Health inspection·November 22, 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 review of clinical records and facility policy and staff interviews, it was determined that the facility failed to notify the resident's representative of a change in condition and/or treatment for one of 24 residents reviewed (Resident R30). Findings include: The facility policy entitled Notification of responsible party and physician procedure dated 10/28/24, revealed Goal: The facility makes reasonable attempts to assure that responsible party and physician are notified and kept aware of a resident's condition, changes in orders, acute situations, lab/x-ray results, significant change in status, incidents that effect a resident's status or transfer from the facility to hospital, another agency or a change in residence. The responsible party will also be notified of incidents and accidents regarding the resident, medication error, change in medication/treatment, labs/x-rays/tests and results or transfer out of the facility. Documentation: Notification and attempts to notify the physician, responsible party and third party vendors should be documented. The DON/ADON [Director of Nursing/Assistant Director of Nursing] should be kept aware of unsuccessful notification attempts. Resident R30's clinical record revealed an admission date of 3/26/21, with diagnoses that included unstageable pressure ulcer of right hip (a type of wound covered by slough or dead/blackened tissue), diabetes mellitus (a disease when the body has trouble controlling blood sugar and using it for energy), weakness, and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Resident R30's clinical record revealed a physician's order dated 11/12/24, for Voltaren External Gel 1% (Diclofenac Sodium Topical), Apply to knees, elbows typically every 6 hours as needed for pain 2 grams. Resident R30's progress notes dated 11/12/24, indicated that x-ray (a type of radiation imaging that creates pictures of the inside of your body) results were reviewed with the Certified Registered Nurse Practitioner (CRNP) and an order was received for Voltaren gel 2 grams every six hours as needed for pain. The clinical record lacked evidence that Resident R30's representative was notified of CRNP's orders/treatment change and x-ray findings dated 11/12/24. An interview with Resident R30's representative on 11/19/24, at 1:00 p.m. revealed the facility does not always update him/her of new orders and/or test results. (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 4 Event ID: 395588 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 395588 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335 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)