Embassy of Saxonburg

In the surveyor’s words

From the most serious findings on record at Embassy of Saxonburg, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 1, 2026

  Based on review of facility policy, facility documentation, clinical records, staff and resident representative interview, it was determined that the facility failed to protect a cognitive impairment resident (Resident R1) from non-consensual sexual contact by Closed Record Resident CR2 (Resident CR2) who had a history of sexually inappropriate behaviors with Resident R1. This failure resulted in an Immediate Jeopardy situation for one of 58 residents, when Resident CR2 was found exposing genitals to Resident R1, and Resident R1's hands were on Resident CR2's genitals. Findings Include: Review of facility policy Abuse, Neglect, and Exploitation dated [DATE], indicated that abuse can be identified as verbal, physical, mental, and sexual. […]

• Immediate jeopardy, isolatedF600Mar 14, 2026

  Based on review of facility policy, clinical records, staff and resident interviews, it was determined that the facility failed to ensure that residents were free from mental and verbal abuse which caused a resident to experience severe psychosocial harm (embarrassment, humiliation) because of the abuse (Resident R1). This situation created an Immediate Jeopardy situation for one of six residents reviewed (Resident R1). Findings Include: Review of the facility provided policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property review date of 1/21/26, indicated This facility will not tolerate Abuse, Neglect, and Exploitation of its residents or the Misappropriation of Resident Property. […]

• Immediate jeopardy, isolatedF607Mar 14, 2026

  Based on policy, employee files, facility documents, staff interviews, it was determined that the facility failed to ensure all staff had a criminal background check prior to working in the facility for one of seven staff members (Social Worker, Employee E1). The facility failed to identify incidents of abuse/neglect, and timely report and investigate allegations of abuse/neglect for one of six residents (Resident R1). The facility put other residents at risk for abuse/neglect from the Nursing Home Administrator (NHA) and Licensed Practical Nurse LPN), Employee E2, by allowing the staff members to continue to work after abuse/neglect occurred. […]

• Actual harm, isolatedF600Nov 13, 2025

  Based on review of facility policy, facility provided documents, clinical records, and staff interviews, it was determined the facility failed to ensure a resident was free from mental abuse and intimidation for one of two residents reviewed (Resident R1), which resulted in psychosocial harm and mental anguish related to the reasonable person concept. Findings include: Review of facility's policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 2/19/25, revealed the facility will not tolerate abuse, neglect, and exploitation of its residents. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. […]

• Actual harm, isolatedF686Feb 16, 2022

  Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to prevent avoidable pressure sore development that resulted in actual harm (stage three pressure sore) for one of four residents reviewed (Resident R1). This was identified as harm for past non-compliance for one resident (Resident R1). Findings include: A review of the facility policy Pressure Ulcer Prevention and Management Program, updated 5/4/21, indicated the facility is committed to providing a comprehensive pressure ulcer prevention and management program to ensure that residents admitted to the facility without pressure ulcers do not develop them unless the individual ' s clinical condition demonstrates they are unavoidable. […]