Park Avenue Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Park Avenue Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 1, 2024

  Based 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. Findings include: Resident # 5 was initially admitted to the facility on [DATE] with diagnoses of vascular dementia, restlessness and agitation, and senile degeneration of brain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. The assessment also included that the resident used a wheelchair and can independently wheel 150 feet in a corridor or similar spaces. […]

• Actual harm, isolatedF686Feb 8, 2023

  Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#3) was provided care and services, consistent with professional standards of practice, to prevent, treat and/or heal a pressure ulcer. The sample size was 3. The deficient practice could result in pain, worsening and/or infection of pressure ulcers. Findings include: Resident #3 admitted to the facility 09/28/22 with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid (severe) obesity due to excess calories and quadriplegia. A Skin/Wound Note dated 09/29/2022 12:02 included an initial visit with the resident. The note revealed that the resident has a Braden scale score of 15 [at risk for the development of pressure ulcers]. […]

• Actual harm, isolatedF689Feb 8, 2023

  Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#3) was provided services to prevent an accident. The census was 134. The deficient practice increases the risk for residents to sustain injury through preventable accidents. Findings include: Resident #3 admitted to the facility 09/28/22 with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, morbid (severe) obesity due to excess calories and quadriplegia. The Initial Admission Record dated 09/28/22 included the resident had weakness in both his right and left legs. […]

• No harm, potential for more than minimal, patternF880Aug 22, 2025

  Based 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.Findings include:An observation was conducted on August 21, 2025, at 10:10 a.m. of a group therapy session occurring in the first-floor lounge room. Residents #44, #45, #55, #180, and #181 were present in the lounge, and being led in various therapy activities by a Physical Therapy Assistant (PTA/ staff #100). There was no hand sanitizer or handwashing station/sink or sanitizing agents such as spray or wipes observed in the lounge room. […]

• No harm, potential for more than minimal, patternF686May 19, 2023

  Based 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. Findings include: -Resident # 535 was admitted on [DATE] with diagnoses of osteomyelitis, acute respiratory failure with hypoxia, muscle weakness, dysphagia, pressure ulcer of sacral region, Stage 4, Type 2 DM, encephalopathy, bacteremia, idiopathic aseptic necrosis of unspecified toes, and nutritional anemia. […]