Health inspection·December 11, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical documentation, review of facility policies, resident interview, and staff interview it was determined that the facility did not ensure a resident was treated with respect and dignity related to searches and drug use policy for one of seven residents reviewed. (Resident R1)Findings Include:Review of facility policy titled, Drug Screening/Searches for Residents with a created date of February 24, 2025. The policy states, Policy: It is a policy of Ivory Wellness Center to maintain a drug free environment to ensure the safety and well-being of all the residents living in the facility. Definition: Illegal Use of Drugs- The use of drugs, the possession or distribution of which is unlawful under the Controlled Substances Act. This does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act. Illicit drugs may include but are not limited to opiates, amphetamines, cannabis, hallucinogens, etc. Further review of the facility policy revealed, Procedure/Responsibilities/Actions:.7. The facility will have searches done randomly to identify residents that may be using or distributing illegal drugs.8. If a resident tested positive for illegal drugs or is found to have illegal drugs in their possession the attending MD will be notified.9. The IDC team will meet to provide counseling and discuss the possibility of being transferred to a more appropriate setting for possible rehabilitation or discharge. The resident may also be requested to sign a contract that stipulates that if there is any further violation of the facility policy or the law, it will not be tolerated and could result in discharge from the facility.10. Out On Pass privileges may be suspended for a certain period as deemed appropriate by the physician.11. The resident's substance abuse behavior will be addressed in the resident's plan of care that will include managing resident behavioral symptoms. It may also include discharge planning if necessary.Review of facility documentation provided by Employee E2 the Director of Nursing states, Drug Consent Policy states, As a Resident at Facility , I___________agree that during my stay at the facility, I will NOT bring in drugs of any kind, I will NOT take any drugs that are not prescribed by my Physician, and I will NOT give or sell drugs of any kind to any other resident, visitor or staff member. I understand and agree that if I am found in possession of drugs or observed taking or selling drugs of any kind, I will be discharged from the facility and not permitted readmission. I agree to be searched / have my room searched for the possessions of drugs*. My Physician as well as the Police department will be notified promptly. If suspected, but not observed taking illegal drugs, I agree to urine and blood drug screening ordered by my Physician. My signature indicates my acceptance and agreement with this Policy. Review of Resident R1's clinical record revealed the resident was re-admitted to the facility on [DATE]. The resident has the following diagnosis: Depression, Insomnia, Psychoactive Substance Abuse, Lower Back Pain, Nicotine Dependence and Anxiety. Interview held at 9:55 a.m. with Employee E4 the physician's assistant who has a history with the resident. Employee E4 stated that for her and physician Employee E6 Page 1 of 2 395446 395446 12/11/2025 Ivory Wellness Center 2004 Old Arch Road Norristown, PA 19401

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they no longer care for Resident R1 due to her constant requests for narcotics. Employee E4 states that Resident R1 has done many things like receiving medications dispensed at that the facility and was found selling it to other residents here. When asked when this occurred, Employee E4 stated it occurred within the last few weeks. Employee E4 states that Resident R1 is a bully to other residents, even as of recently stole a women's credit card in her room and maxed them out. Resident R1 was interviewed at 10:21 a.m. and discussed the situation where she was found with an pill in her possession. The resident stated, one day, like they had done before they had drug sniffing dogs come here and they came into my room. When asked where it came she stated it came into my room by my bed and by my dresser. The resident stated, I then got upset and told them to get out of my room but then realized I was wrong to keep it so I handed it over to them. When asked where the resident got the pill from she stated, from here, one day I was sleeping and the nurse left the cup of pills on my tray stand and I know I shouldn't have hid it but I did and I admitted after it was wrong. Review of facility documentation shows a grievance filed by Resident R1 on October 12, 2025. The grievance states, .I'm harassed by the DON, ADON, NHA and others in the pursuit to locate drugs on location. The resolved date list October 14, 2025. The answer to What action was taken to resolve grievance concern-resident met with unit manager, DON. The answer to Results of action taken-DON conducted Medical Director to follow up Review of physician progress note from October 14, 2025 made by Employee E5 states, Nature of Presenting Illness: Asked to evaluate patient as medical director for substance abuse issues and other concerns. Patient has a history of substance abuse currently on Suboxone. It has been reported by staff and other residents that patient selling her Adderall. This has since been discontinued. Patient also with positive drug test for marijuana. Patient has violated controlled substance policy and was upset at current provider for refusing to continue to write Suboxone along with other controlled substances. During my examination today, both the director of nursing Employee E2 and unit manager Employee E7 were present for the entire conversation. Explained that I will be seeing the patient from here on out because she has refused to see the other providers in the practice. The facility has also reached out to the other physicians in the building who declined to bring the patient on service because of documented behaviors and ongoing substance abuse. Patient was recently found to have Adderall in her room and in her pocket on search by drug dog. I explain to the patient at length why the wean for Suboxone will be ordered. Given the fact that patient is abusing other drugs and found storing Adderall in her room reports from other residents that she is actively selling drug drugs in the facility. Upon me explaining Resident R1 became very agitated and aggressive. Yelling at me that I cannot do this I did offer her choice and did recommend a less restrictive environment as she is [AGE] years old and is able to perform all ADLs and does not need nursing level of care. She refused physical exam Told me to leave the room. She then began to chase me down the hallway, calling me a *ucking prick and that she would report me. The Director of Nursing was interviewed at 11:32 a.m. and asked if the resident ever signed a Drug Use Policy that would be enforceable by the facility and for Resident R1 to be knowledgeable of facility rules. The Director of Nursing Employee E2 stated that she was unsure but that she would check. Later, at 12:10 p.m. the Director of Nursing Employee E2 stated that she asked physician, Employee E5 and he stated that he did not have her sign one because she always refuses to sign anyway. The facility failed to ensure not to conduct searches of a resident or their personal belongings, unless the resident, or resident representative agrees to a voluntary search and understands the reason for the search. 28 Pa. Code: 201.18(b)(2) Management.28 Pa. Code: 201.29(j) Resident's rights. 395446 Page 2 of 2