Health inspection·July 18, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy and clinical record, and staff and resident interviews, it was determined that the facility failed to safely transfer a resident using a mechanical lift for one of one residents reviewed (Resident R9). Findings include: Review of a facility policy entitled Safe Resident Handling/Transfers revised 6/01/24, revealed that two staff members must be utilized when transferring residents with a mechanical lift. Resident R9's clinical record revealed an admission date of 6/14/24, with diagnoses that included Rheumatoid Arthritis (condition where the body's immune system attacks its own tissue, typically in the hands and feet, and causes painful swelling), Lymphedema (tissue swelling caused by any type of problem that blocks the drainage of lymph fluid, most commonly affects the arms or legs), lack of coordination, weakness, and abnormal gait and mobility. Resident R9's [NAME] (documentation system that provides information regarding necessary resident care) included special instructions to utilize a sit-to-stand lift to transfer to power wheelchair, and his/her task indicated he/she was non-ambulatory and included sit-to-stand lift to transfer to power wheelchair. Observation on 7/18/24, at 11:53 a.m. revealed Nurse Aide (NA) Employee E1 lowered Resident R9 into the power wheelchair without the assistance of a second staff member. During an interview on 7/18/24, at 11:54 a.m. NA Employee E1 would not confirm utilizing the sit-to-stand lift without the assistance of another staff member. During an interview on 7/18/24, at 11:57 a.m. NA Employee E2 confirmed that he/she did not assist NA Employee E1 with operating the sit-to-stand lift to place Resident R9 into his/her power wheelchair. During an interview on 7/18/24, at 12:00 p.m. Resident R9 confirmed that usually there are two staff, but today the aide did not get help to use the lift. During an interview on 7/18/24, at 12:10 p.m. Licensed Practical Nurse Employee E3 confirmed that staff are supposed to have two people when using the mechanical lifts. (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 2 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 07/18/2024 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)