Health inspection·July 30, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with resident and staff, review of facility policy and grievances, it was determined that the facility failed to make prompt efforts to resolve resident's grievances for one of four resident records reviewed (Resident R2). Findings include: Review of the facility's policy titled, Grievance/Concern Management, effective February 2021 states, The residents have a right to present concerns, recommend changes in policies and services. These rights include the right to prompt efforts by the facility to resolve residents' concerns. The same policy states that the Nursing Home Administrator (NHA) is responsible for oversight of the concern process. In addition, the Social Services Director in collaboration with the NHA will be the Grievance Officer at the facility. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of Chronic Obstructive Pulmonary disease (respiratory disease), high blood pressure, and major depression (severe sadness). Review of facility grievances/concern reports revealed on May 29, 2024, revealed that Resident R2 submitted a grievance regarding a missing pair of dark brown boots and a pair of brown pumps. On May 31, 2024 the facility followed up stating the articles were not found on Resident R2's inventory sheet and the resident was made aware. An interview was conducted with the Nursing Home Administrator (NHA) and the Grievance Officer on July 29, 2024. The grievance officer (GO) stated two weeks ago she received receipts of the two pairs of shoes and the receipts have been sitting on the GO's desk. Review of these receipts revealed both shoes were purchased online in 2021 and both purchases were mailed to the facility's address. The NHA then stated I told Resident R2 I needed the money in the petty cash to reimburse her and I don't have the money to pay her. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.29 (a) Resident Rights Page 1 of 6 395446 395446 07/30/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff and resident interviews, and review of facility documentation, it was determined that the facility failed to ensure that a resident was free of neglect resulting in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures to the forehead for one of four resident reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes), morbidly obesity and weakness. Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, indicated that the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed. Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed due to the resident's left sided weakness and limited mobility. The resident's care plan inidcated that the resident required the total assistant of one staff member for personal hygiene, and dressing and the use a mechanical aid requiring two staff members for transfers. Resident R1's nursing note dated July 12, 2024 revealed that the resident fell from his bed during care by staff (Nursing Assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead. Interview with Resident R1 on July 29, 2024, at 3:00 p.m. stated, I fell out of my bed onto the floor when I was being washed. The aide just rolled me, and I had nothing to hold onto and fell. I got 5 stitches (pointing to his forehead) and cuts and bruising. My body is still sore and I have had headaches ever since my fall. During an interview on July 30, 2024, at 4:00 p.m. with Nurse aide, Employee E3 confirmed that while providing Resident R1 with morning care, she went to roll him onto his side to wash him, and he rolled off the bed, adding that the bed was also in the highest position. The NA stated she was re-educated and in-serviced because of the way she rolled him. The NA explained, I rolled Resident R1 away from me, not towards me, like I was taught to do. Interview with the Director of Nursing and the Assistant Director of Nursing confirmed Nurse aide, Employee E3 was re-educated for using the incorrect technique while giving care to Resident R1. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services 395446 Page 2 of 6 395446 07/30/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and interview with staff, it was determined that the facility failed to report a serious injury sustained by a resident for one of four clinical records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness. Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, assessed the resident with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed. Resident R1's nursing note dated July 12, 2024, revealed that the resident fell from his bed, placed in the highest position during care by staff (Nursing Assistant, (NA) Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation and received five sutures on his forehead. During an interview on July 30, 2024, at 4:00 p.m. with NA, Employee E3 stated that while providing Resident R1 with morning care, with bed at the highest position, she went to roll him onto his side to wash him, and he rolled off the bed. The NA explained, I rolled Resident R1 away from me, not towards me, like I was taught to do. Interview with the Nursing Home Administrator on July 29, 2024, confirmed the facility failed to report this violations of neglect and report the results of this investigation to the State Survey Agency within prescribed time frame. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(5) Nursing service 395446 Page 3 of 6 395446 07/30/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0656 Level of Harm - Minimal harm or potential for actual harm 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 a review of clinical records, and interviews with staff, it was determined that the facility failed to develop and implement comprehensive person-centered plans of care in a timely manner for one of four resident records reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar ( mental health condition marked by intense mood changes), morbidly obese and weakness. Review of Resident R1's admission MDS (an assessment of resident's needs) dated May 2, 2024, indicated the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. The reisdent needed substantial maximum assistant (helper does more than half the effort) of one staff member for toileting, showering/bathing, dressing and personal hygiene. Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed related to activities of daily living (adl)/self care, performance deficient due to hemiplegia and limited mobility. An intervention developed on May 23, 2024, stated that the resident needed pair care and assist of 2 people for all care related to bed mobility Interview on July 29, 2024, with the Therapy Director, Employee E4 stated at discharge we had placed an enabler bar on his bed in the short-term unit to assist and increase his independence with bed mobility. It was later determined the resident was to be placed in long term care. When the resident was moved to long-term care on the second floor the enabler bar should have been placed on the resident's bed. This was confirmed with the Director of Nursing (DON) on July 29, 2024, at 2:30 p.m. that the facility failed to develop a plan of care, using an enabler as an intervention, to assist Resident R1 with bed mobility. Further review of Resident R1's clinical record revealed on July 12, 2024 the resident fell from his bed during care by staff (Nursing assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead. On July 29, 2024 at 2:30 p.m. the DON confirmed the resident's plan of care for paired care was not implemented during the time of the fall. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395446 Page 4 of 6 395446 07/30/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on the observations, review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to ensure that a resident received necessary equipment to aide with mobility for one of 4 residents reviewed. (Resident R1). Findings include: Review of Resident R1 clinical record revealed an admission date of April 25, 2024, diagnosed with a cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar ( mental health condition marked by intense mood changes), morbidly obese and weakness. Review of Resident R1 admission MDS (an assessment of resident's needs) dated May 2, 2024, indicated the resident was cognitively intact, one sided upper and both sides lower, body impairment, and needed substantial maximum assistant (helper does more than half the effort) of one staff member for toileting, showering/bathing, dressing and personal hygiene. Review of Resident R1's clinical record revealed a plan of care was developed due to the residents left sided weakness and limited mobility requiring total assistants for personal hygiene, dressing and used a mechanical aid requiring two staff members for transfers, created May 2024. Interview on July 29, 2024, with the Therapy Director, Employee E4 stated at discharge we had placed an enabler bar on his bed in the short-term unit to assist and increase his independence with bed mobility. It was later determined the resident was to be placed in long term care. When the resident was moved to long-term care on the second floor the enabler bar should have been placed on the resident's bed. This was confirmed with the Director of Nursing on July 29, 2024, at 2:30 p.m. the enabler was not placed on Resident R1's bed to assist with bed mobility. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code: 201.18 (b)(2) Management 395446 Page 5 of 6 395446 07/30/2024 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, resident and staff interviews, and review of facility documentation, it was determined that the facility failed to ensure that Resident R1 received adequate assistance during bed mobility which resulted in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures on the forehead. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes), morbidly obesity and weakness. Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, indicated that the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed. Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed related to activities of daily living (adl)/self care, performance deficient due to hemiplegia and limited mobility. An intervention developed on May 23, 2024, stated that the resident needed pair care and assist of 2 people for all care related to bed mobility. Resident R1's nursing note dated July 12, 2024, revealed that the resident fell from his bed during care by staff (Nursing assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead. Interview with Resident R1 on July 29, 2024, at 3:00 p.m. stated, I fell out of my bed onto the floor when I was being washed. The aide just rolled me, and I had nothing to hold onto and fell. I got 5 stitches (pointing to his forehead) and cuts and bruising. My body is still sore and I have had headaches ever since my fall. During an interview on July 30, 2024, at 4:00 p.m. with Nurse aide, Employee E3 confirmed that while providing Resident R1 with morning care, she went to roll him onto his side to wash him, and he rolled off the bed, adding that the bed was also in the highest position. The facility failed to ensure that Resident R1 was assisted by two staff members during adl care which resulted in actual harm to Resident R1 who fell out of bed and sustained a laceration on the forehead requiring five sutures. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services 395446 Page 6 of 6