Park Avenue Health Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a mechanical lift with transfers, the Facility failed to ensure his/her safety was maintained during a mechanical lift transfer to prevent an incident/accident resulting in serious injury. On [DATE], during a transfer the mechanical lift stopped functioning with Resident #1 suspended up in the air in lift sling, staff tried to physically move the mechanical lift to position him/her over the bed, Resident #1's body began to sway in the lift sling, and his/her head struck the bedrail. Resident #1 sustained a head laceration, was transferred to the Hospital Emergency Department for evaluation and he/she required five staples to close the wound.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who per staff interviews has always been transferred via two person assist with the use of a mechanical lift, the Facility failed to ensure his/her comprehensive person-based plan of care related to transfer status indicated his/her dependence on the use of a mechanical lift device, that included interventions, goals and outcomes.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain accurate medical records for three residents (#35, #5 and #69), out of a total sample of 18 residents. Specifically,1. For Resident #35 the facility failed to ensure Certified Nursing Assistants (CNAs), accurately documented a. wandering and b. walking on his/her activities of daily living (ADLs) flow sheets. 2. For Resident #5, the facility failed to ensure CNAs, accurately documented wandering on his/her ADLs flow sheets. 3. For Resident #69 the facility failed to ensure CNAs, accurately documented his/her wandering behaviors, resulting in the development of an inaccurate Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement the facility's abuse policy for one Resident #35 out of a total sample of 18 residents. Specifically, for Resident #35 the facility failed to ensure Certified Nurse Assistant (CNA #1), who was accused of neglect, left the facility after she was suspended (placed on leave).

Inspectors wroteBased on record review and interview, the facility failed to revise the plan of care after two Minimum Data Set assessments for one Resident (#7) out of a total sample of 5 Residents selected for the unnecessary medication review. Specifically for Resident #7, the facility failed to revise three separate care plans related to diuretic use (medication used to decrease fluid) when his/her diuretic was discontinued on 5/19/25 and nursing documented his/her care plans were reviewed on 8/12/25 and 10/27/25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assistance with Activities of Daily Living (ADLs) was provided for one Resident (#47) out of a total sample of 18 residents. Specifically, for Resident #47 the facility failed to ensure one-to-one staff assistance was provided with meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the administration of enteral nutrition is consistent with and follows the practitioner's orders for one Resident (#47) out of a total sample of 18 residents. Specifically, for Resident #47 the facility failed to ensure the tube feeding was delivered at the frequency it was ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a therapeutic diet was provided for one Resident (#4) out of a total sample of 18 residents. Specifically, for Resident #4 the facility failed to ensure a 1200 mL (milliliter) fluid restriction was followed.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was found unresponsive by staff, and required staff to initiate a Code Blue, the Facility failed to ensure that Licensed Nursing Staff were competent in the process of calling and responding in the event of a Code Blue situation.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was an elopement risk and resided on a secured unit, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to prevent an incident of elopement, when on 04/08/25 around 2:15 P.M. Resident #1 was able to exit his/her unit and the Facility, undetected by staff and was found sitting on the curb in front of the Facility. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a fractured left elbow.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), the Facility failed to ensure they maintained a complete and accurate medical record, when there was no nursing documentation related to wound measurements for six days following his/her readmission on [DATE], after a hospital stay.

Inspectors wroteBased on records reviewed, interviews and observations for one of six sampled residents (Resident #1), the Facility failed to ensure they provided an adequate level of staff supervision to prevent an incident of elopement, resulting in injuries. 1) On 11/02/24, Resident #1 who had severe cognitive impaired, and was assessed as being at increased risk for elopement, exhibited increased exit seeking behaviors including making multiple attempts to leave the Facility through alarmed exit doors on the unit, asked staff members for a ride home and required constant redirection by staff. Sometime before lunch, Resident #1 was redirected by a staff member to go to an activity going on in the day room. However, that was the last time staff recall seeing Resident #1, and it was not until staff noticed that his/her lunch tray was untouched that staff determined he/she was no longer in the Facility. [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff did not contaminate ready to eat food during service.

Inspectors wroteBased on record review and interview, the facility failed to obtain a signed psychotropic informed consent for one Resident (#67) out of a total sample of 23 residents.

Inspectors wroteBased on observations, record review and interview the facility failed to provide a clean and comfortable homelike environment to one Resident (#21) out of a total sample of 23 residents. Specifically, the facility failed to ensure that Resident #21's room was free from strong odors. Findings Include: Resident #21 was admitted to the facility in August 2021 with diagnoses that include cerebral infarction and diabetes. Review of Resident #21's most recent Minimum Data Set (MDS) Assessment, dated 9/5/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that Resident #21 is cognitively intact. The MDS further indicated that the Resident is dependent for ADLS and toileting and is frequently incontinent of bowel and bladder. On 10/16/24 at 8:48 A.M., the surveyor entered Resident #21's room, which had a strong odor. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a resolution to a grievance filed, specifically related to staff members sleeping on shift.

Inspectors wroteBased on observations, record review and interview, the facility failed to identify and assess the use of mattress bolsters underneath a fitted sheet to bilateral head and foot of the bed as a potential restraint for one Resident (#62) out of a total sample of 23 residents. Findings Include: A physical restraint, as defined in the State Operations Manual, Appendix PP - Guidance to surveyors for Long Term Care Facilities, is any manual method, physical or mechanical device, equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff. Resident #62 was admitted to the facility in May 2023 with diagnoses that include cognitive communication deficit and chronic kidney disease. [...]

Inspectors wroteBased on record review and interview, the facility failed to report allegations of potential abuse for 3 Residents (#55, #78, and #DC1) out of a total sample of 23 residents.

Inspectors wroteBased on record review and interview, the facility failed to investigate allegations of potential abuse for 3 Residents (#55, #78, and #DC1) out of a total sample of 23 residents.

Inspectors wroteBased on observations, record review and interview the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately completed to reflect the status of one Resident (#21) out of a total sample of 23 residents. Specifically, the facility inaccurately documented the use of an indwelling catheter. Findings Include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicates that an indwelling catheter is a catheter that is maintained within the bladder for the purpose of continuous drainage of urine. Resident #21 was admitted to the facility in August 2021 with diagnoses that include cerebral infarction and diabetes. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement an orthotic for contracture management for one Resident (#29) out of a total sample of 23 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow the recommendations from the Wound Physician for one Resident (#10), out of a total sample of 23 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Residents received respiratory care and treatment according to professional standards of practice and in accordance with physician's orders for one Resident (#2) out of a total sample of 23 residents. Specifically, the facility failed to implement Resident #2's physician ordered oxygen flow rate.

Inspectors wroteBased on record review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#27) who had a history of trauma, out of a total sample of 23 residents. Specifically, for Resident #27, the facility failed to develop a comprehensive trauma care plan, with individualized triggers.

Inspectors wroteBased on record review and interviews, the monthly medication review (MRR), which reviews the drug regimen of each resident by a licensed pharmacist, failed to identify an irregularity in one Resident (#2's) drug regime, out of a sample of 23 residents. Specifically the facility failed to identify Resident #2 was receiving double the prescribed dose of Torsemide (medication used to treat fluid retention caused by heart failure).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one Resident (#2), was free from significant medication errors, out of a sample of 23 residents. Specifically, Resident #2 received a double the prescribed dose of the medication Torsemide (a medication that is used to treat high blood pressure, heart failure and a buildup of fluid in the body).

Inspectors wroteBased on record review, and interview the facility failed to protect one Resident (#2) from neglect out of a total sample of 22 Residents. Specifically, the facility failed to ensure that nursing staff identified multiple treatment orders for one wound and neglected to implement treatments ordered by the physician as instructed by the Wound Clinic for his/her coccyx wound from May 2023 through September 2023. Subsequently, Resident #2's wound deteriorated significantly. In July 2023 Resident #2 was hospitalized and was diagnosed with Stage IV decubitus ulcer with osteomyelitis (an infection of the bone) and erosion of the distal sacrum and proximal coccyx.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement physician orders related to pressure ulcers for one Resident (#2) out of a total sample of 22 residents. Specifically, the facility failed to implement treatments ordered by the physician as instructed by the Wound Clinic for his/her coccyx wound from May 2023 through September 2023. Subsequently, Resident #2's wound deteriorated. In July 2023 Resident #2 was hospitalized and was diagnosed with Stage IV decubitus ulcer with osteomyelitis (an infection of the bone) and erosion of the distal sacrum and proximal coccyx.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement interventions related to pressure ulcers for two Residents (#2, #27) out of a total sample of 22 Residents. Specifically: 1. For Resident #2, the facility failed to implement treatments to promote healing ordered by the physician as instructed by the Wound Clinic for his/her coccyx wound from May 2023 through September 2023. Subsequently, Resident #2's wound deteriorated. In July 2023, Resident #2 was hospitalized and was diagnosed with Stage IV pressure injury with osteomyelitis (an infection of the bone) and erosion of the distal sacrum and proximal coccyx. Additionally: 2. For Resident #27, the facility failed to follow the recommendations from the wound physician related to his/her heel wound.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with eating as ordered by the physician for 1 Resident (#75) out of a total sample of 22 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a complete and accurate medical record for 1 Resident (#75) out of a total of 22 sampled residents. Specifically, the facility failed to ensure that nursing staff did not document a hearing aid and nutritional supplement were provided when they had not been provided.

Inspectors wroteBased on observations, policy review, and interview, the facility failed to 1.) ensure nursing staff disinfected reusable resident care equipment (a vital sign machine) between residents and 2.) nursing staff handled a medication that had fallen on the top of the medication cart with ungloved hands and placed that medication into a full cup of poured medication during medication administration pass.