Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Avenue Extended Care Facility during CMS and state inspections, most recent first.
The facility was found to have insufficient nursing staff, impacting resident safety and well-being across all units. The Facility Assessment did not align with actual staffing, leading to late medication administration and missed wound care treatments. Staffing sheets revealed frequent understaffing, particularly on weekends, with staff working extra shifts to cover shortages. Supervisors often had to cover both supervisory and floor nurse duties, making it difficult to complete all required tasks.
A survey found that the facility failed to store, prepare, and serve food according to professional standards. Frozen food items were stored undated and with opened packaging, contrary to the facility's policy. The Food Service Director acknowledged the need for proper wrapping and dating to prevent freezer burn and cross-contamination.
During a survey, it was found that call systems were not accessible to residents in their rooms. A resident with Alzheimer's and a history of falls had their call bell on the floor, out of reach. Another resident with severe cognitive impairment had their call bell out of reach due to a behavior of pushing it away, which was not documented in their care plan. A third resident with dementia was observed twice with the call bell hanging from the wall, out of reach. Staff interviews confirmed the call bells should have been within reach, but this was not ensured.
Two residents were found in a room with a strong urine odor, wearing multiple saturated briefs, and lying on excessive bed padding. The facility's policy for dignified care was not followed, as morning care was delayed and improper incontinence management was observed. Staff interviews revealed a lack of adherence to care protocols.
A resident was prescribed Diclofenac eye drops for visual discomfort following cataract surgery, but the medication was not delivered due to a need for allergy clarification. Despite this, nursing staff documented administering the drops multiple times. Interviews revealed inconsistencies in documentation practices, and the facility's policy for notifying supervisors and physicians of unavailable medication was not followed.
Two residents in an LTC facility did not receive timely assistance with activities of daily living, resulting in unsanitary conditions. One resident was found wearing multiple saturated briefs and had not received care since the previous shift. Another resident also experienced delays in care, with similar issues of incontinence and strong urine odor. Staff interviews revealed that the CNA was delayed due to other duties, and the facility's policy for morning care was not followed.
Two residents in an LTC facility did not receive timely and consistent pressure ulcer care, as identified during a survey. One resident's heel wounds were not treated for 13 days post-admission, and another resident missed several scheduled treatments due to staffing issues and lack of documentation. Interviews revealed systemic issues in adhering to the facility's policy for immediate wound care upon admission or identification.
A resident with End Stage Renal Failure and Congestive Heart Failure was on a fluid restriction of 1200 ml/day, but the facility failed to adhere to this limit. The resident consistently received excess fluids during medication administration and meals due to poor coordination among staff and inadequate documentation practices. The dietitian was unaware of the issue, and the Food Service Director did not adjust fluid amounts, assuming it was the dietitian's responsibility.
A resident with epilepsy did not receive their prescribed Topiramate for four days due to a failure to renew the physician's order after 30 days. The facility's policy required continuous supervision of medical care, which was not followed, leading to an abrupt stop in medication despite no plan to discontinue it.
The facility did not post daily nursing staffing information in a prominent location, as required. Observations showed the absence of staffing postings in public areas like the lobby and elevator bank. The Director of Nursing and Administrator were unaware of the requirement, and the staffing sheet incorrectly listed hours worked instead of the actual number of staff. The posting was moved to a less visible area following a complaint.
A resident did not receive prescribed Diclofenac eye drops for eight days due to a delay in clarification of a potential allergy. The pharmacy requested clarification from the facility, but there was no documented follow-up, resulting in missed doses. Interviews revealed communication lapses among staff, contributing to the delay.
Staffing Deficiencies Lead to Delayed Care and Missed Treatments
Penalty
Summary
The facility was found to have insufficient nursing staff on a 24-hour basis, impacting resident safety and well-being across all six resident units. The Facility Assessment did not align with the actual number of Certified Nursing Assistants (CNAs) assigned, leading to late medication administration on the 3rd and 5th floors during the 7:00 AM-3:00 PM shift. Additionally, wound care was not performed for a resident on the 11:00 PM-7:00 AM shift due to understaffing. The facility's policy aimed to maintain safe staffing levels, but discrepancies were noted between the staffing plan and actual staffing, particularly on weekends. The staffing sheets revealed that units were often understaffed, with fewer CNAs than required according to the Facility Assessment. Interviews with staff indicated that the Director of Nursing Services and the Administrator determined staffing needs based on acuity rather than census, but this approach led to challenges in covering all shifts, especially on weekends. The facility struggled to maintain adequate staffing levels, with staff often working extra shifts to cover shortages. Specific incidents highlighted the impact of understaffing, such as late medication administration on the 3rd and 5th floors and missed wound care treatments for a resident with multiple Stage 4 pressure ulcers. Interviews with nursing staff revealed that supervisors often had to cover both supervisory and floor nurse duties, making it difficult to complete all required tasks. The facility's reliance on Registered Nurse Supervisors to cover last-minute call-outs further exacerbated the staffing issues, leading to missed treatments and delayed medication administration.
Deficiency in Food Storage and Safety Standards
Penalty
Summary
During a Recertification Survey, the facility was found to have deficiencies in food storage, preparation, distribution, and service according to professional standards for food service safety. The survey, which took place from October 28, 2024, to November 4, 2024, revealed that frozen food items such as pancakes, sausage patties, and beef burger patties were stored in the walk-in freezer without proper dating and with opened packaging. This was observed during a kitchen task observation, indicating a failure to adhere to the facility's policy on food receiving and storage, which mandates that all refrigerated and frozen goods should be properly wrapped, labeled, and dated to prevent cross-contamination and ensure food quality. The Food Service Director confirmed during an interview that the food packages in the freezer should be closed to prevent freezer burn and reduce the risk of cross-contamination, which could lead to illness. The director acknowledged that the inner packaging should be dated to indicate when the boxes were first opened, aligning with the facility's policy. The lack of adherence to these procedures was evident in the undated and improperly stored food items, which were exposed to air, potentially compromising their quality and safety.
Inaccessible Call Systems for Residents
Penalty
Summary
The facility failed to ensure that call systems were accessible to residents in their rooms, as observed during a Recertification Survey. Three residents were identified with this deficiency. Resident #350, who required assistance with transfers and locomotion due to Alzheimer's Disease and a history of falls, was found with the call bell on the floor, five feet away from their chair. Despite the facility's policy requiring call bells to be within easy access, the call bell was not placed within reach by the Certified Nursing Assistant, who admitted to not noticing the call bell's position. Resident #4, diagnosed with Cerebral Infarction, Hemiplegia, and Dementia, was observed with the call bell out of reach on two occasions. The resident had severely impaired cognition and was dependent on staff for mobility. Although staff were aware of the resident's behavior of pushing the call bell away, this behavior was not documented in the care plan, and the call bell was not consistently kept within reach. Resident #87, with diagnoses including Dementia and Depression, was observed twice with the call bell hanging from the wall onto the floor, out of reach. The resident required supervision for bed mobility and transfers. Staff interviews confirmed that the call bell should have been within reach, but it was not ensured. The facility's policy and care plans for these residents emphasized the importance of having the call bell accessible, yet this was not adhered to, leading to the deficiency.
Failure to Maintain Resident Dignity and Proper Incontinence Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the conditions observed during the recertification survey. Two residents, who shared a room, were found in bed with multiple layers of linen, cloth chucks, and plastic liners. Both residents were wearing multiple briefs that were saturated with urine, and the room had a strong urine odor. This situation was contrary to the facility's policy, which mandates that residents are afforded their right to a dignified existence and proper care. Resident #92, who had intact cognition, required maximal assistance for toileting and personal hygiene. The resident was observed in a saturated state, expressing a desire to be changed and transferred out of bed. The care plan indicated that incontinent care should be performed every two hours, but the resident reported not seeing their assigned CNA since breakfast. Similarly, Resident #87, with severely impaired cognition, was found in a similar state, with saturated briefs and a strong urine odor in the room. The care plan for this resident also required regular toileting assistance, which was not adhered to. Interviews with staff revealed a lack of awareness and adherence to proper care procedures. CNA #9, who was not regularly assigned to these residents, admitted to not performing morning care until much later in the day due to other duties. The RN and DON confirmed that the use of multiple briefs and excessive bed padding was against protocol, and that morning care should be completed by a specific time. The night shift CNA acknowledged placing multiple briefs on the residents, citing resident preference, which further contributed to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the administration of Diclofenac 0.1% eye drops to a resident without the medication being available. The resident, who had undergone cataract surgery and was diagnosed with bacterial conjunctivitis, was prescribed Diclofenac eye drops for visual discomfort. However, the pharmacy did not deliver the medication until several days after the order due to a need for clarification regarding a potential allergic reaction. Despite the medication's unavailability, nursing staff documented that the eye drops were administered on multiple occasions. Interviews with the involved nursing staff revealed inconsistencies, as some nurses were unavailable for interviews, and one nurse stated they would not sign for medication they did not administer. The facility's policy required nurses to notify supervisors and physicians if medication was unavailable, which was not adhered to in this case. The Medical Director and Director of Nursing Services confirmed that it was unacceptable to document the administration of medication that was not available. The failure to follow proper procedures for medication administration and documentation led to the deficiency, as the facility did not meet the required professional standards of quality care.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This deficiency was identified during a recertification survey for two residents. Resident #92, who required maximal assistance for toileting and personal hygiene, was observed not receiving morning care until 12:50 PM, despite being incontinent and having a strong urine odor in the room. The resident was found wearing three saturated briefs, and their bed linens were also soaked with urine. The resident had not received care since the previous shift, which ended at 7:00 AM. Similarly, Resident #87, who required supervision or touch assistance for toileting and personal hygiene, did not receive morning care until 1:55 PM. The resident was found wearing two saturated briefs, and there was a strong urine odor in the room. The care plan for this resident indicated that they should be assisted with toileting every two to three hours, but this was not adhered to. Both residents were left without proper care for an extended period, leading to unsanitary conditions. Interviews with staff revealed that Certified Nursing Assistant #9 was not regularly assigned to these residents and was delayed in providing care due to other responsibilities. The Director of Nursing Services and Registered Nurse #1 were unaware of the improper use of multiple briefs and excessive bed padding. The facility's policy required morning care to be completed by 11:00 AM, but this was not followed, resulting in the observed deficiencies.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as identified during a recertification and extended survey. Two residents were specifically noted for deficiencies in pressure ulcer care. One resident, admitted with unstageable pressure ulcers on both heels, did not receive documented treatment until 13 days after admission. The initial nursing assessment failed to identify these heel wounds, and there was a lack of treatment orders until much later, despite recommendations from a podiatrist. The resident's refusal of assessment and care was noted, but there was no documentation of any decision to postpone treatment. Another resident with multiple Stage 4 pressure ulcers did not receive scheduled treatments on several occasions. The treatments were missed due to the resident being asleep or due to staffing issues, where nurses were unable to administer treatments because they were covering multiple roles or dealing with emergencies. There was also a lack of documentation explaining why treatments were not administered, and the resident stated they never refused wound care, only assessments by the wound doctor. Interviews with nursing staff and the Director of Nursing Services revealed systemic issues in ensuring timely and consistent wound care. The facility's policy required immediate treatment upon admission or identification of wounds, but this was not followed. The lack of documentation and communication between staff and physicians contributed to the delay and inconsistency in treatment, highlighting a failure to adhere to professional standards of practice for pressure ulcer care.
Failure to Adhere to Fluid Restrictions for Resident
Penalty
Summary
The facility failed to ensure that a resident with specific fluid restrictions maintained acceptable parameters of nutritional and hydration status. The resident, who had diagnoses including End Stage Renal Failure and Congestive Heart Failure, was on a fluid restriction of 1200 milliliters per day as per physician's orders. However, the facility's records and observations indicated that the resident was consistently receiving fluids exceeding this limit. For instance, on multiple occasions, the resident's fluid intake during medication administration and meals surpassed the prescribed amount, with significant overages noted on specific dates. The facility's policy required the dietitian to initiate and monitor fluid restrictions, but there was a lack of coordination and communication among staff. The dietitian, who was new to the facility, was unaware of the issue, and the Food Service Director did not adjust the fluid amounts on meal trays, assuming it was the dietitian's responsibility. Additionally, the Certified Nursing Assistants documented fluid intake in percentages rather than milliliters, which contributed to the oversight of the resident's fluid consumption. Interviews with staff revealed a lack of awareness and adherence to the physician's fluid restriction orders. The Director of Nursing Services acknowledged that the meal tickets and Electronic Medication Administration Record (EMAR) showed extra fluids being given to the resident, and the specific physician's orders were not followed. This deficiency highlights a breakdown in the facility's processes for managing and monitoring fluid restrictions for residents with critical health conditions.
Failure to Renew Epilepsy Medication Order
Penalty
Summary
The facility failed to ensure that a physician provided orders for a resident's immediate care and needs, specifically concerning the management of epilepsy medication. A resident with a diagnosis of epilepsy was receiving Topiramate, an anticonvulsant medication that should be gradually withdrawn to prevent seizures. However, the medication was abruptly stopped for four days due to a failure to renew the physician's order after 30 days, as required by the facility's policy. This lapse occurred despite the resident's medical history indicating a need for continuous epilepsy management. The resident was admitted with a history of seizure disorder and was on a steady dose of Topiramate. The physician's order for the medication was not renewed after the initial 30-day period, leading to a gap in administration from October 19 to October 22. Interviews with the resident and physicians revealed that there was no plan to discontinue the medication, and the physicians were unaware of the lapse in the medication order. The facility's policy required the attending physician to supervise the resident's medical care, including medication orders, which was not adhered to in this case.
Failure to Post Daily Nursing Staffing Information Prominently
Penalty
Summary
The facility failed to ensure that daily nursing staffing information was posted in a prominent location, as required during the Recertification Survey conducted from 10/28/2024 to 11/4/2024. Observations on 10/28/2024 and 10/30/2024 revealed that the staffing information was not displayed in the facility lobby, near the front entrance, near the elevator bank, or in the elevators. Instead, the staffing information was found in an alcove outside the nursing office, which is not a public or prominent area. The Director of Nursing Services was unaware of the requirement to post staffing information in public areas and stated that the information was posted by the staff time clock and vending machine area. Interviews with the Director of Nursing Services and the Administrator revealed a misunderstanding regarding the posting requirements. The staffing sheet listed 7.5 in the number of staff column, which indicated the hours worked per shift by each staff member, rather than the actual number of staff members working. The Administrator mentioned that the posting was moved from the reception desk to the vending area following a complaint from a family member about excessive postings at the front desk. The Staffing Coordinator acknowledged that the staffing posting might need to be revamped to include the actual number of staff working per shift.
Delayed Medication Delivery Due to Lack of Clarification
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of a resident, specifically regarding the timely delivery and administration of prescribed medication. A resident, who had undergone cataract surgery, was prescribed Diclofenac 0.1% eye drops for post-operative care. However, the medication was not delivered to the facility until eight days after the prescription was written, resulting in the resident missing 16 doses of the medication. The delay in medication delivery was due to a clarification request from the pharmacy regarding the resident's known allergy to Aspirin, a nonsteroidal anti-inflammatory drug. The pharmacy required confirmation from the physician to proceed with dispensing the Diclofenac eye drops. Despite multiple attempts by the pharmacy to contact the facility for clarification, there was no documented evidence that the physician was informed or that the clarification was addressed, leading to the delay in medication delivery. Interviews with facility staff revealed a lack of communication and follow-up regarding the pharmacy's request for clarification. The nurse responsible for handling the inquiry did not recall receiving or responding to the request, and the Director of Nursing Services was unaware of the pharmacy's clarification form. The Medical Director expected that any pharmacy inquiries should be addressed within 12 hours to prevent delays in treatment, but this expectation was not met in this case.
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 944 citations issued within 25 miles in the last 12 months — including the 17 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 Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Long Beach Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Beach Terrace Care Center | 0.9 mi | ★★★★★ | 13 | 0 |
| Grandell Rehabilitation And Nu | 0.9 mi | ★★★★★ | 0 | 0 |
| The Grand Rehabilitation And Nursing At South Poin | 1 mi | ★★★★★ | 0 | 0 |
| The Five Towns Premier Rehabilitation & Nursing Ce | 3.6 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Park Avenue Extended Care Facility.
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 October 2026) and official state health department websites.