Embassy Of Saxonburg

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility policy, clinical record, and staff interview it was determined that the facility failed to have

the responsible party sign financial papers for one of two residents ( Resident Resident R2).Findings include: Review of facility policy Resident Rights dated 2/19/25, indicated: The facility will inform the resident both orally and

in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Information about resident rights will be given to the resident understands to the extent possible, considering impediments which may be created by the resident's health and mental status. Review of Resident Resident R2 was admitted [DATE REDACTED]. Review of Resident Resident R2 MDS (minimum data set - a periodic assessment of resident needs) dated 8/28/25, indicated diagnosis of Multiple Sclerosis (is a disease that causes breakdown of the protective covering of

the nerves) muscle wasting and atrophy (is the wasting or thinning of your muscle mass), and hyperlipidemia (excess of lipids or fats in your blood). Question C0500 BIMS Summary Score revealed Resident Resident R2's score to be 11, moderately impaired. Review of Resident Resident R2 clinical record indicated a NOMNC (Notice of Medicare non-coverage - a form given to residents or resident responsible party to notify of ending insurance coverage) was signed by the resident on August 29, 2025. No further information was noted in the clinical record that the responsible party was informed of the ending of Medicare coverage. During an interview on 11/13/25, at 3:26 p.m. Nursing Home Administrator, confirmed that Resident Resident R2 had a BIMS 11 which is moderately impaired, and moderately impaired residents should not sign NOMNC's, and the facility failed to have the responsible party sign financial papers. 28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29 (a) Resident rights.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Saxonburg

223 Pittsburgh St Saxonburg, PA 16056

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0551

Give the resident's representative the ability to exercise the resident's rights.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility provided documents, clinical records and staff interviews, it was determined that the facility failed to ensure that a resident's legal surrogate (power of attorney) was utilized for legal action of non-payment of bills for one of two residents (Resident Resident R1).Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aids in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record revealed that Resident Resident R1 was admitted to the facility on [DATE REDACTED].

Review of Resident 1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/22/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anxiety (a feeling of worry, nervousness, or unease).Question C0500BIMS Summary Score revealed Resident Resident R1's score to be 10, indicative of moderate cognitive impairment. Review of Resident Resident R1's clinical record revealed that a Power of Attorney (giving authority to another person to act in all legal or financial matters on another person's behalf) Form was uploaded into

the electronic health record on 3/6/24, and identified Resident Resident R1's son as her Power of Attorney (POA).

Review of Facility [NAME] Statements revealed that an invoice was sent to Resident Resident R1 on 5/1/25, with a balance due of $26,827.00, and the same invoice was also sent to Resident R1's POA on the same date. Additional invoices dated 6/1/25, 7/1/25, and 8/1/25, were also sent with the above balance. Two copies were sent on each date, one to Resident Resident R1 and the other copy to the resident's POA. Review of a resident representative concern from Former Activities Director Employee E4 dated 10/12/25, stated the following:

On 6/26/25, I personally witnessed NHA accompanied by a sheriff's deputy, verbally and psychologically abusing Resident Resident R1, in the middle of a public hallway. NHA repeatedly told the resident at least seven times that she owed the facility $26,000, stating, 'We issue 30-day notices like candy around here to people who owe money.' The resident was visibly distraught, crying, and repeatedly stated she did not understand why she was being held or what the debt referred to. During an interview on 11/12/25, at 1:54 p.m. the NHA stated that the local sheriff had come in on the day in question with papers. NHA explained that Resident Resident R1 had to spend down $26,000 to qualify for Medicaid, and that the family wasn't compliant with paying her bills, therefore the sheriff was serving her papers for the unpaid balance. The sheriff had come in and asked to be taken to Resident Resident R1's room, and at the time Resident Resident R1 was listed in the medical chart as her own responsible party. The NHA confirmed that Resident Resident R1 does have a POA who is authorized to handle her bills, and that the facility failed to utilize the resident POA for legal action of non-payment of bills for Resident Resident R1. 28 Pa. Code 201.14(b) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(2)(3) Management.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Saxonburg

223 Pittsburgh St Saxonburg, PA 16056

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Based on observations and staff interview, it was determined that the facility failed to post complete contact information for State Long-Term Care Ombudsman program, and accessible, and complete contact information for State Survey Agency at the facility as required. Findings include: During observations completed on 11/13/25, State Long-Term Care Ombudsman information posted in the front hallway did not include the Ombudsman's name, address, or email as required. This observation also revealed that State Survey Agency (SSA) contact information was listed approximately six feet from the floor in small print and did not include email, or current address, and did not include a statement that residents may file a complaint with SSA concerning any suspected violation of State and Federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directive requirements, and requests for information regarding returning to the community as required. During interview, on 11/13/25, at 2:06 p.m. the Nursing Home Administrator confirmed that the facility failed to post complete contact information for State Long-Term Care Ombudsman program, and accessible, and complete contact information for State Survey Agency as required. 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(e) Management.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Saxonburg

223 Pittsburgh St Saxonburg, PA 16056

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

sheriff come into a facility to handle bills before, and that Resident Resident R1 would absolutely feel intimidated with

the sheriff being there. Employee E5 added that about a week after the incident the (former NHA) Employee E2 came into morning meeting and closed the door and told her that she was disappointed with how the witnesses worked together and they accused the NHA of abuse, and If we didn't like it, we could leave. During an interview on11/12/25, at 4:53 p.m. (former NHA) Employee E2 confirmed the investigation file regarding the incident could not be located. During an interview on 11/12/25, at 4:54 p.m. with the NHA, State Agency (SA) read the statement from the above written statement dated 6/27/25, in which the NHA explained that she was nervous in the situation/moment. The NHA confirmed that she was nervous during

the altercation. SA asked that if she (NHA) was nervous at the time as a reasonable person, how would she think Resident Resident R1 felt? NHA confirmed that this would also indeed make Resident Resident R1 feel nervous. During

an interview on 11/13/25, at 1:02 p.m. Nurse Aide (NA) Employee E6 stated that he is familiar with Resident Resident R1 and would not think [he/she] would be able to pay [his/her] own bills as [he/she] can be confused. NA Employee E6 was not present for the incident, but when he was informed the sheriff came into the building to discuss non-payment of bills, he replied They should have stopped 'em at the door. That makes me vomit. During an interview on 11/13/25, at 1:14 p.m. Employee E1 provided a copy of the written statement that she had provided to Former Nursing Home Administrator Employee E2 right after the incident had occurred. Review of this written statement dated 6/26/25, indicated the following: A discussion was overheard in the hallway that included the resident (Resident Resident R1), a sheriff, and the NHA. The conversation was loud enough for me to hear during a meeting down the hall. Other residents were present in the hallway and listening/observing. I only heard parts of the conversation, which were 'you're not in trouble,' and 'this is a long time coming,' and 'this is what happens to people like you who don't want to pay.' Following the interaction, resident was tearful, but able to be redirected. During an interview on 11/13/2025, at 1:30 p.m. NA Employee E7 stated that she is also familiar with Resident Resident R1 and did not witness the incident but when she was told of the occurrence, NA Employee E7 replied That's humiliating. If that happened to me, I wouldn't want to stay here. During an interview on 11/13/25, at 3:26 p.m. the NHA was asked how the sheriff's office became involved in the bill collection process and after conferring with colleagues for information on the process, stated that the Corporate office sent the account to 'collections', which then gets sent to the sheriff's office, and they (corporate) don't communicate with us to give us a heads up. During an interview on 11/13/25, at 3:50 p.m. the NHA confirmed that the facility failed to protect Resident Resident R1 from mental abuse and intimidation. During an interview on 11/14/25, at 8:37 a.m. a Sheriff's Office Representative stated that for the above incident to occur, The facility would have to file paperwork with an attorney at the County Prothonotary Office to file a civil lawsuit. This is then forwarded to the Sheriff's Office with instructions including the person's name and where to find them. This is done with payment of a fee. When SA told the Sheriff Office Representative that the above resident had dementia and had a POA, the representative replied, We would not expect to go in and deal with a person with dementia, and would have served the POA if we were provided with that information. 28 Pa. Code 201.14(b) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(2)(3) Management.28 Pa. Code 211.10(a) Resident care policies.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Saxonburg

223 Pittsburgh St Saxonburg, PA 16056

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with the details of the event and put it underneath FDON Employee E3's door the same day of the incident.

FSW Employee E5 stated that the resident was tearful during the incident, and when she saw her less than

an hour later she was still tearful. FSW Employee E5 stated that she had never seen a sheriff come into a facility to handle bills before, and that Resident Resident R1 would absolutely feel intimidated with the sheriff being there. FSW Employee E5 added that about a week after the incident the FNHA Employee E2 came into morning meeting and closed the door and told her that she was disappointed with how the witnesses worked together and that they accused the NHA of abuse, and If we didn't like it, we could leave. A review of incidents submitted to the State Agency conducted on 11/12/25, did not include the staff-to-resident abuse allegation on 6/26/25. During an interview on 11/13/25, at 1:50 p.m. the NHA confirmed that the facility failed to report an allegation of abuse for one of two residents (Resident Resident R1). 28 Pa Code: 201.14 (a)(c) Responsibility of management28 Pa Code: 201.18 (b)(1)(e)(1) Management.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Saxonburg

223 Pittsburgh St Saxonburg, PA 16056

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm

regarding the incident cannot be located. During an interview on 11/13/25, at 1:50 p.m. the NHA confirmed that the facility failed to identify, and investigate an allegation of abuse for one of two residents (Resident Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Saxonburg

223 Pittsburgh St Saxonburg, PA 16056

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0680

Ensure the activities program is directed by a qualified professional.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility documentation and staff interview it was determined that the facility failed to employ a qualified actives director from October 6, 2025. Findings include: Review of facility documentation: job description Activity Director: The primary purpose of your job position is to plan, organize, develop, direct and implement the overall operation of the Activity Department in accordance with current, federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. During an interview on 11/13/25, at 10:30 a.m. Activity Director Employee E8 indicated her previous employment was as a Nurse Aide, and they did not have prior experience in an activity program. Review of Activity Director Employee E8 file failed to include documentation meeting federal standards. During an interview on 11/13/25, at 3:26 p.m. Nursing Home Administrator confirmed that the facility failed to employ a qualified activities director. 28 Pa. Code 201.9(3) Personnel policies and procedures.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Saxonburg

223 Pittsburgh St Saxonburg, PA 16056

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)