; delivery and proper documentation of patient care. Leads and manages the General and Restorative Nursing Services on a 24 hour basis to ensure the delivery of high quality comprehensive patient care Review of care plan for Resident R27 dated August 25, 2023, revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times, Review of hospital record for Resident R27 dated August 5, 2023, revealed that the resident was hospitalized for homicidal ideation and resident was on 1:1 monitoring and followed by video monitoring in the hospital. Resident was admitted as involuntary 305 admission (A 305 hearing also requires the treating psychiatrist to testify about the consumer's mental health status, at which time the mental health review officer can order treatment for a period not to exceed an additional 180 days). Resident had been hospitalized 24 times for 302 admissions (An involuntary commitment is an application for emergency evaluation and treatment for persons who are a danger to themselves or others due to a mental illness) since 1999 and have ongoing suicidal ideation and homicidal ideation. Review of progress note for Resident R27 dated January 17, 2024, revealed that the resident was seen in the dining area waving a razor around hollering. Staff remove the razor from the resident's hand and redirected her. A search of the resident's belonging were completed to see if resident had anymore weapons no other weapons observed. Observation of the resident on January 17, 2024, at 11:25 a.m. on the second-floor dining room revealed that Resident R27 was screaming and swinging a blue razor at surround residents. It was observed that there were other residents withing 2-3 feet of the resident while she was swinging the resident. There were approximately 10 residents nearby resident. Interview with Employee E23, Nursing assistant, on January17, 2024, at 11:25 a.m. stated that the resident should not be having a razor and that she must have taken it off the cart. Employee E23 stated sometimes she holds utensils in her hands says I got weapons. Employee E23 stated the razors were kept in the medication cart or in the locked supply room. Interview with Employee E24, Licensed Practical Nurse, on January17, 2024, at 11:45 a.m. stated resident steals a lot, and she did not know how resident got hold of that razor. Employee E24 stated resident should only get plasticware for meals. Interview with Employee E2, Director of Nursing, on January17, 2024, at 1:44 p.m. stated resident had a history of hoarding, she clutches all kind of items, such as spoons. She had a history of suicidal ideation. Employee E2 stated resident shows the items and says she uses as a weapon; she swings the fork and anything she gets. 395446 Page 31 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0835 Level of Harm - Minimal harm or potential for actual harm Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the Immediate Jeopardy situation. Refer to F689, F656 Residents Affected - Few 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.18(b)(3) Management 395446 Page 32 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices related to hand washing during medication administration for one 1 of 2 staff observations reviewed. (Resident R72) Residents Affected - Few Findings include: Review of facility policy on Medication Administration dated September 2018, revealed that Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parental, enteral, rectal, and vaginal medications. Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulation and facility policy. Note: Soap and water should be used after contact with resident with Clostridium difficile as microbial sanitizer does not kill the spores produced by Clostridium difficile, which may result in the spread of the infection. Observation of medication administration by Employee E35, Licensed Practical Nurse on January 22, 2024, at 9:22 a.m., revealed that Employee E35 had administered a medication to another resident prior to administering medication for Resident R76. Employee E76 did not wash her hands or sanitize her hand prior to administering medication for Resident R76. Further observation of the medication administration revealed that after administering medication for Resident R76, Employee E35 went to the med cart, picked up the medication cup to prepare medication for next resident. When asked Employee E35 stated she started preparing medications for the next resident. Employee E35 confirmed that she did not wash her hand after administering medication for Resident R76 and discarded the medication cup. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 395446 Page 33 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0908 Keep all essential equipment working safely. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, facility documentations, interviews with staff and resident, it was determined that the facility failed to ensure that patient care equipment was in a safe and operating condition related to shower chairs. This failure resulted in actual harm to Resident R87, who fell from the a shower chair which collapsed while the resident was taking a shower and sustaining an avulsion fracture of medial malleolus (the small prominent bone on the inner side of the ankle at the end of the tibia) and severe sprain of left ankle for one of 25 residents reviewed. (Resident R87) Residents Affected - Few Findings Include: Review of a facility policy Physical Environment, dated September 2023, revealed that A safe, clean, comfortable, and home-life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program. Review of Shower Chair manufactures recommendation dated December 29, 2022, revealed that Periodic visual inspection of this shower chair is recommended to ensure that all parts and hardware are secure, that components are in good working order and not worn, torn, frayed, or loose, and that there are no obstructions or impediments to normal, safe operation. If any part or mechanism appears to be unsafe or damaged, do not use the product. Review of clinical record for Resident R87 revealed that the resident was admitted to the facility on [DATE] with diagnoses including below knee amputation of right lower extremity, hypertension and charcot's (a rare and disabling disorder. It is a result of nerve damage to the feet) joint to left ankle and foot. Review of MDS (Minimum Data Set-Assessment of Resident care Needs) for Resident R87 dated November 10, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that the cognitive status of the resident was intact. Interview with Resident R87 on January 17, 2024, at 10:46 a.m., stated the shower chair collapsed and he fell to the floor when he was taking shower couple months ago. He stated he started taking shower and all the sudden the shower chair broke and fell to the floor. He stated went to the hospital and got a fracture to the leg and back pain. He stated at the moment he had a pain level of 8 out of 10 and the worst pain he experienced was 10. He stated he started taking Oxycontin (pain medication) after the fall. Resident stated he took pictures of the broken shower chair and showed the pictures. He stated staff did not assist him with shower or checked the shower chair prior to the incident. Review of the pictures provided by Resident R87 revealed that the shower chair was broken. The right side legs of the shower chair were broken to the side. One side was intact, and the other side was broken. It was observed that the floor was wet, and resident was wet after the fall. There were rubber tippers on the intact side of the chair. The broken side of the shower chair leg was not visible. Review of a statement completed by Employee E20, Licensed Nurse on November 26, 2023, revealed that the nurse was at the nurse's station around 11:20 a.m. with other staff members when a loud noise 395446 Page 34 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0908 Level of Harm - Actual harm Residents Affected - Few was heard from the bathroom. Upon approaching the common shower room Resident R87 could be heard yelling for help. Nurse found resident on the floor. Resident stated his shower chair broke in half. Resident was complaining his back was hurting. Review of a statement completed by Employee E26, Registered Nurse on November 27, 2023 revealed that the resident reported to the staff that he was sitting in the shower chair in the shower room when it broke. Review of facility investigation dated November 26, 2023 revealed that the resident was found in the shower chair floor. He stated his shower chair broke in half. Also nurse observed that the shower chair broke in half. Resident complained that his back hurting a lot and appeared as if he could not move. Resident stated the shower chair broke and he thought they fixed it. Staff stated other residents recently showered and no other issues noted with the shower chair. Resident was transferred to the emergency room for evaluation. Review of X-ray report for Resident R87 dated November 26, 2023, revealed that resident sustained avulsion fracture of medial malleolus (the small prominent bone on the inner side of the ankle at the end of the tibia). Review of nurse practitioner progress note dated November 27, 2023, revealed that the resident sustained a possible acute avulsion fracture of the medial malleolus status post shower chair collapse. Review of nurse practitioner progress note dated December 6, 2023, revealed that the resident sustained an acute left medial malleolus avulsion fracture. Review of an orthopedics consult for Resident R87 dated December 18, 2024, revealed that the resident sustained a severe sprain of left ankle. Lateral sided swelling and pain consistent with severe sprain. Review of progress note for Resident R87 dated December 13, 2023, revealed that resident had complaints of pain to swelling and pain to his left leg. Resident sustained an acute avulsion fracture related to recent fall. New order for Oxycontin (This medication is used to help relieve severe ongoing pain, belongs to a class of drugs known as opioid analgesics) 10 mg every 12 hours for pain was ordered by the practitioner. Continued review of facility investigation revealed no evidence that the facility conducted a thorough investigation of the reason or cause of shower chair collapse. There was no documented evidence that a maintenance inspection of the broken shower chair. During a follow up interview with Resident R87 on January 22, 2024, at 1:07 p.m., with Nursing Home Administrator stated he was sitting in the shower and started taking shower when all of the sudden the shower chair collapsed, and he fell to the floor. Interview with Maintenance Director, Employee E27 on January 22, 2024, at 1:05 p.m. stated he completed a routine check of started checking emergency exit doors, mag locks, shower chairs, floors room temperature, oxygen supply approximately a month after he started working at the facility which was in October 2023. Prior to his employment there was no routine check. Employee E27 stated he did not think he started the routine check at the time Resident R87's fall from broken shower chair. Employee E27 stated he did not document his daily observation/checks anywhere, so he did not know if there 395446 Page 35 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0908 Level of Harm - Actual harm Residents Affected - Few was the process on November 26, 2023. Employee E26 also stated the incident happened over a weekend and staff should have checked for shower chair prior to resident using it to ensure it was safe to use. Employee E27 stated he did not see the broken shower chair because it was thrown away before he could inspect it, however from the picture it looked like it just collapsed in half possibly due to the age of the chair or due to a broken or missing rubber tippers. Review of clinical record and facility document revealed no documented evidence that the facility staff checked the shower chair for proper functioning and safe condition. Interview with Nursing Home Administrator on January 22, 2024, at 1:05 p.m. stated there was no manufactures recommendations or user guide available for the brand of the shower chair. Administrator also stated it was unable to determine the brand of the broken shower chair. Administrator confirmed that the facility did not have any evidence that a preventative maintenance, visual inspection of the shower chair before and after Resident R87's injury was completed. This failure resulted in actual harm to Resident R87, who fell from the a shower chair which broke while the resident was taking a shower and sustained an avulsion fracture of medial malleolus and a sprain of the left ankle. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395446 Page 36 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were within reach for one of 25 residents reviewed. (Resident R36). Residents Affected - Few Findings include: Review of care plan for Resident R36 dated January 26, 2020, revealed that the resident had an Activities of Daily Living (AdL) self-care deficit, and he could not complete ADL tasks independently and required staff assistance. Review of a care plan intervention revealed an intervention, call bell within reach in the room/bathroom/shower room and remind to use. Observation of Resident R36's room on January 16, 2024, at 12:07 p.m., revealed that the call bell was tangled with resident's beds electric cord on the floor next to the bed. Resident R36 was laying in the bed and was unable to reach the call bell. There was a hand bell sitting on the bed side table which was away from resident's reach. Observation of Resident R36's room on January 17, 2024, at 11:00 a.m., revealed that the call bell was tangled with resident's beds electric cord on the floor next to the bed. Resident R36 was laying in the bed and was unable to reach the call bell. It was at the same position as previous observation. There were two hand bells sitting on the corner of the dresser which was away from resident's reach. Observation of Resident R36's room on January 18, 2024, at 2:00 p.m., revealed that the call bell was tangled with resident's beds electric cord on the floor next to the bed. Resident R36 was laying in the bed and was unable to reach the call bell. It was at the same position as the previous two observations. There were two hand bells sitting on the corner of the dresser which was away from resident's reach. Observation of Resident R36's room on January 22, 2024, at 9:52 a.m., with Employee E36, Nursing Aide, revealed that the call bell was tangled with resident's beds electric cord on the floor next to the bed. Resident R36 was laying in the bed and was unable to reach the call bell. It was at the same position as the previous three observations. There were two hand bells sitting on the corner of the dresser which was away from resident's reach. 28 Pa. Code 211.12(d)(1(5) Nursing services 395446 Page 37 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on the review of facility records, observations and interviews with resident and staff, it was determined that the facility failed to ensure a safe and comfortable environment for resident and staff for two of two floors (Second floor dining room and First Floor Rehab). Finding Include: Review of facility policy Physical Environment dated January 1, 2020, revealed that A safe, clean, comfortable, and home-life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation, and program areas are provided to enable staff to provide resident/patients with needed services. All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program Interview with Resident R297 on January 18, 2024, at 10:50 a.m. revealed that the first floor rehab room was cold and he was wearing three layers of clothes. He stated staff should put the temperature up because he was cold in the room. Observation of the First floor Rehab room on January 18, 2024, at 10:50 a.m. revealed that a resident who was wearing a sweater was leaving the room, she also had a blanket over the sweater and her legs. Interview with Employee E37, Rehab staff, on January 18, 2024, at 10:47 a.m., stated it was cold in the room. Employee E37 stated there were three window heating/air-conditioning unit in the rehab gym and only one was working properly. Employee E37 also stated one unit was not functioning for a long time. A temperature check was completed with Maintenance Director, Employee E27, on January 18, 2024, at 11:07 a.m., of Rehab room, which revealed that the room had a temperature of 69-degree Fahrenheit. A temperature check was completed with Maintenance Director, Employee E27, on January 18, 2024, at 11:17 a.m., of Second floor dining room, which revealed that the room had a temperature of 68-degree Fahrenheit. There were six window heating/air-conditioning unit in the dining room and only 2 were functioning and four were not working. Observation of the Second-floor dining room with Maintenance Director, Employee E27, on January 18, 2024, at 11:17 a.m., revealed that there were approximately 10-12 residents sitting at a table and was playing bingo. During the activity one resident told Employee E27 that it was cold in the room. Interview with Maintenance Director, Employee E27, on January 18, 2024, at 11:30 a.m., stated one window heating/air-conditioning unit in the rehab gym was not functioning for a long time. He said he started working at the facility three months ago and it was not functioning before the start of his employment. Employee E27 also stated he was aware that all of the window heating/air-conditioning unit in the Second-floor dining room was not functioning. Interview with Nursing Home Administrator, on January 18, 2024, at 12:30 p.m., stated he was not aware that there was issue with window heating/air-conditioning unit in the Second-floor dining room 395446 Page 38 of 39 395446 01/22/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0921 Level of Harm - Minimal harm or potential for actual harm and Rehab gym. He stated facility was expected to maintain all equipment in a safe and operating condition. Nursing Home Administrator confirmed that the temperature should be maintained above 70 degrees. 28 Pa. Code 201.14 (a) Responsibility of licensee. Residents Affected - Some 28 Pa. Code 201.18 (b)(1) Management. 395446 Page 39 of 39