Health inspection·January 29, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interviews, it was determined that the facility failed to ensure that residents had a clean and homelike environment by failing to ensure that three medication carts and two mechanical lift machines were free of dirt and debris. Findings include: Observations on January 29, 2024, at 10:00 a.m. revealed that there was one stand-up lift machine parked in the hall that had a large accumulation of dirt, dust, debris, and food on the base of the machine. Observations of the full-body lift in the shower room at that time revealed that there was an accumulation of dirt, dust, and debris on the base of the lift. Interview with Nurse Aide 1 on January 29, 2024, at 10:11 a.m. revealed that she was not sure who was supposed to clean the mechanical lift machines. She stated she just uses them and did not notice the dirt or debris on the bases. Observations on January 29, 2024, at 10:18 a.m. revealed that one medication cart on the 300 hall had a large accumulation of hair, dirt, and debris on both of the rear casters. Interview with Licensed Practical Nurse 2 on January 29, 2024, at 10:18 a.m. revealed that she wipes her cart down at the start of her shift and at the end of her shift, but she does not routinely check the wheels of the carts. She stated the rear wheels do need cleaned and should not have a large build up of hair, dirt, and debris. Observations on January 29, 2024, at 10:20 a.m. revealed that both medication carts on the 200 hall had a large accumulation of hair, dirt, and debris. Interview with Licensed Practical Nurse 3 on January 29, 2024, at 10:20 a.m. revealed that there used to be a housekeeper that would take care of everything, including the wheels on the medication carts; however, she has since retired. He said he had not thought to check the wheels on the carts but that they did need cleaned. Interview with the Maintenance Director on January 29, 2024, at 11:12 a.m. revealed that he does check the equipment, such as the mechanical lifts, for functionality and safety, but he does not clean them. He said that if he notices hair build-up around the casters he takes it off, but he does not routinely clean them. Interview with the Director of Nursing on January 29, 2024, at 12:12 p.m. revealed that the nurses (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: 395697 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 395697 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Woodland Park 18889 Croghan Pike Orbisonia, PA 17243 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)