Inspection Reports for
Park Avenue Extended Care Facility
425 National Boulevard, Long Beach, NY, 11561
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
180% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Capacity: 240
Deficiencies: 11
Date: Nov 4, 2024
Visit Reason
The survey was a Recertification and Abbreviated Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and care, medication administration, pressure ulcer care, nutritional and hydration management, physician orders, staffing adequacy, pharmaceutical services, food safety, and call system accessibility.
Deficiencies (11)
F 0550: The facility failed to ensure residents #92 and #87 were treated with dignity and respect, as they were found wearing multiple saturated briefs and lying on beds with multiple layers of linens and plastic liners.
F 0658: Resident #14 did not receive Diclofenac 0.1% eye drops as ordered from 1/16/2024 to 1/23/2024 due to pharmacy delivery delay and lack of communication.
F 0677: Residents #92 and #87 did not receive timely morning care, with briefs saturated and rooms having strong urine odor, indicating inadequate assistance with activities of daily living.
F 0686: Resident #156's heel pressure ulcers were not treated timely due to delayed wound care orders, and Resident #48's pressure ulcer treatments were missed on multiple occasions due to staffing issues.
F 0692: Resident #102 exceeded physician-ordered fluid restrictions, receiving more fluids than allowed during medication passes and meals.
F 0710: Resident #75's anti-seizure medication Topiramate was abruptly stopped for four days without physician order or evaluation, risking seizure activity.
F 0725: The facility staffing plan did not match actual staffing levels, with frequent understaffing of Certified Nursing Assistants and nurses, leading to delayed medication administration and missed wound care.
F 0732: The facility failed to post daily nursing staffing information in a prominent location with actual numbers of staff per shift.
F 0755: Pharmaceutical services were deficient as Resident #14's Diclofenac eye drops were delayed due to pharmacy clarification issues and lack of timely communication with the physician.
F 0812: Frozen food items in the kitchen freezer were stored with opened packaging and undated, risking freezer burn and cross-contamination.
F 0919: Call bells were not accessible to residents #350, #4, and #87, with bells observed out of reach or on the floor, compromising resident safety.
Report Facts
Medication missed: 16
Medication missed: 4
Pressure ulcer treatments missed: 2
Fluid intake excess: 1120
Facility capacity: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #9 | Named in findings related to delayed morning care and multiple briefs on residents #92 and #87 | |
| Registered Nurse #1 | Interviewed regarding morning care timing and staff awareness of care issues | |
| Director of Nursing Services | Interviewed regarding care expectations, staffing, and medication administration | |
| Licensed Pharmacist #1 | Interviewed regarding pharmacy delay and clarification for Diclofenac eye drops | |
| Physician #1 | Primary Care Physician and Medical Director | Interviewed regarding medication order renewal and seizure medication management for Resident #75 |
| Physician #2 | Interviewed regarding ophthalmology care and Diclofenac eye drop order for Resident #14 | |
| Registered Nurse #4 | Interviewed regarding missed wound care treatments on Resident #48's unit | |
| Registered Nurse #5 | Overnight Supervisor | Interviewed regarding coverage and missed wound care documentation |
| Certified Nursing Assistant #2 | Interviewed regarding call bell placement for Resident #350 | |
| Registered Nurse Supervisor #11 | Interviewed regarding pharmacy communication and medication availability |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Nov 4, 2024
Visit Reason
Complaint Survey with 11 health and 2 life safety code citations, all corrected by January 3, 2025 or December 11, 2024.
Findings
Complaint Survey with 11 health and 2 life safety code citations, all corrected by January 3, 2025 or December 11, 2024.
Deficiencies (13)
ADL care provided for dependent residents
Food procurement,store/prepare/serve-sanitary
Nutrition/hydration status maintenance
Pharmacy srvcs/procedures/pharmacist/records
Posted nurse staffing information
Resident call system
Resident rights/exercise of rights
Resident's care supervised by a physician
Services provided meet professional standards
Sufficient nursing staff
Treatment/svcs to prevent/heal pressure ulcer
Illumination of means of egress
Means of egress - general
Inspection Report
Annual Inspection
Capacity: 240
Deficiencies: 4
Date: Nov 4, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with professional standards of quality, pressure ulcer care, staffing sufficiency, and pharmaceutical services.
Findings
The facility failed to ensure timely and accurate medication administration, specifically for Diclofenac eye drops delayed due to pharmacy clarification. Pressure ulcer care was inadequate with delayed or missed treatments for residents with pressure ulcers. Staffing levels were insufficient on multiple units and shifts, leading to delayed medication administration and missed wound care treatments.
Deficiencies (4)
F 0658: The facility did not ensure medication administration and documentation met professional standards. Diclofenac eye drops were documented as administered before delivery, indicating inaccurate documentation and failure to notify supervisors or physicians of unavailable medication.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers. Treatments for pressure ulcers on residents' heels and sacrum were delayed or not administered as ordered.
F 0725: The facility did not provide sufficient nursing staff on a 24-hour basis, resulting in understaffing on six resident units. This caused late medication administration and missed wound care treatments.
F 0755: Pharmaceutical services did not meet resident needs. Diclofenac eye drops were delayed due to lack of timely clarification between pharmacy and physician, and nursing staff failed to notify the physician or pharmacy promptly.
Report Facts
Bed capacity: 240
Medication administration delays: 16
Certified Nursing Assistants understaffed: 3
Certified Nursing Assistants understaffed: 4
Stage 3 pressure ulcer size: 5
Stage 3 pressure ulcer size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #2 | Physician | Ordered Diclofenac eye drops for Resident #14 and documented follow-up visits. |
| Registered Nurse #11 | Registered Nurse | Documented ophthalmology visit and medication administration for Resident #14. |
| Licensed Pharmacist #1 | Licensed Pharmacist | Reported pharmacy delay in dispensing Diclofenac eye drops due to allergy clarification. |
| Director of Nursing Services | Director of Nursing | Provided statements on medication administration policies and staffing issues. |
| Administrator | Facility Administrator | Discussed staffing challenges and facility assessment. |
| Registered Nurse #4 | Registered Nurse | Documented missed wound care treatments for Resident #48 and explained staffing challenges. |
| Registered Nurse #6 | Wound Care Nurse | Reviewed wound assessments and treatment delays for Resident #156. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 26, 2023
Visit Reason
The survey was a Recertification Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in providing appropriate catheter care and monitoring, ensuring physician supervision for dialysis patients, and timely administration of pneumococcal vaccinations to residents who requested them.
Deficiencies (3)
F 0690: The facility failed to ensure appropriate care and monitoring after removal of an indwelling urinary catheter for Resident #115, resulting in abdominal distension and re-catheterization without proper documentation of voiding monitoring.
F 0710: The facility did not ensure physician supervision with adequate orders for blood pressure monitoring and medication parameters for Resident #367 receiving Midodrine for Orthostatic Hypotension.
F 0883: The facility failed to administer pneumococcal vaccinations in a timely manner to three residents who requested the vaccine, due to vaccine unavailability and lack of follow-up.
Report Facts
Urine output: 1500
Medication hold dates: 4
Residents reviewed for immunization: 5
Residents who did not receive pneumococcal vaccine: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Discontinued Foley catheter and monitored Resident #115; involved in re-catheterization |
| RN #5 | Registered Nurse Supervisor | Supervised monitoring shifts related to Resident #115's voiding trial |
| LPN #4 | Licensed Practical Nurse | Monitored urine output and reported abdominal distension for Resident #115 |
| RN #7 | Registered Nurse | Medication nurse for Resident #367; noted lack of blood pressure parameters in orders |
| Primary Physician #1 | Physician | Provided orders and interviews regarding Resident #115 and Resident #367 care |
| Director of Nursing Services | Director of Nursing | Interviewed regarding documentation and immunization issues |
| Assistant Director of Nursing Services | Assistant Director of Nursing | Interviewed regarding catheter monitoring and immunization vaccine availability |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jan 26, 2023
Visit Reason
Complaint Survey with 3 health and 4 life safety code citations, all corrected by March 7, 2023 or February 28, 2023.
Findings
Complaint Survey with 3 health and 4 life safety code citations, all corrected by March 7, 2023 or February 28, 2023.
Deficiencies (7)
Bowel/bladder incontinence, catheter, uti
Influenza and pneumococcal immunizations
Resident's care supervised by a physician
Electrical systems - essential electric syste
Emergency lighting
Sprinkler system - maintenance and testing
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Feb 19, 2020
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for Park Avenue Extended Care Facility.
Findings
The facility was found deficient in ensuring accurate resident assessments, developing and implementing comprehensive care plans, providing appropriate pressure ulcer care, and preventing significant medication errors. Specific issues included incomplete nutrition assessments, failure to address resident refusals of supplements, incomplete care plans for pressure ulcers and mood/behavior, delayed treatment of pressure ulcers, and medication administration errors.
Deficiencies (5)
F 0641: The facility failed to ensure each resident received an accurate assessment, as Resident #211's Quarterly Minimum Data Set (MDS) did not include the resident's weight despite available weights from hemodialysis records.
F 0656: The facility did not develop or implement complete care plans addressing residents' needs, including failure to address Resident #58's refusal of liquid protein supplement and failure to implement safety interventions for Resident #103 to prevent self-harm.
F 0657: The facility failed to review and revise comprehensive care plans to reflect residents' current status, as Resident #209's pressure ulcer care plan was not updated to include the use of heel booties.
F 0686: The facility did not provide timely pressure ulcer care, as Resident #198's Stage 3 pressure ulcer was not assessed or treated until 15 days after initial skin impairment was noted by staff.
F 0760: The facility failed to ensure residents were free from significant medication errors, as Resident #162 received Metoprolol twice daily for 19 days despite a physician order change to once daily.
Report Facts
Days Metoprolol administered twice daily after order change: 19
Days delay in pressure ulcer treatment: 15
Pressure ulcer wound size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Documented resident refusals of liquid protein supplement and reported wound to supervisor. |
| NP #1 | Nurse Practitioner | Interviewed regarding medication order changes and resident care. |
| RN Supervisor | Registered Nurse Supervisor | Interviewed regarding resident complaints and care plan updates. |
| Director of Nursing Services | DNS | Interviewed regarding medication administration errors and care plan compliance. |
| Chief Clinical Dietitian | Dietitian | Interviewed regarding nutrition assessment and resident weight documentation. |
| MDS Coordinator | MDS Coordinator | Interviewed regarding completion of nutrition section of MDS. |
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