Health inspection·February 10, 2026

F 0551 Give the resident's representative the ability to exercise the resident's rights. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to honor the resident and the responsible party's right to make informed decisions regarding his/her treatment for one of eight residents reviewed (Resident 1).Findings include:A facility policy for residents' rights regarding treatment and advanced directives dated December 10, 2025, indicated that it is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advanced directives. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated January 4, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), and was receiving Hospice (program that gives special care to people who are near the end of life) services. Review of a care plan for Resident 1 dated January 24, 2026, revealed that the resident had a PleurX catheter (small, flexible, tunneled tube surgically placed in the chest or abdomen to provide long-term, at-home drainage of recurrent fluid buildup caused by cancer) and nursing was to observe the wound dressing daily to ensure that the dressing remained intact and that there were no signs and symptoms of infection or increased drainage, and observe for clinical changes, such as infection and/or worsening of the wound.A nurse's note for Resident 1 dated January 15, 2026, at 5:15 p.m. revealed that the resident's wife was requesting the resident be sent to the emergency room because his liver cath was still leaking. The resident's wife requested she speak to the provider and that the resident be sent to the emergency room. The nurse called the Certified Registered Nurse Practitioner (CRNP-an advanced practice registered nurse who can provide comprehensive, patient-centered care, including diagnosing illnesses, prescribing medications, and ordering diagnostic tests ) with a resident assessment. The CRNP then phoned hospice and called that nurse back stating that the CRNP and the hospice nurse were in agreement that the resident did not need to go to the emergency room and that the hospice nurse could come see him at the facility. The resident's wife stated, screw hospice and this facility, I can do what I want with my husband, and you will not tell me otherwise. The resident's spouse was advised that should she decide to leave she will need to sign against medical advice forms. The spouse responded she would not be signing s**t. Staff informed the resident's spouse that they have a right to go to the emergency room, but she could not provide an order for transfer, and it would be against medical advice because the provider wished for them to stick around for the hospice nurse to assess the resident. Interview with the Regional Registered Nurse on January 10, 2026, at 4:14 p.m. revealed that if Resident 1's responsible party requested that the resident be sent to the hospital for evaluation, he should have been sent. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Residents Affected - Few Page 1 of 4 395297 395297 02/10/2026 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

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 Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of eight residents reviewed (Resident 1) and failed to assess a wound for one of eight residents reviewed (Resident 2). Findings include:An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated January 4, 2026, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), and was receiving Hospice (program that gives special care to people who are near the end of life) services. Physician's orders for Resident 1 dated January 4, 2026, included for the resident to receive 500 milligrams (mg) of Cipro (an antibiotic) every morning and at bedtime for purulent (a thick, often yellowish or greenish fluid that indicates an active bacterial infection) drainage for 10 days. Review of the Medication Administration Record (MAR) for Resident 1 dated January 2025 revealed, on January 4, 2026, at 8:00 p.m. and January 5, 2026, at 8:00 a.m. 500 mg of Cipro was documented as not administered, and that 500 mg of Cipro was administered in the morning and at bedtime on January 5, 2026, at 8:00 p.m. through January 14, 2026, at 8:00 a.m. for a total of nine days. Interview with the Regional Registered Nurse on January 10, 2026, at 3:22 p.m. revealed that Resident 1's orders for Cipro should have been adjusted when the first two doses were not administered for the resident to receive it for 10 days as ordered, however it was not. An admission MDS assessment for Resident 2, dated December 22, 2025, indicated that the resident was cognitively intact, was occasionally incontinent of bowel, and had no wounds. A care plan, dated December 15, 2025, revealed that weekly skin assessments were to be completed and the charge nurse was to notify the wound nurse, physician, and family of any new areas.A skin assessment for Resident 2, dated December 16, 2025, revealed the resident's skin was intact. Physician's orders, dated December 16, 2025, included orders for zinc oxide be applied to both buttocks and the coccyx topically every shift for prevention.A skin assessment for Resident 2, dated December 23, 2025, revealed the resident's skin was not intact, the previous area was identified, and the buttocks and coccyx had a treatment in place. However, there was no documented evidence of an assessment when the skin changed from intact to not intact or that the wound nurse was notified of the change.A skin assessment for Resident 2, dated December 26, 2025, revealed that resident had a closed abrasion on the right buttocks measuring 0.5 x 0.5 centimeters (cm) and blanchable redness on both buttocks.Interview with the Regional Registered Nurse on February 10, 2026, at 2:10 p.m. confirmed that the resident had an abrasion and there was no assessment of the area on December 23, 2025.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. Residents Affected - Few 395297 Page 2 of 4 395297 02/10/2026 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were treated with the current physician's orders for one of 8 residents reviewed (Resident 4). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated January 4, 2026, revealed that the resident was confused, required extensive assistance with daily care needs, and had pressure ulcers. Physician's orders for Resident 4, dated, February 4, 2026, was for the right foot to be cleansed with soap and water, apply Calmoseptine, then a heel cup, and to change daily.A Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse that can work independent of a physician) wound nurse note for Resident 4, dated February 3, 2026, revealed that the resident's treatment to the pressure ulcer on her right heel had changed from Gentamicin to Calmoseptine. A review of Resident 4's Treatment Administration Record (TAR) for February 2026 revealed that as of February 10, staff were applying the Gentamicin Ointment to the pressure ulcer on the right heel pressure ulcer in the evenings and also applying the Calmoseptine to the right heel pressure ulcer in the mornings.An interview with the Regional Nurse on February 10, 2026 at 3:56 p.m. revealed that the Gentamicin should have been discontinued on Feburary 3, however, it was not and the staff were applying both ointments, instead of just the Calmoseptine as ordered.28 Pa. Code 211.12(d)(3)(5) Nursing services. Residents Affected - Few 395297 Page 3 of 4 395297 02/10/2026 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of facility policy and observations, as well as staff interviews, it was determined that the facility failed to provide an environment free from accident hazards. Findings include: The facility's policy for Oxygen, dated December 10, 2025, revealed that portable oxygen tanks would be stored in a safe manner, in an upright position.Observations of the 100 hall, short side, on February 10, 2026 at 1:45 p.m. revealed there was a metal stretcher with a full portable oxygen tank laying on the middle section, unsecured. The stretcher was parked outside of resident's rooms and was within reach of the residents.Interview with Licensed Practical Nurse 1 on February 10, 2026 at 1:45 p.m. revealed that the oxygen tank should not have been stored in the hallway on the stretcher. She further stated she did not know why the stretcher was there either.Interview with the Regional Nurse on February 10, 2026 at 2:02 p.m. revealed that the oxygen tank should have been stored securely and not laying on a stretcher in the hallway. 28 Pa. Code 211.12(d)(5) Nursing services. 395297 Page 4 of 4