Below 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 Park Avenue Health Center during CMS and state inspections, most recent first.
Inaccurate ADL charting affected three residents when CNAs documented wandering and walking that did not match resident condition or staff observations. One resident with depression, anxiety, and failure to thrive was charted as wandering and walking despite stating he/she did not walk and staff confirming no wandering or walking. A second resident with Huntington’s disease, anxiety, and apraxia was charted as wandering even though staff said the resident did not wander and was observed reclined in a tilted chair with a seatbelt. A third resident with dementia and other serious diagnoses was charted as wandering on multiple shifts, but nurses and CNAs said the resident stayed in bed, did not move on his/her own, and did not wander, resulting in an inaccurate MDS assessment.
A resident who was cognitively intact reported neglect by a CNA and said the CNA should not be near him/her. Although the DON said the CNA was suspended pending investigation and should have left immediately, surveyors observed the CNA continuing to provide care and remain on the unit and at the nursing station after the suspension. Facility leaders later acknowledged a breakdown in communication and that the CNA stayed in the building and worked the day shift.
Care Plan Not Updated After Diuretic Discontinued: A resident with Alzheimer's disease, AFib, DM, and muscle weakness had torsemide discontinued, but the care plan was not revised after subsequent MDS reviews. Nursing documented care plan reviews, yet the plan still listed diuretic therapy and related dehydration and fall-risk focuses even though the MAR showed no diuretic use after the medication was stopped.
Failure to Provide Ordered 1:1 Feeding Assistance: A resident with Alzheimer's disease, dysphagia, and severe cognitive impairment had an order and care plan for 1:1 feeding assistance, but staff repeatedly only set up meals and left the room. Survey observations showed the resident eating or drinking without staff present, and on one occasion the resident fell asleep during breakfast and the tray was removed. Staff told the surveyor the resident only needed set-up, while the RD and NP confirmed the resident required 1:1 feeding assistance.
A resident with dysphagia, gastrostomy status, and severe cognitive impairment had a tube feeding ordered for 55 ml/hour for 18 hours daily, but surveyors observed the feeding running outside the ordered timeframe on multiple occasions. The MAR lacked documentation for when the feeding was turned off, and the ADON and an RN acknowledged the order was not being followed. The NP stated she was not aware the resident had been receiving the tube feeding outside the ordered schedule and expected the order to be followed.
Therapeutic diet and fluid restriction not followed for a resident with stroke, dysphagia, PEG status, and CHF. The resident had orders for NPO status, enteral feeding, scheduled water flushes, and a 1200 mL fluid restriction, but the tube feeding was observed running past the ordered stop time on multiple occasions. The care plan did not identify the fluid restriction, and staff interviews showed confusion about the feeding schedule and monitoring of intake.
A resident with dementia and a history of wandering exited a secured unit and the facility undetected by staff, following a visitor onto an elevator and out the front entrance. The resident was later found outside with a fractured elbow. Facility staff failed to provide adequate supervision and did not follow protocols for monitoring residents and visitors, resulting in the resident's elopement and injury.
A facility failed to document wound measurements for a resident following their readmission after a hospital stay. The resident, with chronic osteomyelitis and stage four pressure injuries, had no documented measurements for six days post-readmission, despite facility policies requiring such documentation. The DON acknowledged the importance of these measurements for tracking wound progression.
A resident with severe cognitive impairment eloped from an LTC facility due to inadequate supervision and security measures. The resident, known for exit-seeking behavior, was found injured and dehydrated in a neighboring town. The facility also failed to secure a patio area, allowing residents unsupervised access, contrary to policy. Staff were unaware of residents having keypad codes, and gates were left open, contributing to the incident.
The facility failed to adhere to food service safety standards by allowing a cook to contaminate ready-to-eat food with gloves that had been used to touch various surfaces. Despite the facility's policy requiring gloves to be changed between tasks, the cook used the same contaminated gloves to handle edible flowers and hot dog buns for resident plates. This was confirmed by the Food Service Director, who emphasized the importance of preventing contamination.
A facility failed to obtain a signed psychotropic informed consent for a resident with severe cognitive impairment and a court-appointed guardian. The resident was receiving Lithium Carbonate for bipolar disorder without a signed consent form. The DON reported difficulties in contacting the healthcare proxy and guardian, and the medication was administered without consent to avoid potential harm.
A resident's room in an LTC facility was found to have a persistent strong odor due to inadequate maintenance of a purewick system used for incontinence care. Despite daily cleaning, the room had not been deep cleaned recently, and staff were aware of the odor issue but had not increased cleaning frequency. The resident, who is cognitively intact and dependent on assistance, expressed dissatisfaction with the room's condition, particularly while eating meals.
The facility failed to resolve a grievance filed by a resident about staff sleeping during their shift. The facility's Grievance Policy requires a written report of findings within 72 hours and informing the complainant of actions taken within 3-5 working days. However, no resolution was documented for the grievance, and the Director of Nursing acknowledged this oversight.
A facility failed to assess mattress bolsters as a potential restraint for a resident with severe cognitive impairment. The resident had bolsters under the fitted sheet to prevent climbing out of bed, but no restraint assessment, physician's order, or care plan documentation was completed. Staff interviews confirmed the absence of a formal assessment, leading to a deficiency in ensuring the resident's freedom from unnecessary restraints.
The facility failed to report allegations of potential abuse for three residents, including derogatory comments and rough handling by staff. Despite the Social Worker and DON acknowledging the need for investigation and reporting, these incidents were not reported to the state agency, violating the facility's abuse and neglect policy.
The facility failed to investigate allegations of potential abuse for three residents. A resident with intact cognition reported a nurse's derogatory comment, another with moderate cognitive impairment reported a hurtful comment from a CNA, and a severely impaired resident's representative reported rough handling and neglect. The facility did not conduct required investigations for these grievances.
A facility inaccurately documented a resident's use of an indwelling catheter in the MDS assessment. The resident, with cerebral infarction and diabetes, was cognitively intact. The MDS incorrectly indicated an indwelling catheter, while records showed the use of a purewick catheter, an external device. Staff interviews confirmed the coding error.
A resident with severe cognitive impairment and a right upper extremity contracture was not provided with a prescribed orthotic for contracture management. Despite physician orders for a resting hand splint to be worn nightly, observations showed the resident was not wearing the orthotic, and it was not found in the room. The Unit Manager confirmed the order, but nursing notes did not document any refusal by the resident. The DON expects all orders to be followed, highlighting a deficiency in care plan adherence.
A resident with an unstageable pressure wound on the right heel did not receive proper wound care as per the Wound Physician's recommendations. The resident was observed with their foot directly on the bed without the prescribed heel protective booties, and the air mattress was not set to the resident's weight. Interviews with staff confirmed the need for these interventions, but they were not consistently implemented.
A resident with chronic respiratory failure was observed receiving oxygen at a flow rate higher than the physician's order of 1-2 LPM. The oxygen concentrator was set at four LPM on multiple occasions, contrary to the prescribed range. A nurse later corrected the setting to two LPM. The DON acknowledged the importance of adhering to physician's orders to prevent adverse effects.
A facility failed to create a comprehensive trauma-informed care plan for a resident with PTSD. The resident's care plan included general interventions but lacked specific triggers and individualized strategies for PTSD. The social worker was unaware of the PTSD diagnosis, and the psychiatric evaluation and psychotherapy notes did not document it, highlighting a gap in care planning.
A resident with heart failure received double the prescribed dose of Torsemide due to a failure in the monthly medication review (MRR) process. The resident had two active orders for Torsemide, each for 40 mg, leading to a total of 80 mg being administered daily. The MRR did not identify this irregularity, and interviews with facility staff confirmed the expectation for such discrepancies to be recognized.
A resident with heart failure received a double dose of Torsemide for 27 days due to two separate physician orders, leading to significant weight loss and elevated BUN/creatinine levels. The error was not identified by the facility's medication administration processes or during the monthly medication review. The issue was only acknowledged after a review by a nurse and surveyor, prompting clarification from the nurse practitioner.
Inaccurate ADL Documentation for Wandering and Walking
Penalty
Summary
Accurate medical records were not maintained for three residents when CNAs documented wandering and walking that did not match resident condition or staff observations. The facility’s policy stated that accurate medical records shall be maintained, but the ADL flow sheets for Residents #35, #5, and #69 contained entries that staff later said were incorrect. The surveyor reviewed the records, observed the residents, and interviewed CNAs, nurses, and management, who repeatedly stated that the documented behaviors were not accurate. Resident #35 was admitted with diagnoses including major depression, anxiety, and failure to thrive, and the most recent MDS indicated cognitive intactness, no behaviors, and assistance with ADLs. The resident told the surveyor he/she did not walk and had not walked for a while, using a wheelchair for transportation. However, the ADL documentation showed multiple shifts in September, October, and November 2025 where CNAs recorded wandering and walking distances such as 10 feet, 50 feet with 2 turns, and 150 feet with 2 turns. CNAs, a nurse, and the Director of Rehabilitation stated the resident does not wander and has never walked, and the DON stated CNAs should code ADL documentation correctly. Resident #5, who had diagnoses including Huntington’s disease, anxiety, and apraxia, had an MDS showing rare/never understood, wandering 1-3 days, and dependence for ADLs. The resident was observed reclined in a tilted chair using a seatbelt to restrict movement, yet the ADL documentation showed wandering on multiple shifts across September, October, and November 2025. CNAs and the ADON stated the resident does not wander and that the wandering entries were documented in error. Resident #69, who had diagnoses including malnutrition, dysphagia, failure to thrive, seizures, major depressive disorder, and dementia, had an MDS indicating severe cognitive impairment and wandering in the last 4 to 6 days. The resident was observed in bed and said he/she did not get out of bed too often, while nurses and CNAs stated the resident spends the day in bed, does not move on his/her own, and does not wander; the nurse consultant stated CNA documentation is reviewed daily for completion versus accuracy and that the MDS relies on accurate documentation.
CNA Accused of Neglect Remained in Facility After Suspension
Penalty
Summary
The facility failed to implement its abuse policy for one resident when a CNA accused of neglect was not kept away from resident contact after being suspended. The facility policy stated that any employee accused of resident abuse is to be placed on leave with no resident contact until the investigation is complete. The resident involved was admitted in April 2025 with diagnoses including major depression, anxiety, and failure to thrive, and the most recent MDS showed the resident was cognitively intact with a BIMS score of 15 out of 15, had no behaviors, did not reject care, and required assistance with ADLs. On 11/30/25, the resident called police and reported not wanting the overnight CNA to touch him/her, stating that the same staff were being put to work every night on purpose and that he/she wanted to leave the facility. The resident was described as agitated and frustrated and expressed a desire to report the facility for the way he/she had been treated. On 12/1/25, the resident again told the surveyor and staff that the CNA neglected him/her, did not meet needs, and should not be near the resident. The resident identified CNA #1 as the accused and stated that staff should hear about the neglect so they would know there were repercussions. The DON later reported that CNA #1 was suspended pending investigation at 9:30 A.M. on 12/1/25 and that she thought the CNA had left the facility at that time. However, surveyors observed CNA #1 providing care to residents, exiting resident rooms, and being on the unit and at the nursing station after the suspension time. The DON, Administrator, Human Resources, and Nurse Consultant #1 and #2 all acknowledged there was a breakdown in communication and that CNA #1 should have left the building immediately pending the neglect investigation, but she remained in the facility and worked the day shift.
Care Plan Not Updated After Diuretic Discontinued
Penalty
Summary
The facility failed to revise the care plan after two MDS assessments for one resident who was reviewed for unnecessary medication use. The resident was admitted in November 2022 with diagnoses including Alzheimer's disease, atrial fibrillation, diabetes, and muscle weakness. Review of the record showed the resident's torsemide, a diuretic, was discontinued on 5/19/25, and the July, August, September, and October 2025 MARs did not show any diuretic administration after that discontinuation. The facility's care plan reviews on 8/12/25 and 10/27/25 documented that nursing reviewed and revised the care plan, but the plan of care still included a focus stating the resident was on diuretic therapy, with that item last revised on 5/25/23. The resident's plan of care also continued to include a focus for potential dehydration or fluid deficit related to diuretic use, last revised on 10/15/24, even though the diuretic had been discontinued months earlier. In addition, the care plan for fall risk, revised on 8/13/25, still listed medications including diuretics among the contributing factors. During interview, the ADON who completed the care plan reviews stated the care plan for diuretic use should have been resolved during the reviews but was not. The DON stated that care plans need to be revised after the MDS assessment to reflect the resident's most current status.
Failure to Provide Ordered 1:1 Feeding Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs was provided for one resident, specifically failing to provide the ordered 1:1 feeding assistance for Resident #47. Resident #47 was admitted in April 2023 and had diagnoses including Alzheimer's disease, dysphagia, and dementia with psychotic disturbance. The most recent MDS dated 9/25/25 showed severe cognitive impairment with a BIMS score of 6 out of 15 and indicated the resident required set-up or clean-up assistance with eating. The active physician orders listed the resident as a 1:1 feed as of 8/29/25, and the care plans directed staff to provide 1:1 feeding assistance, encourage adequate PO intake, and observe for signs and symptoms of aspiration during meals. Observation and interviews showed staff repeatedly set up the resident's meals and then left the room without providing the ordered one-to-one assistance. On 12/1/25 and 12/2/25, the surveyor observed the resident eating or drinking in bed while staff were not present in the room or in sight, and on one occasion the resident fell asleep during breakfast and the tray was removed without staff waking the resident or assisting further. On 12/3/25, the CNA and nurse stated the resident only needed set-up and could eat alone, while the ADON stated the level of assistance varied with alertness and dementia and that staff should observe and offer the amount of help needed. The RD stated the resident required 1:1 feeding assistance due to impaired cognition and a history of spitting out foods, and the NP stated that if there was an order for 1:1 assistance it should be followed and that the resident was at risk for aspiration if the assistance was not provided.
Tube Feeding Not Given According to Ordered Schedule
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered in accordance with the practitioner’s order for a resident with a feeding tube. The resident was admitted with diagnoses including stroke, dysphagia, gastrostomy status, and congestive heart failure, and the most recent MDS indicated severe cognitive impairment and that the resident received nutrition through a feeding tube. The physician order directed [NAME] Farms Peptide 1.5 Cal via feeding tube pump at 55 ml/hour for 18 hours, with the pump on at 2 P.M. and off at 8 A.M., and the care plan and nutrition assessment reflected the same order. During observation, the surveyor found the tube feeding infusing at 55 ml/hour outside the ordered schedule on multiple occasions, including late morning and early afternoon, and the feeding bag was dated for the day it was observed. The MAR had a place to document when the feeding was hung at 2 P.M., but no box to initial when it was turned off at 8 A.M. The ADON stated she turned the feeding off after realizing it had not been stopped, and staff acknowledged the order was not being followed. The nurse practitioner stated she was not aware the resident had been receiving tube feeding other than according to orders and expected the orders to be followed.
Therapeutic Diet and Fluid Restriction Not Followed
Penalty
Summary
The facility failed to ensure a therapeutic diet order was followed for a resident with stroke, dysphagia, gastrostomy status, and congestive heart failure who was ordered a 1200 mL fluid restriction. The resident’s active orders included NPO status, enteral feeding via pump at 55 mL/hour for 18 hours, 100 mL of water every four hours for hydration, and additional PEG tube flushes with medications. The resident’s care plan did not indicate that the resident was on a fluid restriction, although the quarterly nutrition assessment stated the resident continued a 1200 mL fluid restriction to help manage electrolytes. The surveyor observed the resident’s tube feeding running beyond the ordered stop time on multiple occasions. On one day, the feeding was still infusing four hours after it was supposed to be taken down at 8:00 A.M.; on another day, it was observed infusing several times throughout the day, more than six hours after the ordered stop time; and on a third day, it was still infusing 38 minutes after it was to be taken down. The facility’s dietitian documented that the resident’s formula provided free water and calculated the resident’s daily intake as 1152 mL using formula free water and flushes, while the report also noted that the ordered tube feeding regimen plus water flushes and medication flushes exceeded the 1200 mL fluid restriction. During interviews, the Assistant Director of Nursing stated she knew tube feeding should come down during the day and that when a new bag is hung the pump should be cleared so nursing can monitor how much feeding has infused. She also said that when orders are not followed, the practitioner should be notified. A nurse stated she had not received report about when the tube feeding bag was hung and believed the orders were for the resident to receive tube feeding for 24 hours each day. The dietitian, DON, nurse consultant, and nurse practitioner all stated the resident was on a fluid restriction and that the physician should be notified when the ordered feeding schedule was not followed.
Elopement and Injury Due to Inadequate Supervision and Lapse in Security Protocols
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with diagnoses including Alzheimer's Disease, cognitive communication deficit, amnesia, and dementia with moderate agitation, was able to exit a secured unit and leave the facility undetected by staff. The resident was later found sitting on the curb in front of the facility and was subsequently transferred to the hospital emergency department, where a left elbow fracture was diagnosed. The resident's care plan indicated the need for increased supervision and distraction with alternative activities to maintain safety. Facility policies required identification of residents at risk for unsafe wandering and the implementation of supervision based on individual needs and environmental hazards. The policies also specified that staff must monitor visitors and ensure that residents do not leave the secured unit or facility without appropriate supervision. On the day of the incident, a visitor was touring the secured unit and was allowed access to the elevator by a staff member. The resident followed the visitor onto the elevator and exited the building, apparently unnoticed by staff at the reception desk, who was responsible for monitoring entry and exit. Interviews revealed that staff members on the unit denied entering the elevator code for the visitor, and the receptionist did not realize the resident had exited. The Director of Nursing confirmed that staff were expected to remain at the elevator until it closed to ensure no residents left the secured unit. The failure to provide adequate supervision and to follow established protocols for monitoring residents and visitors resulted in the resident's elopement and subsequent injury.
Failure to Document Wound Measurements Post-Readmission
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following their readmission after a hospital stay. Specifically, there was no nursing documentation related to wound measurements for six days after the resident's readmission. The facility's policy requires that all services provided to the resident, progress towards care plan goals, or any changes in the resident's condition be documented in the medical record. Additionally, the facility's protocol mandates that nursing staff conduct an admissions assessment, including a skin assessment, and document a full assessment of pressure injuries, including measurements. The resident, who was admitted to the facility in December 2024, had diagnoses including chronic osteomyelitis, polyneuropathy, and a stage four pressure injury at the sacral region. Upon readmission to the facility, the admission assessment noted pressure injuries on the coccyx, left buttock, and right buttock, but the section for documenting measurements was left blank. The Director of Nurses confirmed that wound measurements are crucial for tracking progression and should have been documented upon the resident's readmission.
Inadequate Supervision and Security Lead to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a history of exit-seeking behavior and was assessed as being at increased risk for elopement, was last seen before lunch and was found the next day at a convenience store in a neighboring town. The resident sustained injuries, including cuts, bruises, and dehydration, and was admitted to the hospital. Staff interviews revealed that the resident had been exhibiting exit-seeking behavior throughout the day, and the alarm on the exit door had been broken, allowing the resident to leave the facility undetected. Additionally, the facility failed to secure the fenced-in patio area used by residents for smoking and outside activities. During the survey, multiple residents were observed entering the keypad code to access the patio area without staff supervision. The gate leading to the facility parking lot was found wide open, providing an easy escape route for residents at risk of elopement. The facility's policy required staff supervision for residents in the smoking area, but observations showed that residents were left unsupervised, contrary to the policy. The facility's policies on safety and supervision were not effectively implemented, as evidenced by the lack of staff presence in critical areas and the failure to secure exit points. The Director of Nursing and other staff members were unaware that residents had access to keypad codes, and the gates in the smoking area were not kept locked as required. These lapses in supervision and security contributed to the resident's elopement and subsequent injuries.
Food Handling Deficiency Due to Contaminated Gloves
Penalty
Summary
The facility failed to handle food in accordance with professional standards for food service safety, specifically by allowing contamination of ready-to-eat food during service. The facility's policy on Food Preparation and Services, revised in April 2022, mandates that food preparation staff adhere to proper hygiene and sanitary practices, including prohibiting bare hand contact with food and requiring gloves to be worn and changed between tasks. However, during a lunch tray line observation, a cook was seen contaminating his gloves by touching lids of pans and plastic wrap, and then using the same contaminated gloves to handle edible flowers and hot dog buns, which were placed on resident plates. This action was contrary to the facility's policy and was confirmed during an interview with the Food Service Director, who acknowledged the importance of avoiding contamination of ready-to-eat food with contaminated gloves.
Failure to Obtain Psychotropic Informed Consent
Penalty
Summary
The facility failed to obtain a signed psychotropic informed consent for a resident diagnosed with bipolar disorder and schizophrenia. The resident, who was admitted in June 2024, has a severe cognitive impairment as indicated by a score of 2 out of 15 on the Brief Interview for Mental Status (BIMS) and has a court-appointed guardian. The medical record review showed that the resident was receiving Lithium Carbonate, a medication for bipolar disorder, since June 21, 2024. However, the psychotropic consent form was undated and lacked the signature of the resident's representative or healthcare representative. During an interview, the Director of Nursing stated that attempts to contact the healthcare proxy and guardian had been unsuccessful, and the facility continued to administer the medication without consent, citing potential harm if the medication was stopped.
Failure to Maintain a Clean and Odor-Free Environment
Penalty
Summary
The facility failed to provide a clean and comfortable homelike environment for a resident, who was admitted with diagnoses including cerebral infarction and diabetes. The resident, who is cognitively intact and dependent on assistance for activities of daily living and toileting, reported a persistent strong odor in their room, which was confirmed by surveyor observations on multiple occasions. The resident expressed dissatisfaction with the cleanliness of the room, particularly while eating meals. The deficiency was linked to the management of the resident's incontinence care using a purewick system. The facility did not document the maintenance of the purewick system as ordered by the physician, which included changing the catheter head every 12 hours and cleaning the system components. Interviews with staff revealed that the room was cleaned daily, but the last deep cleaning occurred weeks prior, and there was no request to increase cleaning frequency despite awareness of the odor issue. The Unit Manager and Director of Nurses acknowledged the odor problem, attributing it to the purewick system's maintenance needs.
Failure to Resolve Grievance Regarding Staff Sleeping on Shift
Penalty
Summary
The facility failed to resolve a grievance filed by a resident regarding staff members sleeping during their shift. According to the facility's Grievance Policy, upon receiving a written grievance, the grievance officer is required to refer it to the appropriate department head for investigation, who must then submit a written report of findings within 72 hours. The grievance officer or designee is also responsible for informing the complainant of the findings and actions taken within 3-5 working days. However, a review of the grievance log revealed that a grievance was filed concerning staff sleeping during the 11-7 am shift, but there was no documented resolution on the grievance form. During an interview, the Director of Nursing acknowledged that a resolution should have been documented and mentioned that audits were conducted after the grievance was filed, but no documentation of resolution was provided.
Failure to Assess Mattress Bolsters as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of mattress bolsters as a potential physical restraint for a resident with severe cognitive impairment. The resident, admitted in May 2023 with diagnoses including cognitive communication deficit and chronic kidney disease, was observed with mattress bolsters placed under the fitted sheet at both the head and foot of the bed. These bolsters were intended to prevent the resident from climbing out of bed, as noted by the Certified Nurse Aides (CNAs) who stated that the resident frequently attempted to get out of bed despite being unable to stand. The facility did not conduct a restraint assessment to determine if the mattress bolsters limited the resident's freedom of movement, nor was there a physician's order or care plan documentation for their use. Interviews with staff, including a CNA, Unit Manager, and Regional Clinical Director, confirmed the absence of a formal assessment, although there was an informal discussion among the team regarding the use of bolsters. The lack of a documented assessment and physician's order constitutes a deficiency in ensuring the resident's freedom from unnecessary restraints.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of potential abuse for three residents, which is a violation of their policy on abuse and neglect. Resident #55, who has intact cognition, filed a grievance after a nurse made a derogatory comment about them being 'drugged up.' Resident #DC1, with moderate cognitive impairment, reported that a certified nursing aide made a hurtful comment about their spouse not wanting to visit. Resident #78, who has severe cognitive impairment and is dependent on staff for care, had a representative report that certified nursing aides were rough in handling and instructed the resident to relieve themselves in their bed or brief instead of assisting them to the bathroom. The Social Worker, responsible for filing grievances, stated that she would notify the Director of Nursing if she believed an incident rose to the level of abuse. The Director of Nursing confirmed that allegations of abuse require an investigation and a report to the state agency within two hours. However, a review of the Healthcare Facility Reporting System showed that none of these allegations were reported to the state agency, indicating a failure to follow the required protocol for reporting potential abuse cases.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse for three residents, as required by their policies. Resident #55, who has intact cognition, filed a grievance after a nurse made a derogatory comment about them being 'always drugged up.' Resident #DC1, with moderate cognitive impairment, reported that a certified nursing aide made a hurtful comment about their spouse not wanting to visit. Resident #78, who is severely cognitively impaired and dependent on staff for care, had a representative report that certified nursing aides were rough in handling and instructed the resident to relieve themselves in their bed or brief instead of assisting them to the bathroom. The facility's policies require immediate notification and investigation of any grievances that rise to the level of potential abuse, neglect, or misappropriation. However, the facility did not provide any internal investigations for these allegations. Interviews with the Social Worker and Director of Nursing confirmed that allegations of abuse should trigger an investigation and reporting to the state agency, but this process was not followed for the grievances filed by the three residents.
Inaccurate MDS Assessment for Catheter Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately completed for a resident, leading to a deficiency. Specifically, the MDS for a resident inaccurately documented the use of an indwelling catheter. The resident, admitted in August 2021 with diagnoses including cerebral infarction and diabetes, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS assessment dated 9/5/24 incorrectly indicated the use of an indwelling catheter, while the medical record and physician's orders specified the use of a purewick catheter, which is an external catheter and not an indwelling one. Interviews with the Unit Manager and the Director of Nursing confirmed the inaccuracy in coding the purewick catheter as an indwelling catheter on the MDS.
Failure to Implement Orthotic for Contracture Management
Penalty
Summary
The facility failed to implement an orthotic for contracture management for a resident who was admitted with diagnoses including stroke and hemiplegia. The resident, who had a severe cognitive impairment as indicated by a BIMS score of 1 out of 15, was dependent on staff for activities of daily living and had a right upper extremity contracture. The physician's orders specified that a resting hand splint should be worn nightly and removed during the day as tolerated. However, observations on multiple occasions revealed that the resident was not wearing the orthotic, and it was not present in the room. During an observation, the Unit Manager confirmed the physician's order for the orthotic and noted that nursing staff would document if the resident refused to wear it. Despite this, a review of the nursing notes showed no indication of refusal by the resident. The Director of Nursing stated that all orders are expected to be followed as written, yet the orthotic was not being utilized as prescribed, indicating a failure in adhering to the care plan for the resident's contracture management.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to adhere to the wound care recommendations provided by the Wound Physician for a resident with an unstageable pressure wound on the right heel. The resident, who has a history of diabetes, diabetic neuropathy, and osteomyelitis, was observed multiple times with their right foot lying directly on the bed, contrary to the physician's orders to float the heels and use pressure off-loading boots. Despite the presence of a heel protecting bootie, it was found on a chair next to the bed rather than being used on the resident's foot. Additionally, the air mattress, which is part of the wound management protocol, was set at 325 pounds, not adjusted to the resident's actual weight of 150 pounds. Interviews with the nursing staff and the Director of Nursing confirmed that the resident should have been wearing heel protective booties at all times and that the air mattress should be set to the resident's weight for optimal wound healing. The Director of Nursing also mentioned that if the resident refused the interventions, a note of refusal should be documented, which was not indicated in the report. These observations and interviews highlight the facility's failure to implement the prescribed wound care interventions, potentially impacting the resident's wound healing process.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received respiratory care and treatment according to professional standards of practice and in accordance with physician's orders. The deficiency involved a resident with diagnoses including heart failure and chronic respiratory failure with hypercapnia. The resident's physician had ordered oxygen therapy at a flow rate of 1-2 liters per minute (LPM) to maintain oxygen saturation above 90%. However, observations by the surveyor on multiple occasions revealed that the resident's oxygen concentrator was set at four LPM, which was above the prescribed range. A family member of the resident confirmed that the oxygen had been set at four LPM, although it should have been at two LPM according to the physician's order. A nurse later adjusted the oxygen flow to the correct setting of two LPM. The Director of Nursing acknowledged that physician's orders should be followed and noted that setting the oxygen above the ordered range could lead to adverse effects, including circulation issues and imbalanced carbon dioxide levels.
Failure to Develop Comprehensive Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically PTSD. The resident, who was admitted with diagnoses including major depression, anxiety, and PTSD, was moderately cognitively impaired. The care plan initiated for the resident included general interventions such as encouraging the resident to speak up about uncomfortable situations and establishing a rapport to gain trust. However, it lacked specific triggers and individualized interventions related to the resident's PTSD diagnosis. The facility's policy on trauma-informed care, dated March 2019, outlines the need for staff to be trained in identifying triggers associated with re-traumatization. Despite this, the social worker was unaware of the resident's PTSD diagnosis and acknowledged that it should have been addressed in the care plan with specific triggers. Additionally, the psychiatric medication evaluation and psychotherapy notes for the resident did not include the PTSD diagnosis, indicating a gap in the documentation and care planning process.
Failure to Identify Medication Irregularity in Resident's Drug Regimen
Penalty
Summary
The monthly medication review (MRR) conducted by a licensed pharmacist failed to identify an irregularity in the drug regimen of a resident, who was receiving double the prescribed dose of Torsemide. This oversight occurred despite the facility's policies and procedures that require a thorough review of each resident's medication regimen. The resident, who was admitted with a diagnosis of heart failure, had two active physician's orders for Torsemide, each prescribing a 40 mg dose to be administered in the morning for different conditions. The Medication Administration Record (MAR) indicated that both doses were scheduled and administered at different times in the morning, leading to the resident receiving a total of 80 mg of Torsemide daily. The deficiency was identified during a review of the MRR dated 9/30/24, which failed to report the irregularity in the resident's Torsemide orders. Interviews with the Director of Nursing (DON) and the Regional Clinical Director confirmed that the expectation was for the MRR to recognize and report such discrepancies. The resident's moderate cognitive impairment, as indicated by a BIMS score of 10 out of 15, further underscores the importance of accurate medication management to prevent potential adverse effects.
Resident Receives Double Dose of Torsemide Due to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident receiving a double dose of Torsemide for 27 days. The resident, who was admitted with heart failure, had two separate physician orders for Torsemide: one for 40 mg in the morning for edema and another for 40 mg in the morning related to COPD with acute exacerbation. This led to the resident receiving 80 mg of Torsemide daily, which was not identified by the facility's medication administration processes or during the monthly medication review by the consultant pharmacist. The resident experienced significant weight loss and elevated BUN/creatinine levels, indicating potential kidney function issues. Despite the resident's weight loss and abnormal lab values, the facility's at-risk progress notes and physician's progress notes did not address the medication discrepancy. It was only upon review by a nurse and surveyor that the error was acknowledged, and the nurse practitioner was contacted to clarify the order. The Director of Nursing confirmed that the double dosing of Torsemide was a significant medication error, increasing the resident's risk for adverse effects.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,397 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At Lexington | 1 mi | ★★★★★ | 11 | 0 |
| Pine Knoll Nursing Center | 1.8 mi | — | 47 | 1 |
| Winchester Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Aberjona Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Meadow Green Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Park Avenue Health Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.