Park Avenue Health Center: Code Blue Never Called - MA
No Code Blue was called over the intercom. No announcement went out. Staff on the second floor, the third floor, and at the nursing station all said the same thing when inspectors asked: they heard nothing. Several added, unprompted, that they would have dropped what they were doing and responded immediately if they had.
The incident began when a certified nursing assistant, identified in the inspection report as CNA #1, answered a call bell and helped the resident into his wheelchair around 6:00 a.m. She then left the unit and went to the basement to retrieve briefs. When she returned to the nurse's station, Nurse #1 told her the resident did not appear to be breathing.
The two of them went to the room. Nurse #1 left to get the Code Cart and the AED. CNA #1 stayed with the resident. When Nurse #1 returned, they called for a second aide, CNA #2, who was working on the same floor but on a different assignment. CNA #2 said she heard Nurse #1 yell her name. She came in and found the resident still seated in his wheelchair. The three of them transferred him to the floor, applied the AED pads, and called 911. Nurse #1 began compressions.
That was the entire response team. One nurse. Two aides.
CNA #2 told inspectors she was never asked to call a Code Blue and does not remember hearing one paged. She said when a Code Blue is called, other staff come and help.
They did not come. Because no one called.
CNA #4 was working the overnight into the morning shift on the third floor. He told inspectors he does not remember hearing a Code Blue over the intercom and said if he had, he would have responded and done whatever was asked. Nurse #2 was also on the third floor that night. She did not recall hearing a Code Blue at any point during the shift and told inspectors she would have responded immediately if she had. Nurse #4 arrived for work at approximately 6:15 a.m., around the same time the emergency was unfolding. She does not recall ever hearing a Code Blue paged. She told inspectors the nurse needs to call a Code Blue so that other staff can assist with the emergency.
Five staff members. None of them heard anything. All of them said they would have come running.
The facility's own leadership said they had no idea the response had been so thin. The interim Director of Nurses, who also serves as the Regional Clinical Director of Operations, told inspectors she had assumed a Code Blue was paged. She said she had not realized only three staff members were involved with the emergency. She described what the facility expects to happen when a resident is found unresponsive: the nurse assesses the resident, calls out for help, instructs the first staff member to arrive to page a Code Blue overhead, and then directs each additional person who shows up, assigning tasks, retrieving equipment, pulling the chart, calling 911, and managing the scene until EMS arrives.
None of that happened. Nurse #1 handled the code cart and the AED and the compressions with two aides and no additional licensed staff.
The Assistant Director of Nurses told inspectors the facility has not had a Staff Development Coordinator for some time, and that mock Code Blues had not been conducted on a regular basis. She said she was not aware that Nurse #1 had not called a Code Blue.
The inspection report does not say what happened to the resident after EMS arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Avenue Health Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
PARK AVENUE HEALTH CENTER in ARLINGTON, MA was cited for violations during a health inspection on August 28, 2025.
No Code Blue was called over the intercom.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.