Embassy of Park Avenue

In the surveyor’s words

From the most serious findings on record at Embassy of Park Avenue, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 17, 2022

  Based on review of facility policy and clinical record, observation and staff interviews, it was determined that the facility failed to ensure that residents were monitored and adequately assessed to prevent new ulcers from developing, resulting in actual harm of an Unstageable (full-thickness skin and tissue loss) pressure ulcer development of the heel (bottom part of the foot below the ankle) and ankle for one of nine residents reviewed with pressure ulcers (Resident R148). Findings include: Review of facility policy entitled Skin/Wound Care dated 2/16/22, revealed that skin will be observed upon admission and routinely throughout the residents stay and residents will be encouraged / assisted to turn and reposition. […]

• Actual harm, isolatedF686Mar 31, 2021

  Based on review of facility policy, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure a pressure ulcer was consistently assessed, resulting in actual harm from the unmonitored deterioration of the pressure ulcer, and failed to ensure that wound treatments provided were consistent with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility policy entitled, Pressure Ulcer Identification and Wound Management, dated 3/1/21, indicated that comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. […]

• No harm, potential for more than minimal, patternF711Jun 9, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit for six of six residents reviewed (Residents R4, R7, R8, R9, 10, and R11) and failed to ensure that the physician signs and dates all orders during each of his/her visits for one of size residents reviewed (Resident R11). Findings include: A facility Policy entitled Physician Visit and Physician Delegation dated 3/5/26, revealed The physician should see the Resident within 30-day of initial admission to the facility, The physician should date, write, and sign a progress note for each visit and The physician should sign and date all… […]

• No harm, potential for more than minimal, patternF712Jun 9, 2026

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure the physician alternated required resident visits with the nurse practitioner or physician's assistant for four of six residents reviewed (Residents R4, R8, R9, and R10). Findings include: A facility Policy entitled Physician Visit and Physician Delegation dated 3/5/26, revealed The physician should assign alternate physician or physician extender to make visits as appropriate by State Law and At the option of the physician, required visits in SNF's (skilled nursing facilities) after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist that is acting within… […]

• No harm, potential for more than minimal, patternF550Feb 23, 2026

  Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to implement dignified feeding practices and to maintain resident dignity for seven of 18 residents interviewed (Residents R7, R8, R9, R15, R16, R24, and R25).Findings include: Review of facility policy entitled Resident Environmental Quality dated 8/29/25, revealed It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents. […]