Embassy Of Saxonburg
EMBASSY OF SAXONBURG in SAXONBURG, PA — inspection on November 13, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident R2 was admitted [DATE].
Review of 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 R2's score to be 11, moderately impaired.
Review of 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 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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Saxonburg
223 Pittsburgh St Saxonburg, PA 16056
SUMMARY STATEMENT OF DEFICIENCIES
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 R1's score to be 10, indicative of moderate cognitive impairment.
Review of 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 R1's son as her Power of Attorney (POA).
Review of Facility [NAME] Statements revealed that an invoice was sent to Resident R1 on 5/1/25, with a balance due of $26,827.00, and the same invoice was also sent to 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 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 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 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 R1's room, and at the time Resident R1 was listed in the medical chart as her own responsible party.
The NHA confirmed that 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 R1. 28 Pa.
Code 201.14(b) Responsibility of licensee.28 Pa.
Code 201.18(b)(1)(2)(3) Management.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Saxonburg
223 Pittsburgh St Saxonburg, PA 16056
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Saxonburg
223 Pittsburgh St Saxonburg, PA 16056
SUMMARY STATEMENT OF DEFICIENCIES
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 R1 felt? NHA confirmed that this would also indeed make 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 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 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 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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Saxonburg
223 Pittsburgh St Saxonburg, PA 16056
SUMMARY STATEMENT OF DEFICIENCIES
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 R1). 28 Pa Code: 201.14 (a)(c) Responsibility of management28 Pa Code: 201.18 (b)(1)(e)(1) Management.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Saxonburg
223 Pittsburgh St Saxonburg, PA 16056
SUMMARY STATEMENT OF DEFICIENCIES
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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Saxonburg
223 Pittsburgh St Saxonburg, PA 16056
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Saxonburg
223 Pittsburgh St Saxonburg, PA 16056
SUMMARY STATEMENT OF DEFICIENCIES