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 (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 5 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 04/11/2025 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)