Health inspection·October 7, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few then winked at Employee 4. Employee 4 also indicated that after Resident 1 calmed down Employee 3 asked her to assist with trimming the resident's nails. She said Employee 3 held Resident 1's wrist while she trimmed her nails. Employee 4 also said that she heard Employee 3 at the nurse's station verbalizing that she made Resident 1 take the pills and held her mouth shut. The facility investigation notes revealed that they interviewed Employee 5, NA, in person on October 3, 2025, and by telephone on October 5, 2025. Employee 5 indicated that Resident 1 struck her on the shoulder with a Swiffer broom. She indicated that Employee 3 entered the room after hearing the resident yelling. Employee 5 said that they were all looking for the Ativan tablets that Resident 1 hit out of Employee 2's hand. Employee 5 said the Ativan pills were found, one was in bed, and the other was on the floor. Employee 5 then said that she witnessed Employee 3, wrestle Resident 1 onto the bed, place the pills in the resident's mouth, and hold the resident's mouth closed until the pills dissolved. Employee 5 said that Resident 1 looked at Employee 3 and said that she would get hers and that she would get her. Employee 5 also indicated that she heard Employee 3 at the nurse's station saying, I made the resident take the pills because she scratched the shit out of me. The facility investigative notes revealed that they interviewed Employee 3 visa text messages on October 5, 2025, regarding the incident that occurred on October 1, 2025. Employee 3 indicated that she heard yelling twice. When she heard it the second time she went into the hallway and noted Employee 5 backing out of Resident 1's room with a Swiffer broom. She said Employee 5 claimed that Resident 1 hit her with the Swiffer. Employee 3 said that Resident 1 was holding her door closed and Employee 2 told Employee 3 that she needed her to get into the room because the resident knocked narcotics out of her hand, and she couldn't leave them in there on the floor. When Employee 3 entered the room Resident 1 was trying to hit her with a shoe. Employee 3 said she grabbed the shoe from Resident 1, and Resident 1 then clawed her face and chest. Employee 3 then indicated that she walked out of the room. Employee 3 said that she knew the pills were found on the floor and that Employee 2 had them, but she was not sure if they were administered. Employee 3 stated she did see Employee 2 go back into the room. Employee 3 also indicated that after the Resident 1 calmed down her and Employee 4 went in and cut her fingernails. Employee 3 said that she held Resident 1's upper hand and used her other hand to hold up her fingers so Employee 4 could cut the nails. Employee 3 denied hurting Resident 1 or grabbing her. Employee 3 indicated that she reported this event to Employee 6, RN. The facility investigative notes revealed that they interviewed Employee 6 on October 5, 2025, regarding the incident that occurred on October 1, 2025, with Resident 1. Employee 6 indicated that no one reported anything to her on October 1, 2025, regarding an incident with Resident 1. Employee 6 indicated that she had no information about the incident. A social service progress note dated September 18, 2025, at 1:00 PM revealed that an interdisciplinary meeting was held with the son in attendance via telephone. The note indicated that the son said she liked chips, sweets and soda, she was big into horseracing, playing cards, and loved animals. He also indicated that he was aware of her continuous behavior of refusing care and gave tips that could possibly work, including showing her the bandage and point to the area prior to a dressing change, use hand signals, talk loudly, allow her to read lips, and write on a board. He also said she was always non-compliant with medications. Review of Resident 1's current care plan revealed that Resident 1 has a history of and potential to exhibit the following behaviors, physical abuse towards staff, verbal abuse towards staff, refuses medications, vitals, x-rays and will refuses to eat initiated on September 17, 2025. The interventions that were suggest by the son at the meeting on September 18, 2025, were not present in the care plan for her behavior interventions. This was confirmed by the DON during an interview on October 7, 2025, at 12:30 PM. Further Interview with the DON on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395868 If continuation sheet Page 2 of 3 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 10/07/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete October 7, 2025, at 12:30 PM revealed that she was not made aware of the incident that occurred on October 1, 2025, until the bruises were found on October 3, 2025. She confirmed that the incident was not reported to her timely and in turn she did not report to the proper entities until October 7, 2025. She indicated that as soon as she found out on October 3, 2025, Employee 3 was immediately suspended related to the investigation and was then terminated on October 7, 2025, from her employment with the facility due to the facility substantiating her part in the physical abuse to Resident 1 by using excessive physical force by grabbing her arms and causing bruising, for administering medications to Resident 1 (which is outside of her scope of practice as a nurse aide), and holding her mouth shut until the medications dissolved. Interview with the DON and NHA at 2:30 PM on October 7, 2025, revealed that no disciplinary actions have been initiated on the other perpetrators (Employees 2, 4, and 5) yet and that they were still working their normal schedules. They also indicated that re-education on abuse of all staff was initiated this morning, October 7, 2025, but is not finished yet. The facility failed to implement timely measures related to all perpetrators after Resident 1's incident that occurred October 1, 2025. The facility failed to protect Resident 1's right to be free from physical abuse by staff resulting in bruises to her left upper arm and medication administration against her will. 483.12 Freedom from Abuse, Neglect and ExploitationPreviously cited 3/14/202528 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management28 Pa. Code 201.19(6)(7)(8) Personnel policies and procedures28 Pa. Code 201.20(b)(d) Staff development28 Pa. Code 201.29 (a)(c) Resident rights28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Event ID: Facility ID: 395868 If continuation sheet Page 3 of 3