Inspection Reports for Park Avenue Health Center
146 Park Ave, Arlington, MA 02476, United States, MA, 02476
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with nursing staff competencies, specifically regarding their ability to respond appropriately during a Code Blue emergency situation.
Findings
The facility failed to ensure that licensed nursing staff were competent in calling and responding to a Code Blue event. Staff did not overhead page a Code Blue during an actual emergency, resulting in only three staff members responding instead of the expected broader nursing support.
Deficiencies (1)
Failure to ensure nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being, specifically in responding to Code Blue emergencies.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Named in the finding related to failure to call a Code Blue and properly delegate during the emergency. |
| CNA #1 | Certified Nursing Assistant | Responded to the emergency and assisted with resident care during the Code Blue event. |
| CNA #2 | Certified Nursing Assistant | Responded to the emergency and assisted with resident care during the Code Blue event. |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding lack of Code Blue paging during the emergency. |
| Nurse #2 | Nurse | Interviewed regarding lack of Code Blue paging during the emergency. |
| Nurse #4 | Nurse | Interviewed regarding lack of Code Blue paging during the emergency. |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Interviewed about staff development and mock Code Blue drills. |
| Interim Director of Nurses | Interim Director of Nurses (DON) | Interviewed about expectations for Code Blue response and staff competencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 8, 2025
Visit Reason
The inspection was conducted following a complaint related to an incident where Resident #1, an elopement risk residing on a secured unit, was able to exit the facility undetected by staff and was found outside with a fractured left elbow.
Complaint Details
The visit was complaint-related due to an incident on 04/08/25 where Resident #1 eloped from a secured unit and was found outside the facility with a fractured elbow. The complaint was substantiated based on investigation findings.
Findings
The facility failed to provide adequate staff supervision to prevent Resident #1's elopement. Investigations revealed lapses in supervision and security protocols, including failure to monitor elevator access and front door exits. Corrective actions were implemented including increased monitoring, updated care plans, staff education, and security enhancements.
Deficiencies (1)
Failure to ensure adequate staff supervision to prevent elopement of Resident #1, resulting in actual harm (fractured left elbow).
Report Facts
Residents Affected: 3
Date of Incident: Apr 8, 2025
Date Survey Completed: Apr 29, 2025
BIMS Score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist #1 | Receptionist | Mentioned in relation to failure to detect Resident #1 exiting the facility. |
| Housekeeping Supervisor | Housekeeping Supervisor | Reported seeing Resident #1 outside and alerted staff. |
| Director of Social Services | Director of Social Services | Interviewed regarding supervision and visitor access on the secured unit. |
| Director of Nurses | Director of Nurses (DON) | Provided information on facility expectations for visitor access and supervision. |
| Administrator | Administrator | Investigated the incident and coordinated follow-up actions. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain complete and accurate medical records, specifically related to wound measurements for a resident following readmission after a hospital stay.
Complaint Details
The investigation was complaint-related, focusing on the failure to document wound measurements for Resident #3. The Director of Nurses confirmed the importance of wound measurement documentation and acknowledged that nursing should have documented the wounds upon readmission.
Findings
The facility failed to document wound measurements for six days following the readmission of Resident #3, who had multiple stage four pressure injuries. Nursing documentation was incomplete, with no measurements recorded upon or after readmission, contrary to facility policies and protocols.
Deficiencies (1)
Failure to maintain complete and accurate medical records related to wound measurements for Resident #3 for six days following readmission.
Report Facts
Wound measurements: 3
Wound dimensions: 0.4
Wound dimensions: 0.4
Wound dimensions: 0.1
Wound dimensions: 4
Wound dimensions: 2
Wound dimensions: 1.8
Wound dimensions: 2
Wound dimensions: 2
Wound dimensions: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed regarding wound measurement documentation and confirmed nursing should have documented wound measurements upon readmission |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 19, 2024
Visit Reason
The inspection was conducted following a complaint and incident involving Resident #1 who eloped from the facility, resulting in injuries. The investigation focused on the facility's failure to provide adequate supervision and secure the environment to prevent elopement.
Complaint Details
The investigation was triggered by a complaint regarding Resident #1's elopement on 11/02/24. Resident #1, who had severe cognitive impairment and was at increased risk for elopement, was found the next day 3.6 miles away with injuries and admitted to the hospital. The complaint included failure of staff supervision and environmental security.
Findings
The facility failed to provide adequate supervision to prevent Resident #1's elopement, who was found injured after leaving the facility unsupervised. Additionally, the designated smoking area was unsecured, allowing residents to access it and exit the facility unsupervised. Staff were unaware of residents having access codes to exit doors, and supervision protocols were not followed.
Deficiencies (4)
Failure to provide adequate staff supervision to prevent Resident #1's elopement, resulting in injuries.
Failure to secure the fenced patio area used for smoking, allowing residents to exit unsupervised.
Residents had access to keypad codes to exit and enter the designated smoking area unsupervised.
Staff failed to supervise residents in the designated smoking area as required by facility policy.
Report Facts
Residents in day room during activity: 5
Distance Resident #1 was found from facility: 3.6
Temperature range daytime on 11/02/24: 50
Temperature range overnight on 11/03/24: 30
Number of CNA staff on unit 2 day shift: 3
Scheduled smoking times: 6
Duration Resident #5 was unsupervised outside smoking: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Resident #1's nurse on 11/02/24; reported Resident #1's exit seeking and broken alarm door. |
| CNA #1 | Certified Nurse Aide | Observed Resident #1 pacing and exit seeking; last saw Resident #1 before elopement. |
| CNA #3 | Certified Nurse Aide | Observed Resident #1 at exit door and redirected him/her. |
| Activity Assistant | Conducted group activity on 11/01/24; allowed residents to enter smoking area without supervision. | |
| Director of Maintenance | Director of Maintenance | Unaware of broken alarm on exit door until after Resident #1 was missing. |
| Weekend Supervisor | Weekend Supervisor | Unaware of Resident #1's exit seeking and missing status until after incident. |
| Nurse #2 | Nurse | Assisted with search after Resident #1 was reported missing. |
| Director of Nurses | Director of Nurses | Unaware residents had access codes to exit doors; stated expectation that residents should not have codes. |
| Unit Manager | Unit Manager | Unaware residents had access codes; stated staff should supervise smokers outside. |
Inspection Report
Routine
Deficiencies: 13
Date: Oct 18, 2024
Visit Reason
The inspection was a routine survey of Park Avenue Health Center to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain psychotropic medication consent, inadequate odor control in a resident's room, unresolved grievance regarding staff sleeping on shift, improper use and assessment of physical restraints, failure to report and investigate abuse allegations, inaccurate Minimum Data Set (MDS) assessments, failure to implement physician orders for orthotic and respiratory care, medication errors including double dosing of Torsemide, lack of trauma-informed care planning, and improper food handling practices.
Deficiencies (13)
Failed to obtain a signed psychotropic informed consent for one resident.
Failed to provide a clean and comfortable homelike environment due to strong odors in a resident's room.
Failed to provide a resolution to a grievance filed regarding staff sleeping on shift.
Failed to identify and assess mattress bolsters as a potential physical restraint for one resident.
Failed to timely report allegations of potential abuse for three residents.
Failed to investigate allegations of potential abuse for three residents.
Inaccurately documented the use of an indwelling catheter for one resident.
Failed to implement an orthotic for contracture management as ordered for one resident.
Failed to ensure respiratory care and treatment according to physician's orders for one resident, specifically oxygen flow rate.
Monthly medication review failed to identify an irregularity of double dosing Torsemide for one resident.
Failed to ensure resident was free from significant medication errors; resident received double dose of Torsemide.
Failed to develop a comprehensive trauma informed care plan with individualized triggers for one resident with PTSD.
Failed to handle food in accordance with professional standards, contaminating ready-to-eat food during service.
Report Facts
Residents sampled: 23
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Torsemide double dosing days: 27
Weight loss: 26
Oxygen flow rate observed: 4
Oxygen flow rate observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic consent, odor control, grievance resolution, abuse reporting, medication errors, respiratory care, and other deficiencies |
| Unit Manager #1 | Unit Manager | Interviewed regarding odor control, physical restraint assessment, orthotic use |
| Nurse #3 | Nurse | Interviewed regarding odor control and purewick catheter use |
| Housekeeping Manager | Housekeeping Manager | Interviewed regarding odor control in resident's room |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding mattress bolsters use |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding mattress bolsters use |
| Regional Clinical Director | Regional Clinical Director | Interviewed regarding restraint assessment and medication review |
| Social Worker | Social Worker | Interviewed regarding abuse reporting and trauma informed care |
| Nurse #1 | Nurse | Interviewed regarding wound care |
| Nurse #2 | Nurse | Interviewed regarding oxygen therapy and medication administration |
| Food Service Director | Food Service Director | Interviewed regarding food handling practices |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 11, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to protect Resident #2 from neglect and failure to implement physician-ordered wound treatments as instructed by the Wound Clinic from May 2023 through September 2023.
Complaint Details
The complaint investigation focused on allegations that the facility neglected Resident #2 by failing to implement wound care orders, resulting in serious wound deterioration and hospitalization. Additional concerns included failure to assist Resident #75 with eating, inaccurate medical record documentation, inadequate pressure ulcer care for Resident #27, and lapses in infection control practices.
Findings
The facility failed to ensure nursing staff identified and implemented multiple treatment orders for Resident #2's coccyx wound, resulting in significant wound deterioration and hospitalization with Stage IV decubitus ulcer and osteomyelitis. Additionally, the facility failed to provide assistance with eating for Resident #75 as ordered, maintain accurate medical records, and properly offload pressure wounds for Resident #27. Infection control lapses were also observed during medication administration and vital sign monitoring.
Deficiencies (5)
Failed to protect Resident #2 from neglect by not implementing wound treatments ordered by the physician and Wound Clinic from May to September 2023, leading to wound deterioration and hospitalization.
Failed to provide assistance with eating as ordered for Resident #75, resulting in inadequate feeding support.
Failed to maintain complete and accurate medical records for Resident #75, including documentation of hearing aid and nutritional supplement provision when not provided.
Failed to provide appropriate pressure ulcer care and prevent new ulcers for Residents #2 and #27, including failure to implement wound care orders and offload pressure wounds.
Failed to implement an infection prevention and control program by not disinfecting reusable resident care equipment between residents and improper handling of medication during administration.
Report Facts
Residents sampled: 22
Resident #2 wound measurements: 7
Resident #2 weight: 109.6
Wound vac settings: 125
Treatment frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #1 | Attending Physician | Monitored Resident #2's wounds and approved wound clinic orders |
| Nurse Practitioner #1 | Nurse Practitioner | Reviewed and approved wound clinic orders for Resident #2 |
| Unit Manager #1 | Unit Manager | Responsible for relaying wound clinic orders and weekly wound measurements; unaware of some wound vac orders and did not follow up on wound vac replacement |
| Assistant Director of Nursing | ADON | Held weekly risk meetings and acknowledged discrepancies in wound care implementation |
| Nurse #1 | Nurse | Documented hearing aid and nutritional supplement provision for Resident #75 but did not provide them |
| Nurse #2 | Nurse | Observed failing to disinfect vital sign machine between residents and improper medication handling |
| Nurse #4 | Nurse | Stated Unit Manager #1 is responsible for wound measurements |
| Nurse #5 | Nurse | Stated only one treatment should be in place for each wound |
| Nurse #6 | Nurse | Uncertain which order to follow when two orders exist for the same wound |
| Certified Nurse Aide #1 | CNA | Reported Resident #2 is repositioned every two hours and does not refuse treatment |
| Certified Nurse Aide #2 | CNA | Reported Resident #75 requires assistance with hearing aids |
| Registered Dietitian | RD | Reported magic cups were discarded due to freezer malfunction and was unaware Resident #75 did not receive supplement |
| Occupational Therapist | OT | Assessed Resident #75's feeding needs and expected staff to provide assistance and cueing |
Inspection Report
Complaint Investigation
Deficiencies: 20
Date: Sep 15, 2022
Visit Reason
The inspection was conducted based on complaints and concerns raised by residents regarding staff behavior, grievance handling, abuse reporting, and care deficiencies.
Complaint Details
The visit was complaint-related based on multiple resident complaints about staff behavior, grievance handling, abuse reporting, and care deficiencies. Substantiation status is not explicitly stated.
Findings
The facility failed to promptly address resident concerns, complete grievance investigations, report and investigate potential abuse, complete required assessments timely, implement care plans, maintain infection control practices, and ensure medication safety and proper diet adherence.
Deficiencies (20)
Failed to ensure concerns brought up by the resident group were acted on promptly and demonstrate an effective response.
Failed to inform residents how to file grievances and failed to complete two grievances filed by residents.
Failed to timely report potential abuse to the state agency for one resident.
Failed to investigate potential abuse allegations for one resident.
Failed to complete Quarterly Minimum Data Set assessments timely for one resident.
Failed to lock and transmit Minimum Data Set assessments to CMS within required timeframe for one resident.
Failed to accurately code Minimum Data Set assessment for one resident with left wrist and hand contracture.
Failed to develop a baseline care plan within 48 hours of admission for one resident.
Failed to implement skin integrity care plan, failed to develop care plans for activities and communication for three residents.
Failed to follow doctor's order for air mattress pump setting for four residents and failed to administer medications as ordered for multiple residents.
Failed to provide necessary services to ensure effective communication for one resident.
Failed to ensure fingernails were kept trimmed and clean for one resident.
Failed to provide assistance as needed for activities of daily living for three residents.
Failed to document visible bruising upon admission for one resident.
Failed to maintain suprapubic catheter in a manner to reduce risk of infection for one resident.
Failed to address significant weight loss in one resident.
Failed to ensure medication error rate was below 5 percent; one nurse made 7 errors in 29 opportunities.
Failed to ensure medications were secured in locked compartments and stored in original packaging.
Failed to ensure renal diet with low potassium and low phosphorous was maintained for one resident.
Failed to ensure infection control practices were followed during medication administration and blood sampling; failed to maintain infection control program with surveillance and trending.
Report Facts
Medication errors: 7
Weight loss percentage: 12.2
Medication administration delay: 217
Medication administration delay: 157
Air mattress setting: 280
Air mattress setting: 250
Air mattress setting: 400
Air mattress setting: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #9 | Named in medication error findings and infection control violations. | |
| Nurse #1 | Named in air mattress setting and infection control documentation findings. | |
| Nurse #4 | Documented air mattress setting checks inconsistent with observations. | |
| Nurse #3 | Documented air mattress setting checks inconsistent with observations. | |
| Nurse #2 | Interviewed regarding air mattress use and bruising documentation. | |
| Nurse #5 | Interviewed regarding medication administration timing. | |
| Nurse #6 | Observed catheter care and interviewed about catheter bag placement. | |
| Nurse #7 | Interviewed regarding expired bread and medication cart security. | |
| Nurse #8 | Interviewed about communication barriers and interpreter use. | |
| Nurse #10 | Interviewed regarding care plan accuracy. | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple care and medication issues. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding infection control program and air mattress settings. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding air mattress settings and resident care. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding resident feeding assistance and catheter care. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding resident feeding assistance. |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed regarding communication with Resident #56. |
| Administrator | Administrator | Interviewed regarding grievance handling and abuse reporting. |
| Corporate Nurse #1 | Director of Nursing | Interviewed regarding grievance and abuse investigation. |
| Chief Clinical Officer | Chief Clinical Officer | Interviewed regarding missed assessments and care plan accuracy. |
| Dietitian | Registered Dietitian | Interviewed regarding weight loss and diet adherence. |
| Activities Director | Activities Director | Interviewed regarding activities care plan completion. |
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