Health inspection·August 25, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 4 was again escorted to his room. Physician and Psych certified nurse practitioner (CRNP) were onsite and agreed that Resident 4 be sent to the hospital. At approximately 8:00 PM the hospital emergency room called the facility and stated they were sending Resident 4 back to the facility. Documentation revealed the facility attempted to refuse Resident 4's admission but the transport van arrived with a driver, nurse from the local hospital, and Resident 4. Resident 4 got out of the van and again took off running. The facility called 911 again and the police located Resident 4 and returned him to the facility. There were no injuries noted. One on one care is continuing at this time. A picture of the resident was obtained and placed in the elopement book located at the front desk. A follow up elopement evaluation was completed August 5, 2025, and nursing staff assessed Resident 4, as a nine (high risk). Nursing documentation dated August 5, 2025, at 2:26 PM revealed Resident 4 was still pacing the halls trying to open windows. Documentation noted one to one remains in place. Nursing documentation dated August 13, 2025, at 9:39 AM revealed Resident 4 continued to exhibit exit seeking behaviors by going to the door and pushing numbers on the keypad. Staff was to maintain visual supervision when Resident 4 is having an acute episode. Nursing documentation dated August 14, 2025, at 3:25 PM revealed Resident 4 was walking throughout the halls, actively exit seeking, and clicking buttons at exit doors. Nursing documentation dated August 16, 2025, at 10:58 AM revealed Resident 4 was walking throughout the nursing unit, often going up to the keypads by the exit doors and typing in numbers. Nursing documentation dated August 22, 2025, at 9:56 AM revealed Resident 4 continued to seek exit doors and attempted to type in codes. Resident 4 was found pushing and pounding on the stairwell door on the unit. Further review of Resident 4's clinical record revealed no documentation of staff' one-to-one supervision with Resident 4. Review of Resident 4's plan of care-initiated August 4, 2025, revealed Resident 4 was at risk for wandering and elopement, but did not include any interventions regarding increasing Resident 4's supervision. Interview with the Nursing Home Administrator and Director of Nursing on August 25, 2025, at 11:30 AM confirmed they were unable to provide any documentation that the staff were completing one to one, or close supervision with Resident 4. The Director of Nursing stated she thinks Resident 4 was on one-to-one supervision from August 4 to 8, 2025, but was unable to provide any further documentation. During a meeting with the Nursing Home Administrator and Director of Nursing on August 25, 2025, at 9:30 AM the Nursing Home Administrator received a call from Resident 4's son indicating that Resident 4 left the facility and showed up at his former job location on the [NAME] State campus, approximately three quarters of a mile from the facility. The facility staff were unaware that Resident 4 left the building. Observation of Resident 4's room with the Director of Nursing on August 25, 2025, at 1:25 PM revealed that Resident 4 removed the screws from the window in his room, and there was no screen present. It was observed that Resident 4 would have had to walk down a hill to the facility courtyard, and from the courtyard it appeared that Resident 4 walked through two unsecured doors into an area the Director of Nursing called the breezeway, and then had access to the parking lot where he exited the facility. Nursing documentation dated August 25, 2025, at 3:22 PM noted the Nursing Home Administrator received a call from Resident 4's son stating Resident 4's son received a call from his former job location on the [NAME] State University campus. They notified Resident 4's son that his dad was there. The local police went to the location and returned Resident 4 to the facility. After a room search it was revealed that Resident 4 departed the facility through his room window. A butter knife was found in his bedside nightstand that is believed to have been used to unscrew the bolts that had the window secured. The facility failed to provide the highest practical care to Resident 4, preventing his elopement. The current facility policy entitled Medication Errors, revealed medication errors once identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395868 If continuation sheet Page 2 of 4 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 395868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Hearthside 450 Waupelani Drive State College, PA 16801 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete will be evaluated to determine if they are considered significant or not. If a medication error occurs, the nurse assesses and examines the resident's condition and notifies the physician as soon as possible. The nurse will monitor and document the resident's condition, including response to medical treatment or nursing interventions. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident report. Closed clinical record review revealed the facility admitted Resident CR1 on June 3, 2025. Further review revealed Resident CR1 remained in the facility until July 21, 2025, when he was sent to the hospital and was admitted with diagnoses including anemia (lack of healthy red blood cells), bronchitis, and hyperglycemia (high blood sugar). Review of Resident CR1's Medication Administration Record (MAR, a form utilized by the facility to document the administration of medications) dated July 2025, revealed the following three orders for Prednisone (medication used to decrease inflammation and suppress the immune system): Prednisone 20 milligrams (mg), two tablets one time only for cough and congestion on July 21, 2025, at 1:15 AMPrednisone 20 mg, two tablets four times a day for cough and congestion for four days on July 21, 2025, at 8:00 AMPrednisone 20 mg, two tablets one time a day for cough and congestion for four days on July 22, 2025, at 8:00 AM Interview with the Director of Nursing on August 25, 2025, at 1:20 PM confirmed the registered nurse wrote the Prednisone order on July 21, 2025, at 8:00 AM wrong, indicating it was supposed to be Prednisone 20 mg, two tablets one time a day instead of four times a day. The licensed practical nurse administered Resident CR1's 8:00 AM and 1:00 PM Prednisone doses. The nurse did not report the medication error, or complete an incident report, The facility failed to provide the highest practical care to Resident CR1 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395868 If continuation sheet Page 3 of 4 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 395868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Hearthside 450 Waupelani Drive State College, PA 16801 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined the facility failed to store food in accordance with professional standards for food service in the facility's main kitchen. Findings include: An observation in the facility's main kitchen on August 25, 2025, at 11:30 AM with Employee 1 (dietary manager) revealed the following: In the dry storage area, there was a bag of elbow macaroni, and a bag of opened egg noodles, with no open or use by dates. On the bread racks, there were six packs of English muffins, three loaves of bread, two packs of sandwich rolls, and one pack of hotdog rolls with no received or use by dates. In the walk-in Freezer, there was a box of mixed vegetables with no open or use by dates. The vegetables were not covered or sealed. In the walk-in refrigerator, there were boxes of mushrooms, lemons, and oranges with no open or use by dates. The items were not covered or sealed. In the reach-in cooler, there was an opened container of grape jelly and strawberry juice with no open or use by dates. In the production area, there was an opened box of thick and easy, bag of flour, container of peanut butter, container of quick oats, box of cream of rice, box of potato pearls, and a container identified by Employee 1 as Cream of Wheat. All of these items were opened with no open date or use by dates. The above findings in the main kitchen were reviewed with the Nursing Home Administrator and Director of Nursing on August 25, 2025, at 3:04 PM. 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 3/14/25 28 Pa. Code 201.14 (a) Responsibility of Licensee Event ID: Facility ID: 395868 If continuation sheet Page 4 of 4