Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observations, and staff interview, it was determined that the facility failed to ensure that a safe,
clean, comfortable homelike environment was maintained related to resident's wheelchair for one of four
units observed (Rehabilitation Unit).
Findings include:
Observation on 12/10/23, at 11:24 a.m. revealed Resident R115's protective covering on the bilateral
armrest of his/her wheelchair was cracked exposing some of the foam and had duct tape wrapped around
them.
During an interview on 12/10/23, at 11:27 a.m. Licensed Practical Nurse (LPN), Employee E2 confirmed
that Resident R115 had a damaged wheelchair armrest with cracked protective covering and duct tape
around them.
Observation on 12/10/23, at 11:40 a.m. revealed Resident R94's protective covering on the bilateral
armrest of his/her wheelchair was cracked, peeling, and torn exposing the foam.
During an interview on 12/10/23, at 11:50 a.m. LPN Employee E1 confirmed that Resident R94 had
damaged wheelchair armrests with cracked, peeling, and torn protective covering.
28 Pa. Code 201.18(b)(1) Management
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
395588
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Park Avenue
14714 Park Ave Extension
Meadville, PA 16335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on review of facility policy and clinical records, and staff interview it was determined that the facility
failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R94).
Residents Affected - Few
Findings include:
Review of facility policy entitled Comprehensive Care Plans dated 1/4/23, stated It is the policy of this
facility to develop and implement a comprehensive person-centered care plan for each resident . to meet a
resident's medical, mental, and psychosocial needs that are identified in the resident's comprehensive
assessment.
Resident R94's clinical record revealed an admission date of 11/10/23, with diagnoses that included Kidney
Cyst (fluid-filled pouches found on the kidney), Benign Prostatic Hyperplasia (BPH - an enlarged prostate),
and Leakage of urine from Nephrostomy Catheter (a tube that drains urine directly from the kidneys into a
drainage bag).
Resident R94's clinical record revealed a Bowel and Bladder Evaluation form dated 11/10/23, that identified
Resident R94 as having bilateral nephrostomies.
The clinical record lacked evidence that a care plan had been developed to address Resident R94's
nephrostomy tubes.
During an interview on 12/11/23 at 2:50 p.m. the Assistant Director of Nursing confirmed that a care plan
had not been developed to address Resident R94's nephrostomy tubes.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395588
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Park Avenue
14714 Park Ave Extension
Meadville, PA 16335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on review of facility policy and clinical records, observations, and resident and staff interviews, it was
determined that the facility failed to ensure that residents with limited range of motion received physician
ordered treatment and services to prevent further decrease in range of motion for one of 24 residents
reviewed (Resident R13).
Findings include:
Review of the facility policy entitled Resident Mobility and Range of Motion, dated 1/4/23, indicated that
Residents with limited range of motion will receive treatment and services to increase and/or prevent a
further decrease in ROM.
Resident R13's clinical record revealed an admission date of 7/26/21, with diagnoses that included
hemiplegia (paralysis/limited use of one side of the body) due to a stroke, muscle weakness and dementia
(a disorder of mental processes).
Resident R13's clinical record revealed a physician's order dated 5/31/23, that identified Apply Right hand
roll Splint with a.m. care and remove with p.m. care to facilitate contracture management. The clinical record
lacked documentation that Resident R13 was utilizing the right-hand roll splint.
Observations on 12/9/23, at 1:40 p.m., on 12/10/23, between 12:00 p.m. and 3:00 p.m. and on 12/11/23, at
2:20 p.m. revealed that Resident R13 was in his/her chair watching TV and did not have the right-hand roll
splint on.
During an interview on 12/11/23, at 2:20 p.m. when Resident R13 was asked about his/her splint, Resident
R13 stated that he/she lost it and needed it.
During an interview on 12/11/23, at 2:50 p.m. the Director of Nursing confirmed that Resident R13 was not
wearing the right-hand roll splint as ordered.
28 Pa. Code 211.10 (d) Resident care policies
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa. Code 201.18 (b)(1) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395588
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Park Avenue
14714 Park Ave Extension
Meadville, PA 16335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility
failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the
mind) medication beyond 14 days for one of 24 residents reviewed (Resident R64).
Findings include:
Review of a facility policy entitled Use of Psychotropic Medications dated 1/4/2023, indicated that PRN
orders for all psychotropic drugs shall be used only when the medication is necessary .and for a limited
duration 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for PRN
order to be extended beyond 14 days, he/she shall document their rationale .
Review of Resident R64's clinical record revealed an admission date of 3/25/22, with diagnoses that
included diabetes, dementia with anxiety (a disease that affects short term memory, the ability to think
logically and causes a person to feel nervous), and hypertension (high blood pressure).
Review of Resident R64's medication orders revealed a physician order dated 11/26/23, to administer
Ativan (anti-anxiety) 0.5 milligrams (mg) by mouth every eight hours as needed for anxiety. The medication
order lacked the required stop date within 14 days or a clinical rational for continuing beyond 14 days.
During an interview on 12/11/2023, at 2:08 p.m. the Director of Nursing confirmed that Resident R64's
Ativan order lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14
days.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395588
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Park Avenue
14714 Park Ave Extension
Meadville, PA 16335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations and staff and resident interviews, it was determined that the facility failed to serve
food that was palatable for taste and temperature for four of four units.
Residents Affected - Some
Findings include:
On 12/9/23, and 12/10/23, during resident interviews, the following residents had complaints regarding their
meals:
Residents R2, R13, R28, R33, R36, R90, and R100 expressed frustration that their meals were not
palatable because the food was cold when delivered by staff. Residents R24, R31, R66, R79, R92, and
R103 expressed frustration that their meals were not palatable because the food is cold and is either
undercooked or overcooked most of the time.
Observations on 12/11/23, from 11:25 a.m. through 12:25 p.m. revealed the menu/meal consisted of
breaded sliced beef, noodles, and green beans.
Observation on Havenwood Unit further revealed the following regarding that some residents received
overcooked / burnt slices of breaded beef that the residents were unable to cut:
Resident R28 questioned, What is this black thing on my plate? and asked nursing staff to get him/her a
new piece of meat.
Resident R66 stated This meat, if that is what you call it, is not edible. Resident R66 was then asked if
he/she would like something else to eat, they stated they would just eat the noodles and beans and
declined a new piece of beef or alternate.
During an interview on 12/11/23, at 12:52 p.m. the Dietary Director confirmed that the slice of beef was
overcooked and was not able to be cut or eaten.
28 Pa. Code 201.14(a) Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395588
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Park Avenue
14714 Park Ave Extension
Meadville, PA 16335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility policy, observation and staff interview, it was determined that the facility failed to
ensure that the garbage and refuse was disposed of properly for two of two dumpsters.
Residents Affected - Few
Findings include:
Review of facility policy entitled Commercial Dumpster Use Policies and Procedures, dated 1/4/23, revealed
that, The side and top doors should be closed when the dumpster is not in use.
Observation on 12/9/23, at 12:25 p.m. with Kitchen Employee, E3, revealed two dumpsters that had the
sliding doors on the side of the dumpster that were open. At the time of the observation, Employee E3
confirmed that the dumpster doors should be closed so that the refuse doesn't spill out and to keep
rodents/animals from getting into the dumpsters.
During an interview on 12/9/23 at 12:35 p.m. Dietary Director confirmed that the side doors of the dumpster
should be closed when the dumpster is not in use.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395588
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395588
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Park Avenue
14714 Park Ave Extension
Meadville, PA 16335
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Potential for
minimal harm
Based on review of facility policy, observations, and staff interview, it was determined the facility failed to
properly maintain safe operation of essential equipment in the main kitchen and failed to ensure safe
operating equipment for two of eight food carts used to transport meals from the main kitchen to the
individual units.
Residents Affected - Many
Findings include:
Review of facility policy entitled, Cleaning Instructions: Freezers last reviewed 1/4/23, revealed that freezers
will be defrosted as needed (when the frost is greater than or equal to 1/4 inch thick).
Observations of the walk-in freezer in the Main Kitchen on 12/9/23, at 12:05 p.m. revealed areas with an
accumulation of ice to include on the ceiling that extended out from the condenser to the other side of the
walk-in-freezer, as well as multiple areas on the floor including the entrance to the freezer, and around the
sides of the door, affecting the seal to the door.
Observation on 12/9/23, at 12:12 p.m. revealed two food carts used to transport trays from the main kitchen
to the individual resident units that had a melted/warped door and two malfunctioning wheels that had the
rubber pulling away from the metal part of the wheels.
During an interview on 12/9/23, at 12:35 p.m. Dietary Director confirmed that there was an accumulation of
ice on the ceiling extending out from the condenser to the other side of the walk-in-freezer as well as
multiple areas on the floor including the entrance to the freezer and around the sides of the door. The
Dietary Director also confirmed that two of the eight food carts had damage to the doors and wheels.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(2.1) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395588
If continuation sheet
Page 7 of 7
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F688 - Mobility
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.
F758 - Medication Errors
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
FAQ · About this visit
Common questions about this visit
What happened during the December 12, 2023 survey of EMBASSY OF PARK AVENUE?
This was a inspection survey of EMBASSY OF PARK AVENUE on December 12, 2023. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EMBASSY OF PARK AVENUE on December 12, 2023?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.