Onyx Wellness Center

Inspectors wroteBased on review of facility policies, drug manufacture's information, interview with resident, and staff interviews, it was determined the facility failed to ensure a newly admitted resident diagnosed with End-Stage Renal Disease (ESRD) and a kidney transplant recipient received life sustaining medication. This failure resulted in the resident missing a total of eight doses of the medication Tacrolimus 0.5 milligrams, which led to critical laboratory values and placed the resident in an Immediate Jeopardy situation of organ rejection for Resident 119.

Inspectors wroteBased on review of clinical records, facility documentation, and interview with staff, it was determined the facility failed to ensure a resident's snack bin was not in a location easily accessible to resident, which resulted in actual harm to Resident R87, while trying to obtain snacks, fell out of bed sustaining a laceration to the head, requiring two sutures and multiple steri-strips for one of two residents reviewed for falls (Resident R87). This deficiency was cited as past non compliance.

Inspectors wroteBased on record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure residents' advance directives and physician orders for Life-Sustaining Treatment (POLST) were followed according to the residents' expressed wishes for 2 of 2 residents reviewed with advance directives. Resident R116 and R121)

Inspectors wroteBased on review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure a baseline care plan was developed within 48 hours of admission related to dementia care for one of 22 residents reviewed. (Resident R9) Findings Include: Review of Resident 9's clinical records revealed Resident R9 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Dementia (progressive disease characterized by impaired memory, thinking and behavior that affects ability to perform daily tasks), bipolar disorder (mood disorder marked by extremes in feelings of elation or depression), cerebral ischemia (lack of blood flow to brain causing damage or death to brain tissue), chronic obstructive pulmonary disease ( COPD, a progressive lung disease causing breathing difficulties), and difficulty in walking. [...]

Inspectors wroteBased on review of facility policy, observations and interviews with staff, it was determined that the facility failed to ensure that residents were provided appropriate supervision while dining for 6 of 6 residents observed. (Resident R60, R92, R58, R94, R101, and R39)

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure safe and sanitary food storage practices on four of the facility's four nursing units.

Inspectors wroteBased on review of clinical records, facility policies, job descriptions, medication documentation, and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure that a newly admitted resident diagnosed with End-Stage Renal Disease (ESRD) and a kidney transplant recipient received life sustaining medication. This failure resulted in a resident missing a critical immunosuppressive medication and placing the resident an Immediate Jeopardy situation. (Resident 119)

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to maintain essential kitchen equipment in clean and sanitary conditions related to the ice machine. Findings Include: A tour of the main kitchen was conducted on May 20, 2025, at 9:20 a.m. with Food Service Director, Employee E16. Observations inside the ice machine revealed the white, plastic, inner lining had a blackish/brown stain along the bottom half perimeter. Further observations of the area surrounding the ice machine revealed the plastic baseboard along the wall adjacent (facing) the ice machine was peeling off and has significant build-up of dirt and debris. The floor underneath and surrounding the area of the ice machine was dirty and had a significant build up of dirt and debris. Three to four fruit flies were hovering the area of the ice machine. 28 Pa. [...]

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for two of two nursing units (First floor and Second floor nursing units). Findings Include: Observations during the initial tour on May 20, 2025 at 1:01 p.m. revealed Resident R92's room had a NPO (nothing per mouth) sign posted at the head on the resident's bed on the wall. The sign had nine residents information listed. Four residents listed as NPO Four residents listed as Necar Thick One resident listed as Honey. Two residents listed as No straws Two residents listed as Do Not Leave Liquids at Bedside Observations on May 20, 2025 at 12:34 p.m. of the first floor nursing units activities/dining room revealed residents were being served their meals on plastic trays. [...]

Inspectors wroteBased on observations, resident interviews, and staff interviews, it was determined that the facility did not ensure clean and homelike environment was maintained in resident care areas and dining experience for two of two nursing units observed (First Floor and Second Floor). Findings Include: Observations on May 20, 2025, at 10:20 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed a red paint colored on the wall next to the A-Bed. Observations on May 20, 2025, at 10:40 a.m. on East Wing First Floor in room [ROOM NUMBER] revealed the baseboard along the perimeter of the wall behind the B-bed was peeling off. Observations on May 20, 2025, at 10:51 a.m. revealed the resident had a bathroom with a leak behind toilet, on the floor was a wet saturated towel between the sink and toilet area along the wall. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to ensure the POLST form accurately reflected the resident's code status for one of 32 residents reviewed (Resident R15). Findings Include: Review of Resident R15's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of Senile Degeneration of Brain ( a decline in an individual's memory, behavior, and cognitive abilities) and Chronic Obstructive Pulmonary Disease (a progressive lung disease characterized by difficulty breathing, often caused by long-term exposure to irritants). [...]

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to timely arrange a podiatry appointment for one of two residents reviewed for foot care (Resident R47). Findings Include: Review of Resident R47's comprehensive care plan revised December 3, 2022, revealed the resident had potential for impaired skin integrity related to congestive heart failure (heart is not able to pump enough blood to meet the body's needs causing fluid build up in the body), type 2 diabetes mellitus (body's inability to effectively process sugars (glucose) causing high blood sugar levels), and hypertension (high blood pressure). Intervention dated January 5, 2025, included to consult podiatry as ordered. [...]

Inspectors wroteBased on observations, review of facility documentation, review of personnel files and interviews with residents and staff, it was determined that the facility failed to ensure that agency nursing staff demonstrated competencies and skill sets necessary to care for residents' needs for three of three agency personnel files reviewed (Employees E9, E10 and E11).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 32 residents reviewed (Resident R 67). Findings Include: Review of the admission sheet of Resident 67, revealed that Resident R67 was admitted to the facility on [DATE], with diagnoses including Dementia (Dementia is a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). On May 21, 2025, at 1:55 p.m., review of Resident R67's interdisciplinary plan of care revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R67. [...]

Inspectors wroteBased on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact information, readily accessible on two of two nursing floors. (1st Floor, 2nd Nursing Units) Findings Include: Review of facility policy titled, Resident Rights with a revision date of August 31, 2022 states, Purpose: Ensures residents know that they can lodge complaints without reprecussions. During an observation of First Floor nursing units on May 20, 2025 at 11:00 a.m. revealed there was no posting for the required Department of Health contact information. A tour of the lobby area revealed there was a standard size page for the contact information for Department of Health but the phone number was outdated in between the exterior door of the lobby and the interior glass door of the lobby. [...]

Inspectors wroteBased on observations of care and services, interviews with residents and staff, review of clinical records and policy and procedures, it was determined that the facility failed to develop and implement a comprehensive care plan to meet the behavioral health and medical needs of one of seven residents reviewed with anxiety disorder, bipolar disorder, post traumatic stress disorder and spinal stenosis. ( Resident R1)

Inspectors wroteBased on review of clinical records, facility documentation, and staff interviews, it was determined the facility failed to ensure adequate supervision of two staff members was provided during incontinence care to Resident R1. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a fracture of the left arm and a fracture of the left hip for one of seven residents reviewed. (Resident R1)

Inspectors wroteBased on observations, interviews and review of facility documentation, it was determined that the facility failed to ensure a resident safe, comfortable and home like environment for 9 out of 9 residents reviewed (Resident R1, R2, R3, R4, R5,R6, R7, R8, and R9).

Inspectors wroteBased on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for 18 of 18 residents interviewed (Residents R79, R89, R65, R39, R30, R97, R64, R35, R74, R21 R62, R53, R78, R88, R28, R27, R22 and R66.)

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to accurately complete a resident assessment for one of 21 residents reviewed (Resident R102).

Inspectors wroteBased 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 three of 21 resident records reviewed (Residents R56, R97 and R71).

Inspectors wroteBased on observation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide restorative nursing programs for one of 21 residents reviewed (Residents R56).

Inspectors wroteBased on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E4).

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, review of video footage and interviews with staff, it was determined that the facility failed to ensure that one of six residents reviewed were free from physical abuse from nursing staff. This failure resulted in an Immediate Jeopardy situation with Resident R2 who was struck twice, and rough handled sustaining left upper arm bruising. (Resident R2). Findings Include: Review of facility policy on Abuse Prevention Program dated August 2020 states, The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. [...]

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to make certain that residents were protected from physical abuse from a nursing staff for one of six residents reviewed. (Resident R1) This failure resulted in an Immediate Jeopardy situation for Resident R2.