Inspection·January 19, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of three residents (Resident R23) to accurately reflect the current status of the resident after an elopement event. Findings include: Review of facility policy Comprehensive Care Plan dated 2/15/23, indicated the facility will develop and implement a comprehensive care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents progress. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (a periodic assessment of care needs). Alternative interventions will be documented, as needed. Review of the facility policy Elopements and Wandering Residents dated 2/15/23, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. Review of admission Record indicated that Resident R23 was admitted to facility 12/19/23. Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23, indicated diagnoses Alzheimer's disease (a degenerative brain disorder resulting in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood), anxiety disorder (a group of mental illnesses that cause constant fear and worry, characterized by sudden feeling of worry, fear and restlessness), and high blood pressure. Review of Resident R23's admission assessment dated [DATE], indicated that resident does not have the cognitive ability to be orientated to room/surroundings, and that resident is currently receiving hospice services. Further review identified that has she has impaired cognition and/or decision making skills, and is independent with indoor mobility (ambulation). Review of Resident R23's Wander/Elopement assessment dated [DATE], indicated that she is at risk for elopement. Further review indicated that Rationale for Risk Decision: Resident has been diagnosed with Alzheimer's disease. She has gathered her belongings in a blanket and stated I am going home as she came out of her room to hallway. Further review indicated that appropriate interventions have (continued on next page) 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 Page 1 of 2 Event ID: 395160 Printed: 05/15/2026 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 395160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 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)