Inspection·March 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on clinical record review and staff interview, it was determined the facility failed to notify the physician of a change in condition for twelve of nineteen residents testing positive for Covid-19 (Resident R1, R2, R5, R7, R8, R10, R11, R12, R16, R17, R18, R19). Findings include: Review of the facility policy Notification of Changes last reviewed 2/15/23, indicate the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include but not exclusive to circumstances that require a need to alter treatment, significant change in the resident's physical, mental or psychosocial condition. Review of Resident R1's clinical record indicated admission to facility on 9/11/20, with the diagnosis of Lymphoma (form of cancer), diabetes (high blood sugar levels) edema (swelling). Review of facility covid line listing indicated Resident R1 tested positive for COVID-19 on 2/21/24. Review of Resident R1's progress notes did not include information on physician notification of COVID-19 testing results. Review of Resident R2's clinical record indicate admission to facility on 12/23/23, with the diagnosis of diabetes, Parkinson's disease (degenerative neurological disorder), hypertension (high blood pressure). Review of facility covid line listing indicated Resident R2 tested positive for COVID-19 on 2/24/24. Review of Resident R2's progress notes did not include information on physician notification of COVID-19 testing results. Review of Resident R5's clinical record indicate admission to facility on 1/16/24, with the diagnosis of fracture of left femur (thigh bone), multiple sclerosis (autoimmune disease), dysphagia (difficulty swallowing). Review of facility covid line listing indicated Resident R5 tested positive for COVID-19 on 2/16/24. (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 5 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 03/18/2024 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)