Park Avenue Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 19, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Oct 11, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF658Oct 11, 2023

  Based 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. Findings include: Review of the [NAME] Manual of Nursing Practice, 11th Ed. […]

• Immediate jeopardy, isolatedF686Oct 11, 2023

  Based 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. […]

• Actual harm, isolatedF689Jun 22, 2026

  Based 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. […]