Park Avenue Health and Rehabilitation Center

Inspectors wroteBased on interviews, review of clinical record, the State Agency (SA) complaint portal, and review of facility policy and procedure, the facility failed to ensure the facility investigation and medical record were complete and accurate for one resident (#2), and regarding an incident of abuse. The deficient practice could result in care team members not being adequately informed regarding the status of the resident and lead to missed or delayed care.

Inspectors wroteBased on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure infection control policies were followed during therapy sessions for five residents (#44, #45, #55, #180, and #181). The deficient practice could lead to spread of infection.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure that the catheter bag was covered for one resident (#176). The deficient practice could result in resident not being treated with dignity and respect.

Inspectors wroteBased on clinical record review, interviews, facility documentation and review of the facility policy, the facility failed to ensure that a change of condition, for one resident (#3) out of 3 sampled, was immediately reported to the physician. The deficient practice could result in clinically adverse outcomes for the resident.

Inspectors wroteBased on clinical record review, interviews, and policy and procedures, the facility failed to ensure that an allegation of abuse was reported to the state agency for one of of three residents. The deficient practice could further endanger the resident and impede an investigation.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 14 sampled residents (Resident # 28) was free from abuse by another resident (Resident # 23). The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy review, the facility failed to provide care and services in accordance with the resident's care plan for one resident (#34) regarding administration of scheduled medications as ordered by the physician. This deficient practice has the potential to result in residents not receiving necessary antibiotic treatment as planned, placing them at increased risk for unresolved infections and adverse health conditions.

Inspectors wroteBased on interviews, records review, policy review, and the SA Complaint Tracking System the facility failed to ensure adequate supervision was provided to one resident (#5) to prevent injury/accident. The deficient practice could result in harm and injury.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policy and procedures, the facility failed to ensure that care and services related to pressure ulcers was provided for two residents (#535 and #537). The deficient practice resulted in lack of thorough pressure ulcer assessments and/or identifying wound deterioration timely. The facility census was 101 and the sample was 22.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy and procedure, the facility failed to ensure the resident representative was notified after a change in condition for one resident's (#537). The deficient practice could result in resident representative not notified and the required decisions for the resident are not made. The facility census was 101, and the sample was 22.

Inspectors wroteBased on observation, clinical record review, staff interviews, policy and procedures review, the facility failed to ensure one resident (#68) was free from restraint. The deficient practice could result in harm to a resident secondary to restricted mobility of extremities.

Inspectors wroteBased on observations, clinical records, facility documents, resident and staff interviews, the facility failed to ensure the necessary dermatology appointment was scheduled for one resident (#104). The deficient practice could result the resident missing the appointment and not receiving the appropriate and necessary treatment.

Inspectors wroteBased on observations, staff interviews, Influenza Vaccine Manufacturer's Guidelines and the Centers for Disease Control and Prevention (CDC)guidelines, the facility failed to ensure expired medications were not readily accessible for resident use; and, the facility failed to ensure open multi-dose vials were dated and discarded according to manufacturer's guidelines. The deficient practice could result in alterations in the effectiveness of the medications that the residents are receiving.

Inspectors wroteBased on clinical record review, resident and staff interviews and facility assessment review, the facility failed to ensure that assistance in making the necessary dental appointment was provided for one resident (#81). The deficient practice could result in resident having dental complications.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy review, the facility failed to ensure three residents (#53, #415 and #426) and their representatives were provided a summary of the baseline care plan. The sample size was 24. The deficient practice could result in a summary of the baseline/comprehensive care plan not being provided to residents and their representatives.

Inspectors wroteBased on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure that two residents (#81 and #28) did not receive unnecessary medications. The sample size was 5. The deficient practice increases the risk of residents receiving medications unnecessarily.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that meals were served at an appetizing temperature. The deficient practice could lead to issues with nutrition and impact residents' quality of life.

Inspectors wroteBased on observations, staff interview, and the dishwasher manual, the facility failed to ensure food safety requirements were followed. The deficient practice could result in foodborne illness.

Inspectors wroteBased on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure that a Level I Pre-admission Screening and Resident Review (PASRR) accurately reflected one resident's diagnoses (#28), and failed to ensure two residents (#28 and #50) received PASRR Level I screening after remaining in the facility longer than 30 days. The sample size was 3. The deficient practice increases the risk that individuals identified with mental disorders may not be evaluated to receive care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased upon clinical record review, observation, and resident and staff interviews, the facility failed to ensure that one of two sampled residents (#6) received care and treatment in accordance with professional standards regarding a rash. The deficient practice could result in treatment being delayed or not being provided.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure that one of two sampled residents (#69) received treatment and services to prevent/heal a pressure ulcer/injury consistent with professional standards of practice. The deficient practice increases the risk for infection and rehospitalization.

Inspectors wroteBased on observations, staff interviews, and the glucometer guide, the facility failed to ensure infection control standards were maintained regarding glucometers. The deficient practice could result in transmission of infection.

Inspectors wroteBased on observations, family and staff interviews, and policy and procedure, the facility failed to ensure the call light for one resident (#74) was functioning correctly. The sample size was 24. The deficient practice could result in residents not having the means to communicate with staff and not receiving care and services in a timely manner.