Fifth Avenue Health Care

In the surveyor’s words

From the most serious findings on record at Fifth Avenue Health Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 23, 2026

  Based on observations, staff and resident interviews, record review, and review of the facility policies titled Accidents and Incidents - Investigating and Reporting, Elopement, and Dementia Care, the facility failed to maintain an accident-free environment and provide adequate supervision to prevent accidents for one of three sampled residents (R) (R1). This had the potential to affect at least 10 additional residents identified as being at risk for wandering/elopement. Specifically, the facility failed to implement effective interventions to prevent the elopement of R1, creating an ongoing risk for resident elopement and injury. This deficient practice placed residents at risk for serious harm, injury, and death. […]

• Actual harm, isolatedF689Jun 21, 2024

  Based on observations, interviews, and record reviews, the facility failed to provide an environment free from accident hazards for one of six residents (R)(R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital. Findings included: A review of the electronic medical record (EMR) revealed that R1 was initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses included but not limited to hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, peripheral vascular disease, chronic pain, vascular dementia, anxiety, Alzheimer's… […]

• Actual harm, isolatedF908Jun 21, 2024

  Based on interviews and record reviews, the facility failed to ensure that resident care equipment was maintained in safe operating condition for one of six residents (R) (R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital. Findings included: A review of the electronic medical record (EMR) revealed that R1 was initially admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, Alzheimer's Disease, and morbid (severe) obesity. […]

• No harm, potential for more than minimal, widespreadF804Aug 28, 2025

  Based on observations and staff interviews, and review of the facility policy titled, Preparing Pureed Foods, the facility failed to prepare pureed food in a manner that preserved the nutrient value of resident meals. The deficient practice had the potential to affect 15 of 15 residents receiving an oral pureed diet.Findings include:A review of the facility policy titled Preparing Pureed Foods last revised March 2024 revealed under Procedure: 1. Prepare food following the recipe for the regular textured foods. Pureed food should have the same flavor as their regular texture counterpart.Review of the recipe for Pureed Spaghetti Noodles dated March 2024 revealed instructions were:1. Place spaghetti noodles in a food processor.2. […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2025

  Based on observations, interviews, and a review of the facility policy titled Food Storage Guidelines, the facility failed to discard food items past the best-by date. This deficient practice had the potential to affect 66 of 66 residents receiving an oral diet.Findings include:Review of facility policy titled Food Storage Guidelines last revised August 2017 revealed under Procedure: .2. Discard will be up to the expiration and/or Used By Date on the Product.Observation on 8/26/2025 at 10:00 am of the walk-in cooler revealed a box containing one open bag of bacon with a best by date of 8/23/2025. […]