Health inspection·April 1, 2025

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 review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of five residents reviewed (Resident 4). Residents Affected - Few Findings include: The facility's policy regarding medication administration, dated March 13, 2025, indicated that medications are to be administered by licensed nurses in accordance with professional standards. Staff are to compare the medication source (bubble pack, vial, etc) with the Medication Administration Record (MAR) to verify the resident name, medication name, form, dose, route, and time. The staff are to observe resident consumption of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had constipation and dementia. A care plan for Resident 4, dated April 29, 2024, revealed that the resident was at risk for constipation and complained of gas pains at times. Staff were to administer medications as ordered by the physician. Physician's orders for Resident 4, dated September 10, 2024, included an order for the resident to receive 8.6-50 milligrams of senna-docusate sodium (stool softening medication) with instructions to give three tablets by mouth once time a day for constipation at 8:00 p.m. Observations of Resident 4 on April 4, 2025, at 4:24 p.m., revealed that she was lying down in bed, and there was a medication cup with three red pills and a cup of water on the over-bed table. Resident 4 sat up and took the pills. Interview with Licensed Practical Nurse 1 on March 1, 2025, at 4:47 p.m. confirmed that she left the medication at bed side, and it was to be administered in the evening. She identified the medication as senna-docusate. Interview with the Director of Nursing on April 1, 2025, at 5:17 p.m. confirmed that licensed staff responsible for medication administration should administer the medication at the physician-ordered time. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 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 2 Event ID: 395697 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 395697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodland Park 18889 Croghan Pike Orbisonia, PA 17243 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)