Health inspection·April 11, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to implement dignified feeding practices and to maintain resident dignity and respect by serving meals in a timely manner to individuals seated at the same table for two of two dining areas observed (North and Haven). Findings include: Review of facility policy entitled Dining Experience Policy dated 10/28/24, indicated All residents seated at the same table should be served before moving to another table. Review of facility policy entitled Safe and Homelike Environment dated 10/28/25, indicated In accordance with residents' rights, the facility will provide a . comfortable and homelike environment . Observations of the afternoon meal in the North and Haven dining rooms on 4/9/25, between 12:40 p.m. and 1:00 p.m. revealed the following. On 4/9/25, at 12:40 p.m. there was a table in the north dining room with five residents seated together around the table. Four residents were consuming their meals while one resident without their meal, watched the others eat. The last resident at the table was served at 12:50 p.m. and began eating his/her meal. At that time, the four other residents finished their meals and had left the table. On on 4/9/25, at 12:55 p.m. there was a food cart being delivered to Haven dining room. In the dining room were four different tables with residents seated together. The first table had four residents seated together and one resident had consumed his/her meal and the other three were just being served their meals. The second table had two residents seated together and one resident had consumed their meal and the other one was just being served their meal. The third table had four residents seated together and one resident had consumed their meal and the other three had not been served yet. The fourth table had three residents seated together and one resident had consumed their meal and was leaving the table. The other two residents had not been served their meals yet. During an interview on 4/9/25, at 1:10 p.m. Nursing Assistant Employee E1 stated the first meal cart was delivered at 12:35 p.m. He/she confirmed that residents that were seated at the same table together and were not served at the same time. He/she also confirmed that some residents had consumed their meals and were leaving the dining room. Interviews on 4/9/25, between 10:00 a.m. and 1:00 p.m. with Resident's R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10, confirmed they received meals in Styrofoam containers several days a week and the Page 1 of 5 395588 395588 04/11/2025 Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few food is often cold as a result. Residents listed above revealed they are aware meals were being served in Styrofoam containers as a result of dietary staffing shortages. Interview on 4/9/25, at 11:40 a.m. with Resident R11's family member revealed that they eat at the facility with Resident R11 several days a week. They confirmed that meals are served in Styrofoam containers several days a week and the food is often cold as a result. Interview on 4/9/25, at 12:50 p.m. with Dietary Aide Employee E2 revealed that dietary uses Styrofoam containers due to not having enough staff in the dietary department. Interview on 4/9/25, at 12:20 p.m. with the Dietary Manager Employee E3 revealed that the dietary department is not staffed adequately. He/she also revealed that meals are served in Styrofoam containers when the dietary department is not staffed adequately. Interview on 4/9/25, at 1:30 p.m. with the Dietary Manager Employee E3 confirmed that Styrofoam containers are used for resident's meals due to staffing in the dietary department. He/she also confirmed that residents sitting at the same table for meals should be served at the same time. Refer to F802 Sufficient Dietary Support Personnel 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services 395588 Page 2 of 5 395588 04/11/2025 Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335

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 facility policy and clinical record, and staff interviews, it was determined that the facility failed to notify the resident's physician and emergency contact timely regarding a change in condition for one of 13 residents reviewed (Resident R1). Findings include: The facility policy entitled Notification of Responsible Party and Physician Procedure, dated 10/28/24, indicated that the nurse should notify the Primary Care Physician when a resident has a significant change in clinical status such as a decline in condition, new/worsening symptoms, new/change in pain status The nurse or designee will notify the responsible party regarding change in the resident's clinical status The clinical record revealed that Resident R1's initial admission date was 1/17/23, with diagnoses including nstemi myocardial infarction (a serious heart attack causing damage related to a reduced blood supply to the heart), type II diabetes (when the body does not use insulin properly with poor blood sugar control), and muscle weakness. The clinical record progress notes revealed that on 1/25/25, at 12:38 a.m. Resident R1 was a little off and had slurred speech. The physician and emergency contact were not notified of these changes in condition timely. During an interview on 4/11/25, at approximately 9:30 a.m. the Director of Nursing and Nursing Home Administrator confirmed that the physician and emergency contact should have been contacted and it should have been documented in the clinical record at the time of the slurred speech. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 395588 Page 3 of 5 395588 04/11/2025 Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observations, review of facility records, and resident and staff interviews, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the kitchen. Findings include: Review of facility policy entitled Safe and Homelike Environment dated 10/28/25, indicated In accordance with residents' rights, the facility will provide a . comfortable and homelike environment . Review of four weeks of dietary schedule lacked evidence that the appropriate number of trained dietary staff were scheduled each day. Review of grievances revealed that residents going to dialysis did not have meal trays ready for residents to consume before going to dialysis. Review of Resident Council meeting minutes and food committee minutes from 3/25/25, revealed resident concerns of food is warm or not hot. Interviews on 4/9/25, between 10:00 a.m. and 1:00 p.m. with Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10 revealed that they are receiving meals in Styrofoam containers several days a week and the food is often cold as a result. Residents identified above revealed they are aware meals were being served in Styrofoam containers as a result of dietary staffing. Interview on 4/9/25, at 11:40 a.m. with Resident R11's family member revealed that they eat at the facility with Resident R11 several days a week. They confirmed that meals are served in Styrofoam containers several days a week and the food is often cold as a result. Interview on 4/9/25, at 12:50 p.m. with Dietary Aide Employee E2 revealed that dietary uses foam containers due to not having enough staff in the dietary department. He/she expressed that there have been several shifts that there had only been a cook and one dietary aide working. Interview on 4/9/25, at 12:20 p.m. with the Dietary Manager Employee E3, revealed that the dietary department is not staffed adequately. He/she revealed there have been shifts when there are only two staff working in the dietary department. He/she also revealed that meals are served in Styrofoam containers when the dietary department is not staffed adequately. Interview on 4/9/25, at 1:30 p.m. with the Dietary Manager Employee E3, confirmed that Styrofoam containers are used for resident's meals due to staffing in the dietary department. He/she also confirmed that residents sitting at the same table for meals should be served at the same time. Interview on 4/11/25, at 10:50 a.m. with the Nursing Home Administrator (NHA) he/she confirmed that staffing levels in the dietary department should be one cook and three dietary aides for each shift. Refer to F550 Resident Rights 395588 Page 4 of 5 395588 04/11/2025 Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335

F 0802 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(3) Management Residents Affected - Few 395588 Page 5 of 5