Health inspection·July 10, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of manufacturer's directions, clinical records, incident/accident reports, staff training records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to ensure that safe techniques were used during a transfer onto a mechanical wheelchair lift for one of three residents reviewed (Resident 2), resulting in a head injury. Findings include: Manufacturer's directions for use of the [NAME] Corporation FMVSS Public Use Lift (the type of lift platform in the facility's wheelchair van), undated, indicated that the lift platform must be positioned at floor level when loading and unloading in and out of the vehicle. The lift operator would load and unload the wheelchair passenger on the lift and use the up and down switch to control the movement of the platform. A visual and audible warning would activate if the threshold area was occupied when the platform was greater than one inch below floor level of the van. The bus and van competency checklist for Nurse Aide/Transporter 1, dated November 30, 2023, revealed that staff received training prior to operating the electronic lift of the vehicle and demonstrated proper procedure for using the lift to load standard and electric wheelchairs. Nurse Aide/Transporter 1 met the standard to raise and lower the lift platform safely and in the correct position. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 21, 2024, revealed that the resident was cognitively intact, required extensive assistance from staff for her daily care including transfers, and used a wheelchair. A nursing note and incident report for Resident 2, dated June 26, 2024, at 3:26 p.m. revealed that the resident was lying on her left side on the pavement with her head on the lift platform that is used to load and unload residents from the van. Nursing notes for Resident 2, dated June 26, 2024, at 4:16 p.m. revealed that the resident had a skin tear on her right forearm and right foot, an abrasion on her right knee, scratches on her knuckles, and a 2.5 centimeter (cm) x 2.5 cm lump on the back of her head. A nursing note for Resident 2, dated June 26, 2024, at 5:06 p.m. revealed that the resident was sent to the hospital for a CT scan (diagnostic imaging test) after a fall with head injury. A statement from Nurse Aide/Transporter 1, undated, revealed that she unhooked the safety hooks, (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 07/10/2024 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)