A list of the most recent deficiencies for Embassy of Park Avenue. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-12 | 2024-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-12 | 2024-01-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-12 | 2024-01-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-12 | 2024-01-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-12 | 2024-01-22 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-12-12 | 2024-01-22 | Y |
| Keep all essential equipment working safely. | Health | 2023-12-12 | 2024-01-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-13 | 2024-01-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-13 | 2024-01-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-13 | 2024-01-19 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-01-12 | 2023-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-12 | 2023-02-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-18 | 2023-02-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-18 | 2023-02-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-18 | 2023-02-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-18 | 2023-02-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-17 | 2022-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-17 | 2022-03-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-17 | 2022-03-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-17 | 2022-03-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-17 | 2022-03-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-17 | 2022-03-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-02-17 | 2022-03-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-17 | 2022-03-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-17 | 2022-03-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-02-17 | 2022-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-16 | 2022-02-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-16 | 2022-02-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-02-16 | 2022-02-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-31 | 2021-05-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-20 | Not Fixed | Y |
