Inspection Reports for
Park Terrace Care Center

59-20 Van Doren Street, Rego Park, NY, 11368

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 29 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

469% worse than New York average
New York average: 5.1 deficiencies/year

Deficiencies per year

80 60 40 20 0
2022
2023
2025

Inspection Report

Annual Inspection
Deficiencies: 5 Date: Sep 9, 2025

Visit Reason
The inspection was a Recertification and Abbreviated Survey to assess compliance with regulatory requirements for the nursing home.

Findings
The facility was found deficient in multiple areas including failure to notify a resident's representative about a bed bug infestation, inadequate environmental cleanliness and maintenance, improper care and verification of gastrostomy tube placement, unsafe and unsanitary conditions in the dining and kitchen areas, and ineffective pest control with ongoing roach and rodent sightings.

Deficiencies (5)
F 0580: The facility failed to notify Resident #199's representative about a bed bug infestation in the resident's room despite documented evidence of infestation and treatment.
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment in Unit 4, with peeling paint, dirty baseboards, stained floors, and unclean air conditioning units observed in multiple rooms.
F 0693: The facility failed to ensure appropriate care for residents with feeding tubes by not properly verifying gastrostomy tube placement prior to medication and feeding administration for three residents.
F 0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment, with ripped chairs in dining rooms, dust accumulation in the kitchen, dirty floors and walls, and corroded metal cabinets observed.
F 0925: The facility failed to maintain an effective pest control program, evidenced by multiple roach and rodent sightings on Unit 4, the kitchen, and other floors despite ongoing extermination efforts.
Report Facts
Residents reviewed for Notification of Change: 40 Residents reviewed for medication administration task: 25 Pest sightings reported: 14 Pest sightings reported: 5

Employees mentioned
NameTitleContext
Registered Nurse #2Interviewed regarding lack of notification to Resident #199's representative about bed bug infestation.
Director of NursingInterviewed about notification responsibilities and gastrostomy tube placement policies.
Director of Social WorkInterviewed about family notification procedures for bed bug infestations.
Housekeeping DirectorInterviewed about cleaning deficiencies and pest control.
Licensed Practical Nurse #5Observed and interviewed regarding gastrostomy tube placement verification.
Registered Nurse #1Observed and interviewed regarding gastrostomy tube placement verification and roach sightings.
Licensed Practical Nurse #2Observed and interviewed regarding gastrostomy tube placement verification.
AdministratorInterviewed about environmental rounds, pest control, and facility conditions.
Food Service DirectorInterviewed about kitchen cleanliness and pest control.
Certified Nursing Assistant #2Interviewed about roach sightings throughout the facility.
Registered Nurse #3Interviewed about daily rounds and furniture condition.

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 12 Date: Sep 9, 2025

Visit Reason
Complaint Survey with 7 health and 5 life safety citations, including food procurement, pest control, notification of changes, physician visits, environment, tube feeding, and life safety door and lighting issues.

Findings
Complaint Survey with 7 health and 5 life safety citations, including food procurement, pest control, notification of changes, physician visits, environment, tube feeding, and life safety door and lighting issues.

Deficiencies (12)
Food procurement,store/prepare/serve-sanitary
Maintains effective pest control program
Notify of changes (injury/decline/room, etc.)
Physician visits - review care/notes/order
Safe/clean/comfortable/homelike environment
Safe/functional/sanitary/comfortable environ
Tube feeding mgmt/restore eating skills
Doors with self-closing devices
Emergency lighting
Gas equipment - cylinder and container storag
Maintenance, inspection & testing - doors
Vertical openings - enclosure

Inspection Report

Annual Inspection
Deficiencies: 7 Date: Sep 9, 2025

Visit Reason
The inspection was a Recertification and Abbreviated Survey to assess compliance with regulatory standards for nursing home care.

Findings
The facility was found deficient in multiple areas including failure to notify a resident's representative about a bed bug infestation, inadequate environmental cleanliness and maintenance, improper care and verification of gastrostomy tube placement, inaccurate physician documentation, food safety violations, poor hand hygiene practices, unsafe and unsanitary environment, and ineffective pest control with ongoing roach and rodent sightings.

Deficiencies (7)
F 0580: The facility failed to notify Resident #199's representative about a bed bug infestation in the resident's room despite documented presence and treatment.
F 0584: Housekeeping and maintenance services were inadequate in Unit 4, with peeling paint, dirty air conditioning units, stained floors, and unclean baseboards observed.
F 0693: Licensed nurses did not appropriately verify gastrostomy tube placement prior to administering medications and enteral feeding for three residents, relying on auscultation of gurgling sounds instead of aspirating gastric contents.
F 0711: Physicians failed to accurately review and document residents' total program of care, with progress notes not reflecting current therapy status for Residents #107 and #184.
F 0812: Food safety violations included expired food items in the kitchen, staff without beard restraints, food stored at improper temperatures, and failure of a nursing assistant to perform hand hygiene between assisting residents.
F 0921: The facility environment was unsafe and unsanitary with ripped chairs in dining rooms, dust accumulation in the kitchen, dirty floors and walls, corroded metal cabinets, and peeling paint.
F 0925: The facility failed to maintain an effective pest control program, with multiple roach and rodent sightings reported on Unit 4 and in the kitchen, including a live roach observed on kitchen equipment.
Report Facts
Residents reviewed: 40 Residents reviewed for medication administration: 25 Residents affected by gastrostomy tube placement deficiency: 3 Residents affected by physician documentation deficiency: 2 Residents affected by food safety and hand hygiene deficiencies: Some Residents affected by environmental safety deficiencies: Some Residents affected by pest control deficiency: Some

Employees mentioned
NameTitleContext
Registered Nurse #2Registered NurseInterviewed regarding lack of notification of bed bug infestation and responsibility of Social Worker
Director of NursingDirector of NursingInterviewed regarding notification policy for bed bug infestation and gastrostomy tube placement policy
Director of Social WorkDirector of Social WorkInterviewed regarding notification responsibilities and staffing shortages
Housekeeping DirectorHousekeeping DirectorInterviewed regarding cleaning deficiencies and pest control
Licensed Practical Nurse #5Licensed Practical NurseObserved and interviewed regarding gastrostomy tube placement verification
Registered Nurse #1Registered NurseObserved and interviewed regarding gastrostomy tube placement verification
Licensed Practical Nurse #2Licensed Practical NurseObserved and interviewed regarding gastrostomy tube placement verification
Medical Doctor #1Medical DoctorInterviewed regarding errors in therapy documentation
Registered Nurse #6Rehabilitation NurseInterviewed regarding therapy status of residents
Director of Rehabilitative TherapyDirector of Rehabilitative TherapyInterviewed regarding therapy assessments and recommendations
Food Service DirectorFood Service DirectorInterviewed regarding expired food, food temperature, kitchen cleanliness, and pest control
Certified Nursing Assistant #3Certified Nursing AssistantObserved and interviewed regarding hand hygiene failures
Registered Nurse #3Registered NurseInterviewed regarding hand hygiene and environmental rounds
Dietary Aide #2Dietary AideInterviewed regarding pest sightings in kitchen
Certified Nursing Assistant #2Certified Nursing AssistantInterviewed regarding pest sightings throughout facility
Registered Nurse #1Registered NurseInterviewed regarding pest sightings in staff bathroom
AdministratorAdministratorInterviewed regarding environmental rounds, pest control, and overall facility issues

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Oct 30, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Oct 23, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Oct 17, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Oct 10, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Oct 2, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Sep 25, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Sep 18, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Sep 11, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Sep 5, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Complaint Investigation
Census: 54 Deficiencies: 1 Date: Aug 31, 2023

Visit Reason
The inspection was conducted as a recertification and complaint survey to investigate a fall incident involving Resident #90 and to assess compliance with accident prevention and supervision requirements.

Complaint Details
The complaint investigation (NY00312405) was substantiated. Resident #90 fell during transfer due to inadequate supervision. The investigation concluded no abuse, neglect, or mistreatment occurred.
Findings
The facility failed to ensure adequate supervision and assistance to prevent Resident #90 from falling out of bed during transfer, resulting in a laceration. The investigation found no evidence of abuse or neglect, and staff were counseled on safe transfer procedures.

Deficiencies (1)
F 0689: The facility did not ensure a resident received adequate supervision and assistance to prevent accidents. Resident #90 fell out of bed after transfer with a Hoyer lift and sustained a laceration on the right facial cheek.
Report Facts
Residents reviewed for accidents: 4 Sampled residents: 54 Laceration size: 2

Employees mentioned
NameTitleContext
Certified Nursing Assistant #6CNANamed in the fall incident and investigation for Resident #90
Certified Nursing Assistant #7CNAAssisted in transfer and involved in the fall incident
Registered Nurse #3RNInitiated Accident/Incident Report and participated in investigation
Assistant Director of NursingADNSConducted investigation and interviewed involved staff
Director of NursingDNSProvided statements regarding the incident and staff in-service

Inspection Report

Annual Inspection
Deficiencies: 13 Date: Aug 31, 2023

Visit Reason
The survey was a recertification annual inspection conducted from 8/24/2023 to 8/31/2023 to assess compliance with regulatory requirements for nursing home care.

Findings
The facility was found deficient in multiple areas including residents' rights and dignity, care planning, medication administration, assistance with activities of daily living, pressure ulcer care, range of motion care, respiratory care, food safety, infection control practices, and the qualifications of the designated Infection Preventionist.

Deficiencies (13)
F 0550: The facility did not ensure residents' right to a dignified existence; staff fed residents standing over them and placed clothing protectors without permission.
F 0577: The facility did not ensure survey results and plans of correction were posted in a place readily accessible to residents and families.
F 0657: The facility did not ensure a resident's comprehensive care plan was reviewed and revised with new interventions after a fall.
F 0658: The facility did not ensure blood pressure was assessed prior to administering blood pressure medication as ordered.
F 0677: The facility did not ensure a resident who required assistance with meals was assisted and fed appropriately.
F 0686: The facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards, resulting in actual harm.
F 0688: The facility did not ensure residents with limited range of motion received appropriate treatment and services to prevent further decline, including proper use of splints and hand rolls.
F 0695: The facility did not ensure a resident needing respiratory care had oxygen tubing changed and documented according to policy; tubing lacked labeling.
F 0812: The facility did not ensure proper sanitation and food handling; ungloved hands replaced cleaned slicer parts and unlabeled, undated food was stored in a resident pantry refrigerator.
F 0814: The facility did not ensure garbage was disposed of properly; trash bin was transported uncovered and trash placed in an uncovered, unlocked dumpster.
F 0842: The facility did not ensure resident records were accurately documented; CNA documentation overstated resident intake and nurse documented blood pressure without assessment.
F 0880: The facility did not ensure infection control practices were maintained; wound care nurse failed to perform hand hygiene before and during wound care, failed to set up a sterile field, and contaminated the wound care environment.
F 0882: The facility did not designate an Infection Preventionist with specialized training as required; the designated IP had only completed one module of the required training at the time of survey.
Report Facts
Residents sampled: 54 Residents affected: 3 Modules completed: 1 Modules completed: 15

Employees mentioned
NameTitleContext
Registered Nurse #3Named in dignity rights and medication administration findings.
Licensed Practical Nurse #2Named in dignity rights and food handling findings.
Certified Nursing Assistant #2Named in dignity rights and food handling findings.
Certified Nursing Assistant #5Named in feeding assistance and documentation findings.
Director of Nursing (DON)Interviewed regarding multiple findings including dignity, medication, infection control, and IP training.
Infection Preventionist (IP)Named in infection control and IP training findings.
Wound Care Nurse (WCN)Named in infection control and wound care findings.
Director of Respiratory TherapyNamed in respiratory care findings.
Acting Director Food and Nutrition Services (ADFN)Named in food handling and trash disposal findings.
AdministratorNamed in trash disposal findings.

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 19 Date: Aug 31, 2023

Visit Reason
Complaint Survey with 14 health and 5 life safety citations including ADL care, care plan, garbage disposal, food procurement, accident hazards, mobility, infection prevention, resident rights, pressure ulcer treatment, and multiple life safety code issues. Many deficiencies were corrected by October 30, 2023.

Findings
Complaint Survey with 14 health and 5 life safety citations including ADL care, care plan, garbage disposal, food procurement, accident hazards, mobility, infection prevention, resident rights, pressure ulcer treatment, and multiple life safety code issues. Many deficiencies were corrected by October 30, 2023.

Deficiencies (19)
ADL care provided for dependent residents
Care plan timing and revision
Dispose garbage and refuse properly
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Increase/prevent decrease in rom/mobility
Infection prevention & control
Infection preventionist qualifications/role
Resident records - identifiable information
Resident rights/exercise of rights
Respiratory/tracheostomy care and suctioning
Right to survey results/advocate agency info
Services provided meet professional standards
Treatment/svcs to prevent/heal pressure ulcer
Gas and vacuum piped systems - central supply
Hazardous areas - enclosure
Maintenance, inspection & testing - doors
Physical environment
Sprinkler system - maintenance and testing

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Aug 28, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Aug 21, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Aug 14, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Capacity: 60 Deficiencies: 1 Date: Aug 7, 2023

Visit Reason
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Findings
Covid-19 Survey with 1 health citation related to reporting to the national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Jun 27, 2022

Visit Reason
Complaint Survey with 1 health citation for free of accident hazards/supervision/devices at Level 3 severity, corrected as of August 4, 2022.

Findings
Complaint Survey with 1 health citation for free of accident hazards/supervision/devices at Level 3 severity, corrected as of August 4, 2022.

Deficiencies (1)
Free of accident hazards/supervision/devices

Inspection Report

Annual Inspection
Deficiencies: 5 Date: May 26, 2022

Visit Reason
The inspection was a Recertification Survey conducted from 05/18/2022 to 05/26/2022 to assess compliance with regulatory requirements for the nursing home.

Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding catheter privacy, use of physical restraints without physician orders, inaccurate resident assessments regarding wander guard devices, lack of resident participation in care planning, and improper medication storage with expired drugs found.

Deficiencies (5)
F 0550: The facility did not ensure a resident's Foley catheter bag and tubing were covered to maintain dignity, leaving them exposed to public view.
F 0604: The facility did not ensure a resident remained free from physical restraints, as a wheelchair seatbelt was used without a Medical Doctor Order.
F 0641: The facility did not accurately document the use of wander guard devices in Minimum Data Set assessments for two residents.
F 0657: The facility did not ensure residents were afforded the opportunity to participate in comprehensive care plan meetings, with evidence that two residents were not invited to care plan meetings.
F 0761: The facility did not ensure all drugs were labeled and stored properly, as five expired medications were found in the medication room and cart on Unit 5.
Report Facts
Residents reviewed for dignity: 2 Residents reviewed for restraints: 4 Residents sampled for assessments: 40 Units observed for medication storage: 12 Expired medications found: 5

Employees mentioned
NameTitleContext
Certified Nursing Assistant (CNA) #1Interviewed regarding failure to place Foley catheter privacy bag.
Assistant Director of Nursing (ADN)Interviewed about facility policy on Foley catheter privacy bags.
Director of Nursing (DON)Interviewed about uncovered Foley catheters, restraint policies, and expired medication.
Certified Nursing Assistant (CNA) #3Interviewed about use of wheelchair seatbelt restraint without physician order.
Registered Nurse (RN) #1Interviewed about restraint use and knowledge of seatbelt locking.
Medical Doctor (MD)Interviewed about lack of physician order for wheelchair seatbelt restraint.
Certified Nursing Assistant (CNA) #5Interviewed about monitoring residents on wander guard devices.
Certified Nursing Assistant (CNA) #4Interviewed about resident on wander guard device.
Licensed Practical Nurse (LPN) #2Interviewed about wander guard device and physician orders.
MDS CoordinatorInterviewed about facility policy on wander guard documentation.
Social Worker (SW)Interviewed about invitations to care plan meetings.
Director of Social Services (DSS)Interviewed about care plan meeting invitation policies.
Licensed Practical Nurse (LPN) #1Present during observation of expired medications.

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 11 Date: May 26, 2022

Visit Reason
Complaint Survey with 6 health and 5 life safety citations including accuracy of assessments, care plan timing, drug labeling, reporting alleged violations, resident rights, physical restraints, and multiple life safety code issues. All corrected by July 2022.

Findings
Complaint Survey with 6 health and 5 life safety citations including accuracy of assessments, care plan timing, drug labeling, reporting alleged violations, resident rights, physical restraints, and multiple life safety code issues. All corrected by July 2022.

Deficiencies (11)
Accuracy of assessments
Care plan timing and revision
Label/store drugs and biologicals
Reporting of alleged violations
Resident rights/exercise of rights
Right to be free from physical restraints
Doors with self-closing devices
Electrical systems - essential electric syste
Electrical systems - other
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures

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