Deficiency Records for Park Avenue Healthcare and Wellness Center
Updated as of January 01, 2021
This is not the most recent data for Park Avenue Healthcare and Wellness Center. For the most recent information, click here.
A list of the most recent deficiencies for Park Avenue Healthcare and Wellness Center. 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? |
|---|---|---|---|---|
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2020-11-05 | 2020-11-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-25 | 2020-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-31 | 2020-09-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-06-05 | 2020-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-06-05 | 2020-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-05-28 | 2020-06-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-04-27 | 2020-05-11 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-25 | 2020-03-24 | 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 | 2020-02-25 | 2020-03-24 | N |
| Construct fire resistant interior walls. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-25 | 2020-03-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-25 | 2020-03-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-25 | 2020-03-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-25 | 2020-03-24 | N |
| 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 | 2020-02-25 | 2020-03-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-25 | 2020-03-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-25 | 2020-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-25 | 2020-03-24 | N |
| Post nurse staffing information every day. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-25 | 2020-03-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-25 | 2020-03-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-25 | 2020-03-24 | N |
| Keep all essential equipment working safely. | Health | 2020-02-25 | 2020-03-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-02-25 | 2020-03-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-25 | 2020-03-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-25 | 2020-03-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-07 | 2020-03-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-12-18 | 2020-01-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-06 | 2019-11-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-06 | 2019-11-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-07-11 | 2019-11-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-11 | 2019-11-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-11 | 2019-11-13 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-19 | 2019-10-15 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-08-19 | 2019-10-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-19 | 2019-09-19 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-08-19 | 2019-09-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-19 | 2019-09-19 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-08-19 | 2019-09-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-08-19 | 2019-09-19 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-08-19 | 2019-09-19 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2019-08-19 | 2019-09-19 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-08-19 | 2019-09-19 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-08-19 | 2019-08-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-19 | 2019-08-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-16 | 2019-05-29 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-03-15 | 2019-05-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-01 | 2019-04-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-07 | 2019-03-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-07 | 2019-03-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-07 | 2019-03-26 | N |
| 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 | 2019-02-07 | 2019-03-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-02-07 | 2019-03-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-02-07 | 2019-03-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-07 | 2019-03-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-07 | 2019-03-26 | N |
| Post nurse staffing information every day. | Health | 2019-02-07 | 2019-03-26 | 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 | 2019-02-07 | 2019-03-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-02-07 | 2019-03-26 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-02-07 | 2019-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-07 | 2019-03-26 | 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 | 2019-02-07 | 2019-03-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-26 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| Be properly staffed | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2019-02-06 | 2019-03-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-26 | 2019-03-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-26 | 2019-03-06 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-13 | 2018-11-21 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-11-13 | 2018-11-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-08-16 | 2018-11-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-12 | 2018-10-25 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-07-11 | 2018-09-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-26 | 2018-07-31 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-07-03 | 2018-07-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-03 | 2018-07-12 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-05-14 | 2018-05-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-14 | 2018-05-21 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2018-02-07 | 2018-04-11 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-02-07 | 2018-04-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-02-07 | 2018-04-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-02-07 | 2018-04-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-02-07 | 2018-04-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-07 | 2018-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-07 | 2018-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-07 | 2018-04-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-02-07 | 2018-04-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-07 | 2018-04-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-02-07 | 2018-04-11 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-02-07 | 2018-04-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-07 | 2018-04-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-02-07 | 2018-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-07 | 2018-04-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-02-07 | 2018-04-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-02-07 | 2018-04-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-02-07 | 2018-04-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-02-07 | 2018-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-07 | 2018-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-07 | 2018-04-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-02-07 | 2018-04-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-07 | 2018-04-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-07 | 2018-04-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-02-07 | 2018-04-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-07 | 2018-04-11 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2018-02-02 | 2018-03-06 | 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 | 2018-02-02 | 2018-03-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-02-02 | 2018-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-26 | 2018-02-13 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-01-26 | 2018-02-13 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-01-12 | 2018-02-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-01-18 | 2018-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-28 | Not Fixed | N |
