Inspection·December 3, 2024

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation of life equipment, and staff interviews, it was determined that the facility failed to maintain patient care equipment in a safe operating condition to keep mechanical lift in safe operating condition for one of four mechanical lifts reviewed ). Residents Affected - Few Findings include: Review of the facility policy, Safe Lifting and Movement of Residents dated 1/31/24, indicated the maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure it remains in good working order. Review of the Manufacturer Instructions Preventive Maintenance Schedule for the Maxi Move Arjo dated 9/6/2023. Staff should visually inspect the unit prior to use and yearly inspections to be conducted by a qualified service technician. Review of the facility Preventive Maintenance documents for 9/9/24 and 10/7/24, revealed internal checks of the lift equipment is completed and maintained in a logbook. Review of the facility Preventive Maintenance documents for the lifts, revealed their contracted vendor ISS Solutions inspects the lift equipment. The most recent ISS inspection was completed on 9/20/24. Lift Serial number SEE0613041 was deemed ok for use. Review of the four of twenty-four residents utilizing lift equipment 12/3/24, no lift related incidents. Resident R3, Resident R8, Resident R9, and Resident R10. During an observation on 12/3/24, at 12:10 p.m. two of the three lifts were observed in the lift equipment room. The third lift was in use. During an interview on 12/3/23 at 12:00 p.m. Employee E1 reported the lift was visually checked prior to lifting Resident R1, with no observed issues, green pad utilized and two staff performed lift per policy. During an interview on 12/3/24, at 12:30 p.m. Employee interviews conducted with Employee E1, E2, E3, E4 and E5 who confirmed locations of lifts, the number of lifts available and visual check is done prior to use. During an Interview on 12/3/23 at 12:50 p.m. Employee interviews conducted with Employee E1, E2, E3, E4 and E5 who confirmed receiving education on lifts upon hire and additional education after the fall of Resident R1. (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: 395675 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 395675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waynesburg Nursing and Rehab 300 Center Avenue Waynesburg, PA 15370 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)