Inspection·August 19, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify a family representative of a change in condition for one of three residents. (Resident R1). Residents Affected - Few Findings include: A review of the facility Change in Condition Notification Protocol reviewed 3/27/24, indicates the facility will inform the resident; consult with the residents physician; and if known notify the residents legal representative/and or resident representative when there is a significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications). A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). A review of Resident R1's clinical record indicates an admission date of 11/21/2023, with the diagnosis of peripheral vascular disease (PVD-narrowing of blood vessels), hypertension (high blood pressure), and atrial fibrillation (abnormal heart rhythm). A review of Resident R1's progress note 8/11/24, 2:41 p.m. indicate Staff approached desk to report that resident was urine was an abnormal color. Entered room to observe that resident had voided into urinal which was a noticeably darker brown color. Denies any pain or discomfort when urinating. Vitals obtained; 97.7, 112, 20, 136/74, 95% RA. Resident also noted to having slight tremors/shaking in bilateral upper extremities as well as facial grimacing. When asked if he was in pain, he reported that his right elbow was sore and that he was overall uncomfortable. Received PRN (as needed) tramadol 50mg at 1:51 p.m. EMAR (electronic medical record). RN supervisor made aware and back to assess resident. When asked if he would like to go to the hospital for evaluation resident replied No. Call bell within reach, encouraged resident to increase fluid intake and alert staff if he changed his mind about going out to the hospital. Resident verbalized understanding. A review of nursing progress notes 8/11/24, at 3:33 p.m. indicate physician notified of resident continued weakness, no consumption for lunch, B/P 134/70 HR 112 Temp 97.3 BS 117 SPO2 91% resident denies SOB at this time. States he has chills when room door is opened. Reassessment of resident T 99.1 HR 110 SPO2 now 85% O2 applied at 2L N/C as per nursing measure. Resident repositioned in bed, HR tachycardic Cool cloth to forehead, appears to be resting more comfortably. Notified physician of updated vitals. A review of physician orders dated 8/11/24 indicate oxygen at 2 liters per minute via nasal canula (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 3 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 08/19/2024 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)