Health inspection·February 19, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R1).Findings include: Review of facility policy Fall Prevention and Management dated 1/15/26, indicated in the event of a fall, the resident will be assessed by a Licensed Nurse, the Physician/Nurse Practitioner and Responsible Party will be notified and an intervention(s) aimed to prevent further falls will be implemented. Details of the fall will be gathered and documentation completed as indicated.Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of high blood pressure, seizure disorder, and hyponatremia (low levels of sodium in the blood). Review of a nursing progress note dated 1/18/26, stated, At 1615 (4:15 p.m.) LPN (Licensed Practical Nurse) floor nurse notified writer that resident was on the floor in his room in front of his bed sitting on his buttocks. Resident was laughing at the situation. [NAME] was on the floor on it's side. Wheelchair was bedside resident. Resident denies pain or discomfort. ROM (range of motion) was completed and wnl (within normal limits). No apparent injuries. VSS (vital signs stable). VS: 97.9 (temperature) - 113/74 (blood pressure) - 89 (heart rate) - 18 (respirations) - 98% on RA (oxygen saturation on room air). Resident was redirected to ring his call bell and not attempt to stand up and self-transfer himself. Resident was transferred per orders back into his wheelchair. Sister was notified. Director of Nursing and physician were notified. Neuro checks (neurological assessment) initiated per facility protocol. All appropriate paperwork was completed. Resident is in his wheelchair eating his supper in his room. Call bell within reach and safety measures in place.Review of a 72-Hour Neurological Assessment Sheet indicated this assessment should be completed at the following intervals for follow up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Any [NAME] in resident condition requires a phone call to the primary care physician. Initial assessment, followed by every 15 minutes x 4, every 30 minutes x 4, every hour x 2, once per shift for 72 hours.Review of Resident R1's 72-Hour Neurological Assessment Sheet dated 1/18/26, indicated only eight neurological checks were completed out of 18 opportunities. During an interview on 2/19/26, at 4:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that a resident received neurological assessments after an incident involving a fall for one of five residents (Resident R1) 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services. Residents Affected - Few Page 1 of 3 395160 395160 02/19/2026 Embassy of Saxonburg 223 Pittsburgh St Saxonburg, PA 16056

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of six residents (Residents R2, R3, R4, R5, and R6).Findings include:Review of facility policy Activities of Daily Living (ADLs) dated 1/15/26, indicated care and services will be provided for the following activities of daily living: bathing, dressing, grooming, and oral care; transfer and ambulation; toileting; eating to include meals and snacks, and using speech, language or other functional communication systems. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of facility policy Activities dated 1/15/26, indicated it is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. All staff will assist residents to and from activities when necessary. The facility will consider accommodations in schedules, supplies and timing in order to optimize a resident's ability to participate in an activity of choice. During an interview on 2/19/26, at 11:09 a.m. Resident R2 stated, Things are not good at all. There is no staff, mostly the aides. We go to Bingo every Monday, Wednesday, and Saturday and we haven't been there for a week because there's no staff on the 2 p.m. to 10 p.m. shift to get us back into bed. We don't get up out of bed at all sometimes because there is not enough staff to get us back to bed. If there aren't enough staff on the day shift, I don't get my shower. I'll put my call light on and sometimes it can take up to an hour for someone to answer it. It has been really bad lately. The Activities Director has come in and said we aren't having Bingo today because we don't have enough staff on 2 p.m. to 10 p.m. shift to put residents back to bed. During an interview on 2/19/26, at 11:29 a.m. Resident R3 stated, I think if you ask any resident here, they'll all tell you the same thing. We don't get out of bed now, maybe that will change if we get more staff. They have cancelled activities because there aren't enough staff. I've missed some of my showers, they tell me they can't do it on my shower days because there aren't enough staff.During an interview on 2/19/26, at 1:28 p.m. Resident R4 stated, They are running a little short-handed. Sometimes it takes up to 30 minutes to answer my call bell. I think they did once cancel an activity due to not having enough staff.During an interview on 2/19/26, at 1:34 p.m. Resident R5 stated, Activities are being cancelled due to not having enough staff. We haven't had Bingo since last week. We haven't been able to go down to the dining room to eat on-and-off because there aren't enough staff to supervise and help the people who need it. Staff have told me we can't go to the dining room because there aren't enough staff for the shift. It has been happening since the end of January; people are not coming out to work. I like to play cards with Resident R2, but if there aren't enough staff to get Resident R2 out of bed, we can't play cards.During an interview on 2/19/26, at 1:50 p.m. Resident R6 stated, Things are terrible. There are not enough staff, especially the aides. Staff say they can't give showers because we don't have enough help. It makes me so frustrated. During an interview on 2/19/26 at 4:06 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of five of six residents (Residents R2, R3, R4, R5, and R6). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code: 211.12(d)(1)(2)(3)(4)(f.1)(i)(2) Nursing services. 395160 Page 2 of 3 395160 02/19/2026 Embassy of Saxonburg 223 Pittsburgh St Saxonburg, PA 16056

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's plan of correction, documents and staff interviews it was determined that the facility failed to make a good faith effort to correct and sustain improvement for one of two citations issued for failure to provide the required number of Nurse Aides (NA) per resident per shift as required (Citation P5520).Findings include:A review of the facility's plan of correction revealed the following: Administrator and Director of Nursing (DON) educated by Regional Director of Clinical Operations on 1.19.26 on required state Certified Nursing Assistant ratios. In an attempt to achieve appropriate staffing ratios the facility has implemented a daily assignment grid that designates the required Certified Nursing Assistant ratios to meet state requirements. Assignment grids will be reviewed during labor meetings no less than 3x a week for 3 weeks. When a call off is received the supervisor will make every effort to fully replace hours. In the event it cannot be covered, the Director of Nursing will be notified so Administrative staff can reach out to employees for coverage. The facility will continue with recruitment and retention efforts to include enforcing the attendance policy. The facility will monitor staffing ratios utilizing the DOH staffing calculator tool 3x a week for 3 weeks. The results will be reviewed in future QAPI meetings to determine further need of audits. A review of facility-provided documents revealed the Nursing Home Administrator (NHA) and Director of Nursing (DON) received in-service education on 1/20/26, regarding the required state Certified Nurse Aide ratios. The provided documentation failed to include the assignment grids that were to be reviewed during labor meetings three times a week for three weeks.A review of the facility's staffing worksheet completed for 1/29/26, through 2/3/26, revealed that the facility was using an outdated staffing hours calculator that does not reflect current NA ratio regulations. During an interview on 2/19/26, at 10:57 a.m. the NHA confirmed that the facility was mistakenly using a staffing data calculator intended for outdated staffing regulations. A review of the facility's staffing worksheet, completed using the current staffing hours calculator, revealed that the facility failed to improve and sustain improvement regarding staffing ratios for NAs. It was determined that for the time period of 1/25/26, through 2/13/26, the facility failed to provide staffing to provide care to residents for 40 of 63 shifts for the NA position.During an interview on 2/19/26, at 4:06 p.m. information was disseminated to the NHA and DON that the facility failed to make a good faith effort to correct and sustain improvement for one of two citations issued for failure to provide the required number of Nurse Aides (NA) per resident per shift as required (Citation P5520). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.12(d)(1)(2)(3)(4)(f.1)(i)(2) Nursing services. Residents Affected - Many 395160 Page 3 of 3