Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Park Avenue during CMS and state inspections, most recent first.
The facility failed to follow its own policies prohibiting routine use of disposable food service items, resulting in meals being served in Styrofoam containers on multiple evenings and weekends over several weeks. Several residents reported that food served in these containers was cold, did not taste good, and in some cases was not eaten, with one resident choosing to order out instead. Resident council and food committee notes had already documented concerns that food was cold and sometimes hard. Nursing staff, CNAs, and dietary staff acknowledged that Styrofoam containers were used for dinner meals, sometimes due to staffing, and leadership confirmed that this practice had occurred, affecting residents’ perception of meal quality and dignity.
The facility failed to honor resident bathing preferences and follow its own personal care policy by not providing showers or baths as requested or scheduled for multiple residents. One resident with significant neurological and gastrointestinal conditions reported wanting daily showers and at least twice-weekly bathing but had limited documented shower offers and was observed with greasy hair. Another resident with cardiac and metabolic conditions reported missing a scheduled shower that staff attributed to a lack of hot water, while records inaccurately documented the event as a refusal. Several other residents scheduled for showers on the same day received bed baths instead, with staff citing no hot water, although the Maintenance Director confirmed hot water was available. The NHA and DON acknowledged that these residents did not receive showers or baths according to their stated preferences and that required twice-weekly bathing was not consistently provided.
The facility failed to follow its planned menus and did not document or communicate food substitutions to residents and staff. Multiple residents reported receiving foods that did not match the posted menu without prior notice. Staff interviews revealed that substitutions, such as serving cabbage instead of brussels sprouts, mashed potatoes instead of biscuit mix for pot pie, and pears instead of apples, occurred because ordered food items were not delivered or ran out. An LPN noted that nursing staff and residents were not informed of these changes, and required documentation on the menu substitution log and updates to posted menus were not completed.
The facility did not follow its freezer maintenance policy requiring regular cleaning and removal of excess ice in the main kitchen walk-in freezer. Surveyors observed heavy ice accumulation on the ceiling extending from the condenser, on the floor near the entrance, and on frozen food boxes on top shelves, with the condenser coils encased in ice. The Dietary Manager confirmed these conditions and acknowledged that the ice should be removed.
Surveyors found that two nurse station closets used for oxygen storage were not properly designed or constructed for storing over 300 cubic feet of oxygen cylinders, and one cylinder was left unsecured. The maintenance supervisor confirmed these deficiencies during the survey.
Surveyors observed that the first floor therapy exit door was obstructed by ice and snow, preventing it from opening fully and resulting in an unsafe evacuation surface. The maintenance supervisor confirmed the deficiency during the inspection.
Resident Food Storage Not Maintained per Policy: Surveyors observed resident refrigerators on two units containing expired and unlabeled food and drink items, including cottage cheese, orange juice, coffee creamer, and a beverage can without a resident name or date. An RN and a CNA confirmed that the items were not labeled as required and/or were expired, which was inconsistent with the facility’s food storage policy.
The facility did not meet required NA staffing ratios on multiple day, evening, and overnight shifts, as confirmed by staffing records and the Nursing Home Administrator. These deficiencies were identified through review of staffing documents, with actual NA numbers falling below the minimum required based on resident census.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on two reviewed days, as confirmed by staffing records and the Nursing Home Administrator.
The facility did not ensure dignified meal service, as residents seated at the same table were not served at the same time, leading to some eating while others waited or finished before their tablemates received food. Meals were often served in Styrofoam containers and were reported to be cold, with staff and residents attributing these issues to dietary staffing shortages.
A resident with a history of NSTEMI, type II diabetes, and muscle weakness experienced slurred speech and appeared off, but the physician and emergency contact were not notified promptly as required by facility policy. The DON and administrator confirmed that notification and documentation should have occurred at the time of the incident.
The facility did not maintain adequate dietary staffing, leading to meals being served in Styrofoam containers and often arriving cold. Residents and a family member reported these issues, and staff confirmed that staffing shortages caused the use of foam containers and inconsistent meal service. The expected staffing levels were not met, impacting meal quality and service.
The facility did not meet the required nurse aide staffing ratios during a day shift, with only 9.38 NAs available for 114 residents, falling short of the mandated 11.40 NAs. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to notify a resident's representative of a change in treatment and x-ray findings, as required by their policy. The resident, who had multiple health issues, received a new order for Voltaren Gel, but there was no evidence of communication with the representative. Both the resident's representative and the DON confirmed the lack of notification.
The facility failed to provide proper care for two residents with indwelling catheters, as their catheter drainage bags were found uncovered and on the floor, contrary to facility policy. One resident had a recent hospitalization for a UTI, and both residents have medical histories that include conditions affecting bladder function. The DON confirmed the bags should not be uncovered or on the floor due to infection risks.
The facility did not maintain the safe operation of the walk-in freezer in the main kitchen, as required by their policy. Observations revealed significant ice accumulation on the ceiling, floor, and condenser coils, with water and ice dripping onto frozen food boxes. The Dietary Manager confirmed these conditions.
A facility failed to follow its policy requiring two staff members for mechanical lift transfers, as observed when a nurse aide transferred a resident with rheumatoid arthritis and mobility issues without assistance. Interviews with staff and the resident confirmed the usual practice of having two aides, highlighting a deficiency in management and nursing services.
Use of Styrofoam Meal Containers Undermining Resident Dignity
Penalty
Summary
The facility failed to honor resident dignity and self-determination by not implementing dignified feeding practices and by serving meals in Styrofoam containers on multiple occasions over several weeks. Facility policies stated that the environment must be safe, functional, sanitary, and comfortable, and that paper products such as disposable plates, bowls, cups, and utensils were prohibited in dietary operations except in approved emergency situations, in part to support resident dignity. Despite this, residents reported that meals were served in Styrofoam containers at dinner on evenings and weekends, and that the food was often cold and unpalatable when served this way. Resident council and food committee minutes documented prior concerns that food was cold and sometimes hard. Multiple residents reported that they had been receiving meals in Styrofoam containers for the last few weeks, not only during a recent water issue but also at other times without explanation. Several residents stated that when meals were served in disposable containers, the food was cold, did not taste good, and in at least one case was considered not worthy of eating, leading that resident to order food from outside the facility instead. Nursing staff, including LPNs and CNAs, confirmed that evening and weekend meals had been served on Styrofoam quite a few times in recent weeks. Dietary staff reported that Styrofoam was sometimes used for dinner meals mainly due to staffing. The NHA and DON confirmed that Styrofoam containers had been used on occasion for residents’ meals over the past few weeks, contrary to the facility’s stated policy and contributing to resident dissatisfaction and concerns about dignity.
Failure to Honor Resident Bathing Preferences and Accurately Document Care
Penalty
Summary
The deficiency involves the facility’s failure to honor resident choice and provide showers or baths according to resident preference and facility policy for seven of thirteen residents reviewed. The facility’s Personal Care Procedure policy states that baths/showers are to be provided based on individual status and needs, that showers may be given at any time the resident chooses, and that a shower may be necessary 2–3 times per week or more per resident request, with bed baths on non-shower days per resident preference. For one resident with epilepsy, Crohn’s disease, cerebral infarction, and monoplegia of an upper limb, clinical records showed that from 1/21/26 through 2/19/26 the resident was only offered showers/baths on four specific dates. The resident reported wanting a daily shower but being satisfied with twice weekly, stated that a scheduled shower was missed, and was observed with greasy hair. The resident also indicated they could shower independently but were not allowed to do so for safety reasons. Another resident with atrial fibrillation, diabetes mellitus, morbid obesity, and cardiac heart failure was documented as being offered showers/baths on five specific dates during the same review period and reported that showers should occur on Sundays and Wednesdays. This resident stated they did not receive a scheduled shower due to staff citing a lack of hot water, while facility documentation recorded the event as a refusal, which the resident later denied. Further review showed that several other residents scheduled for showers/baths on that same day did not receive them and instead received bed baths, with CNAs and an LPN attributing this to no hot water being available. The Maintenance Director, however, confirmed that hot water was available for those residents’ showers/baths. The NHA and DON confirmed that these residents did not receive showers/baths per their preferences and that there was no evidence that one resident received showers/baths at least twice weekly as preferred.
Failure to Follow Planned Menus and Communicate Undocumented Food Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were prepared and served according to the planned menus, that menu changes were documented and updated, and that residents were notified of substitutions. The facility’s own menu change policy, dated 8/29/25, required that any change to the posted or planned menu be intentional, documented, and communicated to residents and staff, with substitutions of equal nutritional value that meet resident preferences and dietary restrictions, and that all changes be recorded on a monthly menu substitution log and communicated via pre-meal huddles, nursing staff, and menu boards or general communication. Despite this policy, multiple residents reported recently receiving foods that were not on the posted menu without prior notification of the changes. Interviews with residents and staff, along with confidential interviews, revealed that food substitutions were occurring due to ordered items not being delivered or running out of specific foods, and that these substitutions were not documented or communicated. Examples included cabbage being served to approximately 12–15 residents instead of brussels sprouts, mashed potatoes being served in place of biscuit mix for pot pie, and pears being served instead of apples for dessert, as well as a planned cream of broccoli soup that was not delivered as ordered. An LPN reported noticing food substitutions on resident trays without notification from the kitchen to nursing staff or residents. Follow-up interviews confirmed that the facility failed to follow the planned menus, complete the monthly menu substitution log, update posted menus, or alert residents to menu changes, in violation of the cited state regulatory requirements for management and dietary services.
Failure to Maintain Safe Operation of Walk-In Freezer Equipment
Penalty
Summary
The facility failed to properly maintain safe operation of essential equipment in the main kitchen walk-in freezer as required by its policy. The facility’s freezer policy, last reviewed on 8/29/25, required that all walk-in freezers be cleaned at least every six months, that excess ice buildup be removed, and that any damage or need for repair be reported to the Maintenance Department. During an observation of the main kitchen walk-in freezer on 2/18/26 at 10:30 a.m., surveyors noted an accumulation of ice on the ceiling extending from the condenser to the opposite side of the freezer, as well as multiple areas of ice on the floor near the entrance. Ice accumulation was also observed on frozen food boxes stored on the top shelves to the right and left of the entrance door, and the condenser coils were found frozen in ice. In an interview at the time of the observation, the Dietary Manager confirmed the presence of these ice accumulations and the frozen condenser coils, and acknowledged that the ice should be removed. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the condition and maintenance of the walk-in freezer equipment and surrounding environment in the main kitchen.
Oxygen Cylinder Storage Deficiencies in Nurse Station Closets
Penalty
Summary
Surveyors observed that the facility failed to maintain gas equipment requirements in two of three nurse station closets. Specifically, the north and east oxygen storage closets were not designed and constructed to accommodate storage of over 300 cubic feet of oxygen cylinders, as required by NFPA 101 and NFPA 99 standards. Additionally, in the east oxygen closet, one oxygen cylinder was found unsecured at the time of the survey. These deficiencies were confirmed during an interview with the maintenance supervisor, who acknowledged the issues with the storage closets and the unsecured cylinder. No information was provided regarding any residents directly involved or affected at the time of the deficiency.
Plan Of Correction
At the time of surveyor identification, the unsecured oxygen cylinder was secured and the facility's oxygen cylinders were rearranged in the designed oxygen storage closets throughout the facility to ensure that the East and North oxygen storage closets did not have over 300 cubic feet of oxygen cylinders stored. No further action is needed. All staff will be re-educated that the oxygen cylinders must be secured appropriately and that there cannot be more than 300 cubic feet of oxygen cylinders stored in any of the oxygen storage closets. The Maintenance Director will do weekly monitoring throughout the facility to ensure that all the oxygen cylinders are secured appropriately and that none of the oxygen storage closets have over 300 cubic feet of oxygen cylinders stored. On identification, unsecured oxygen cylinders will be secured and if needed oxygen cylinders will be removed from storage closets to ensure that there is no more than 300 cubic feet of oxygen cylinders stored in any one oxygen storage closet.
Obstructed Exit Due to Ice and Snow Buildup
Penalty
Summary
A deficiency was identified when the first floor therapy exit door was found to have a buildup of ice and snow, which prevented the door from opening to its full width. Additionally, the exit discharge surface was not maintained in a manner that would allow for safe evacuation during an emergency. These conditions were observed during a facility inspection and were confirmed by the maintenance supervisor at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
At the time of surveyor identification, the buildup of snow and ice was removed from the first floor therapy entrance door and surface in order to permit the exit door to open to its fullest width in order to allow a safe evacuation in the event of an emergency. No further action is required. All staff will be re-educated that all surfaces, exit discharges, exit locations, and entrance accesses must be maintained free of the buildup of ice and snow in order to maintain a continuous means of egress in case of emergency. The Maintenance Director will do weekly monitoring throughout the facility to ensure that all surfaces, exit discharges, exit locations, and entrance accesses are maintained free of the buildup of ice and snow. On identification, any buildup of snow or ice will be removed.
Resident Food Storage Not Maintained per Policy
Penalty
Summary
The facility failed to ensure that food was stored in accordance with food safety standards in resident pantries on the Rehab Unit and North Unit. A review of the facility policy on use and storage of food brought in by family or visitors stated that prepared items may be refrigerated if labeled and dated, must be consumed within 3 days, and otherwise are to be discarded by staff. During observation of the Rehab Unit resident refrigerator, surveyors found three single-serve containers of cottage cheese labeled with a resident name and an expiration date of 11/24/25, along with one can of Celsius-Retro Vibe drink that had no resident name or date. An RN confirmed at the time of the observation that items in the refrigerator were not labeled as required and/or were expired. During observation of the North Unit resident refrigerator, surveyors found one bottle of orange juice labeled with a resident name and expiration date of 6/15/25 and one bottle of hazelnut coffee creamer labeled with a resident name and expiration date of 11/15/25. A nursing assistant confirmed at the time of the observation that items in the refrigerator were expired.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The policy titled "Use and Storage of Food Brought in by Families or Visitors" was reviewed and remains appropriate. At the time of surveyor identification, the items identified in the resident refrigerators that were not labeled as required and/or expired were removed per policy. All staff will be re-educated on the "Use and Storage of Food Brought in by Families or Visitors" policy. This will be the responsibility of the Administrator and/or designee. To ensure ongoing compliance, a weekly audit of all resident refrigerators will be conducted to ensure that all items in the resident refrigerators are labeled as required and that all expired items were removed per the "Use and Storage of Food Brought in by Families or Visitors" policy. This audit will be the responsibility of the Administrator and/or designee. This audit will occur weekly x 4 weeks, then every other week for a month, then monthly until practice is determined to be in compliance. Audits will be reviewed no less than quarterly by the Quality Assurance Performance Improvement committee.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as mandated by regulation for several shifts over multiple days. Specifically, on three days, the day shift did not have the minimum required number of NAs per resident, with actual staffing falling short of the calculated requirement based on the resident census. On two days, the evening shift also did not meet the required NA-to-resident ratio, and on three days, the overnight shift was similarly understaffed. These deficiencies were identified through a review of facility nursing staffing documents covering several time periods. During an interview, the Nursing Home Administrator confirmed that the facility did not meet the minimum NA ratios for the specified days and shifts. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The findings are based solely on staffing records and administrative confirmation.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. In an effort to maintain compliance with the regulation, the facility should utilize the following process: 1. In an attempt to achieve appropriate staffing ratios, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. Additionally, the Scheduler will be re-educated on the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. In the event that the Supervisor is unable to fully cover the hours of a staff call-off and the loss of staff might impact the facility's compliance with the regulatory requirement, the RN Supervisor will notify the Director of Nursing and Assistant Director of Nursing so that all administrative clinical staff can be notified of the need so they can assist with coverage. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing ratios weekly utilizing the DOH staffing calculation tool for 1 month, then monthly for 2 months then quarterly until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct general nursing care per resident per day for two out of twenty-one days reviewed. Specifically, on two dates, the provided nursing care hours were 3.16 and 3.14 per patient day, which is below the regulatory standard. This was confirmed through a review of facility nursing staffing documents covering several periods and was acknowledged by the Nursing Home Administrator during an interview. No additional details about specific residents or their conditions were provided in the report.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. In an effort to maintain compliance with the regulation, the facility shall utilize the following process: 1. In an attempt to achieve general nursing care hours of at least a minimum of 3.2 hours of direct resident care hours per resident in a 24-hour period, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of direct care staff in relation to Resident census. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing PPD's on a daily basis utilizing the DOH staffing calculation tool until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee. 5. The scheduler and RN Supervisors will be re-educated on the regulatory guidelines for the minimum number of general nursing care hours of 3.2 hours of direct resident care hours per resident in a 24-hour period. This will be the responsibility of the Director of Nursing.
Failure to Provide Dignified and Timely Meal Service
Penalty
Summary
The facility failed to implement dignified feeding practices and maintain resident dignity and respect by not serving meals in a timely manner to individuals seated at the same table in both the North and Haven dining areas. Observations revealed that residents seated together were not served their meals at the same time, resulting in some residents eating while others waited and watched, and in some cases, residents finishing and leaving the table before others had received their meals. Facility policy requires that all residents at the same table be served before moving to another table, but this was not followed during the observed meal service. Additionally, multiple residents and a family member reported that meals were frequently served in Styrofoam containers, which often resulted in cold food. Staff interviews confirmed that the use of Styrofoam containers and delays in meal service were due to inadequate staffing in the dietary department. The dietary manager acknowledged that staffing shortages led to the use of disposable containers and confirmed that residents at the same table should be served simultaneously, as per facility policy.
Failure to Timely Notify Physician and Emergency Contact of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician and emergency contact in a timely manner following a significant change in the resident's condition. According to facility policy, nursing staff are required to inform the primary care physician and responsible party when there is a notable decline in a resident's clinical status. In this case, a resident with a history of NSTEMI myocardial infarction, type II diabetes, and muscle weakness exhibited slurred speech and appeared 'a little off' during the night. Despite this change, there was no timely notification to the physician or emergency contact, nor was this action documented in the clinical record at the time of the incident. The Director of Nursing and Nursing Home Administrator later confirmed that proper notification and documentation should have occurred.
Insufficient Dietary Staffing Resulting in Cold Meals and Use of Styrofoam Containers
Penalty
Summary
The facility failed to provide sufficient staffing in the dietary department, as evidenced by a review of four weeks of dietary schedules that lacked the appropriate number of trained dietary staff each day. Resident grievances and council meeting minutes documented concerns about meals not being ready for residents going to dialysis and food being served warm or not hot. Multiple residents reported receiving meals in Styrofoam containers several days a week, resulting in food often being cold. These issues were attributed to inadequate dietary staffing, as confirmed by both dietary aides and the dietary manager, who stated that the use of foam containers was due to insufficient staff and that there were shifts with only a cook and one dietary aide present. A family member corroborated that meals were frequently served in Styrofoam containers and were often cold. The dietary manager and aides confirmed that staffing shortages led to the use of these containers and that residents at the same table should be served simultaneously, which was not consistently happening. The Nursing Home Administrator acknowledged that the expected staffing level was one cook and three dietary aides per shift, which was not being met. These findings were supported by facility policy and state regulations regarding the responsibility of the licensee and management.
Nurse Aide Staffing Shortage on Day Shift
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios during the day shift on January 12, 2025. Specifically, the regulation mandates a minimum of one NA per 10 residents during the day shift. On the day in question, the facility had a census of 114 residents, necessitating 11.40 NAs to meet the required ratio. However, only 9.38 NAs were available, resulting in a staffing shortage. This deficiency was confirmed during a telephone interview with the Nursing Home Administrator on January 14, 2025, who acknowledged that the NA ratios were not met for the specified day and shift.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. In an effort to maintain compliance with the regulation, the facility should utilize the following process: 1. In an attempt to achieve appropriate staffing ratios, the facility has created a daily assignment grid for the Scheduler to complete daily that designates the required amount of Certified Nurse Aides per shift that are required to meet the regulatory requirements. The assignment grids will be reviewed during Labor Meetings to be held no less than weekly. This review will be the responsibility of the Director of Nursing or designee. 2. When a call-off is received, the Supervisor will make every effort to replace hours fully. In the event that the Supervisor is unable to fully cover the hours of a staff call-off and the loss of staff might impact the facility's compliance with the regulatory requirement, the RN Supervisor will notify the Director of Nursing and Assistant Director of Nursing so that all administrative clinical staff can be notified of the need so they can assist with coverage. 3. The facility will continue with recruitment efforts and will continue to enforce the attendance policy. 4. The facility shall complete a monitor of staffing ratios weekly utilizing the DOH staffing calculation tool for 1 month, then monthly for 2 months, then quarterly until such time it is determined by the Quality Assurance Committee that the facility is maintaining compliance. This shall be the responsibility of the Director of Nursing or designee.
Failure to Notify Resident's Representative of Treatment Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition and treatment, as required by their policy. Specifically, the clinical record of a resident with multiple diagnoses, including an unstageable pressure ulcer, diabetes mellitus, weakness, and COPD, showed a physician's order for Voltaren External Gel to be applied as needed for pain. However, there was no evidence that the resident's representative was informed of this new order or the x-ray findings that prompted it. An interview with the resident's representative confirmed that the facility did not always update them on new orders or test results. The Director of Nursing also confirmed that the facility did not notify the resident's representative of the new orders and x-ray findings. This lack of communication is a violation of the facility's policy, which mandates notifying the responsible party and physician of changes in a resident's condition or treatment.
Failure to Ensure Proper Catheter Care for Residents
Penalty
Summary
The facility failed to ensure proper care and services for residents with indwelling catheters, leading to potential infection risks. Specifically, two residents with indwelling catheters, identified as R19 and R79, were observed with their catheter drainage bags uncovered and placed on the floor beside their beds. This is contrary to the facility's policy, which mandates that catheter drainage bags should be covered and not placed on unclean surfaces to prevent infections. Resident R19, who has a history of cerebral infarction, aphasia, neuromuscular dysfunction of the bladder, and urinary tract infections, was observed with an uncovered catheter bag on the floor. The resident's representative confirmed a recent hospitalization for a urinary tract infection. Similarly, Resident R79, with diagnoses including encephalopathy, dementia, and a history of urinary tract infections, was also observed with an uncovered catheter bag on the floor. The Director of Nursing confirmed that the catheter bags should not be left uncovered or placed on the floor, acknowledging the risk of infection.
Failure to Maintain Safe Operation of Walk-In Freezer
Penalty
Summary
The facility failed to maintain the safe operation of essential equipment in the main kitchen, specifically the walk-in freezer. The facility's policy, titled 'Cleaning Instructions: Freezer,' with a review date of 10/28/24, mandates defrosting the freezer when frost exceeds 1/4 inch thick and according to a cleaning schedule. However, observations on 11/19/24 revealed significant ice accumulation in the walk-in freezer, including on the ceiling, extending from the condenser to the opposite side, and on the floor near the entrance. Water and ice were observed dripping and freezing on boxes of frozen food items on the top shelves, and the condenser coils were encased in ice. The Dietary Manager confirmed these observations during an interview on 11/20/24.
Failure to Follow Safe Transfer Protocols
Penalty
Summary
The facility failed to adhere to its policy on safe resident handling and transfers, which mandates the use of two staff members when transferring residents with a mechanical lift. This deficiency was observed during the transfer of a resident diagnosed with rheumatoid arthritis, lymphedema, lack of coordination, weakness, and abnormal gait and mobility. The resident's care plan specified the use of a sit-to-stand lift for transfers to a power wheelchair, indicating the resident was non-ambulatory. However, on the observed date, a nurse aide transferred the resident using the mechanical lift without the assistance of a second staff member. Interviews conducted with various staff members, including the nurse aide involved, another nurse aide, a licensed practical nurse, the assistant director of nursing, and the nursing home administrator, confirmed the requirement for two staff members to operate mechanical lifts. The resident also confirmed that typically two staff members assist with the lift, but on this occasion, only one aide was present. This failure to follow the established policy for safe transfers constitutes a deficiency in the facility's management and nursing services, as outlined in the relevant Pennsylvania Code sections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Meadville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesbury United Methodist Commu | 2.2 mi | ★★★★★ | 0 | 0 |
| Crawford Care Center | 2.4 mi | ★★★★★ | 18 | 1 |
| Meadville Medical Ctr Tcu | 2.7 mi | ★★★★★ | 6 | 0 |
| Rolling Fields, Inc | 12.2 mi | ★★★★★ | 31 | 0 |
| Edinboro Manor | 14.4 mi | ★★★★★ | 22 | 0 |
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