Park Avenue Health Center
Inspection Findings
F-Tag F0726
F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
actual Code Blue event and said that he should have had someone overhead page a Code Blue so other nursing staff could have responded in the emergent situation.During a telephone interview (which included
a review of her written statement) on [DATE REDACTED] at 12:35 P.M., CNA #1 said Resident #1 was on her assignment for the 11:00 P.M. - 7:00 A.M. shift on [DATE REDACTED] into [DATE REDACTED]. CNA #1 said around 6:00 A.M.
Resident #1 had put his/her call bell on and asked to get into his/her wheelchair. CNA #1 said when she left Resident #1's room he/she appeared to be fine, then she left the unit and went down to the basement to get some briefs.CNA #1 said upon return to the unit, while at the nurse's station Nurse #1 said to her that Resident #1 did not appear to be breathing so she went to his/her room with Nurse #1. CNA #1 said that Nurse #1 left the room to get the Code Cart and AED while she stayed with Resident #1 and when Nurse #1 returned, they placed him/her onto the floor, applied the AED pads, called 911 and Nurse #1 began compression. CNA #1 said she does not recall hearing a Code Blue being paged overhead and said she was not asked to overhead page a Code Blue by Nurse #1.During a telephone interview on [DATE REDACTED] at 9:22 A.M., CNA #2 said that on [DATE REDACTED] she was working on the second floor (Resident #1's unit) that shift, however Resident #1 was not on her assignment. CNA #2 said that she heard Nurse #1 yell her name for help and said when she entered the room, Resident #1 was still sitting in his/her wheelchair, and she helped CNA #1 and Nurse #1 transfer and lower Resident #1 onto the floor. CNA #2 said she was not asked to call a Code Blue and does not remember hearing a Code Blue being paged overhead. CNA #2 said when a Code Blue is called other staff come and help.During an interview on [DATE REDACTED] at 12:12 P.M., CNA #4 said that he was working on the third floor for the 11:00 P.M. (night shift) on [DATE REDACTED] into the (morning shift) 7:00 A.M. of [DATE REDACTED]. CNA #4 said he does not remember hearing a Code Blue called over
the intercom and said if he had, he would respond to help and do what was asked of him.During an
interview on [DATE REDACTED] at 1:03 P.M., Nurse #2 said she was working the overnight shift that the incident occurred, however she was on the third floor. Nurse #2 said she did not recall hearing a Code Blue be paged at any time during the shift.Nurse #2 said that if she had heard a Code Blue being paged, she would have responded immediately to help. During a telephone interview on [DATE REDACTED] at 11:44 A.M., Nurse #4 said that she came to work on [DATE REDACTED] at approximately 6:15 A.M., however said she does not recall ever hearing a Code Bue being paged.Nurse #4 said that if she had heard a Code Blue, she would have stopped what she was doing and go to the location announced to help with whatever was needed. Nurse #4 said that the nurse needs to call a Code Blue so that other staff can assist with the emergency.During an
interview on [DATE REDACTED] at 3:53 P.M., the Assistant Director of Nurses (ADON) said that the Facility has not had
a Staff Development Coordinator for some time and Mock Code Blue's were not being done on a regular basis.The ADON said that she was not aware Nurse #1 had not called a Code Blue and said if he had, licensed staff would have responded to assist.During an interview on [DATE REDACTED] at 1:40 P.M., the Interim Director of Nurses (DON, who also serves as the Regional Clinical of Operations), said that she was not aware that Nurse #1 had not called or instructed anyone else to call a Code Blue.The interim DON said that
she assumed that a Code Blue was paged and had not realized only three (3) staff members (1 Nurse and 2 CNA's) were involved with the emergency incident. The interim DON said that if Nurse #1 had called a Code Blue other licensed staff would have been available to help.The interim DON said the Facility's expectation is that if a resident is found unresponsive, the responding Nurse is to assess the resident, call out for help, and instruct the first staff member to arrive to page a Code Blue.The interim DON said as staff arrives to assist, the Nurse should instruct each staff member as what to do, retrieve the code cart, AED, resident's chart, call 911, and anything else needed until EMS arrives and takes over the situation.
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PARK AVENUE HEALTH CENTER in ARLINGTON, MA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ARLINGTON, MA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PARK AVENUE HEALTH CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.