Inspection Reports for
Park Terrace Care Center
59-20 Van Doren Street, Rego Park, NY, 11368
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Inspection Report — Sep 9, 2025
State
Date: Sep 9, 2025
Visit Reason
State-compiled facility profile showing 20 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
The state logged 33 complaints about this facility; 8 led to on-site inspections. 12 citations resulted from those complaints.
Findings
Across 20 inspections, 57 citations were issued with 42 related to standard health and 15 to life safety code. The facility had 33 complaints with 8 on-site inspections and 3 enforcement actions totaling $22,000 in fines.
Citations (31)
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary conditions were not properly maintained.
Standard Health Citation — quality of care: Maintains Effective Pest Control Program was deficient.
Standard Health Citation — quality of care: Failed to Notify Of Changes (injury/decline/room, etc.) appropriately.
Standard Health Citation — quality of care: Physician Visits - Review Care/notes/order were inadequate.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment was not ensured.
Standard Health Citation — quality of care: Safe/functional/sanitary/comfortable Environment was deficient.
Standard Health Citation — quality of care: Tube Feeding Management and restoration of Eating Skills were inadequate.
Life Safety Code Citation — NFPA requirements: Doors With Self-closing Devices were not compliant.
Life Safety Code Citation — NFPA requirements: Emergency Lighting was deficient.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage was not properly maintained.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors were inadequate.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure was deficient.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was not properly conducted.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient.
Standard Health Citation — quality of care: Care Plan Timing And Revision was inadequate.
Standard Health Citation — quality of care: Dispose Garbage And Refuse Properly was not ensured.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices was deficient.
Standard Health Citation — quality of care: Increase/prevent Decrease In Range of Motion/mobility was inadequate.
Standard Health Citation — quality of care: Infection Prevention & Control was deficient.
Standard Health Citation — quality of care: Infection Preventionist Qualifications/role were inadequate.
Standard Health Citation — quality of care: Resident Records - Identifiable Information was not properly maintained.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights were not fully respected.
Standard Health Citation — quality of care: Right To Survey Results/advocate Agency Info was deficient.
Standard Health Citation — quality of care: Services Provided Meet Professional Standards was inadequate.
Standard Health Citation — quality of care: Treatment/services To Prevent/heal Pressure Ulcer caused actual harm.
Life Safety Code Citation — NFPA requirements: Gas And Vacuum Piped Systems - Central Supply were deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure was inadequate.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors were deficient.
Life Safety Code Citation — NFPA requirements: Physical Environment was not compliant.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices caused actual harm.
Report Facts
Inspections on page: 20
Total violations/deficiencies cited: 57
Inspections with violations: 16
Inspections without violations: 4
Total complaints: 33
On-site complaint inspections: 8
Citations from complaints: 12
Enforcement actions: 3
Total fines: 22000
Inspection Report — Sep 9, 2025
Annual Inspection CMS
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.
Citations (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
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Interviewed regarding lack of notification of bed bug infestation and responsibility of Social Worker |
| Director of Nursing | Director of Nursing | Interviewed regarding notification policy for bed bug infestation and gastrostomy tube placement policy |
| Director of Social Work | Director of Social Work | Interviewed regarding notification responsibilities and staffing shortages |
| Housekeeping Director | Housekeeping Director | Interviewed regarding cleaning deficiencies and pest control |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Observed and interviewed regarding gastrostomy tube placement verification |
| Registered Nurse #1 | Registered Nurse | Observed and interviewed regarding gastrostomy tube placement verification |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed and interviewed regarding gastrostomy tube placement verification |
| Medical Doctor #1 | Medical Doctor | Interviewed regarding errors in therapy documentation |
| Registered Nurse #6 | Rehabilitation Nurse | Interviewed regarding therapy status of residents |
| Director of Rehabilitative Therapy | Director of Rehabilitative Therapy | Interviewed regarding therapy assessments and recommendations |
| Food Service Director | Food Service Director | Interviewed regarding expired food, food temperature, kitchen cleanliness, and pest control |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene failures |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding hand hygiene and environmental rounds |
| Dietary Aide #2 | Dietary Aide | Interviewed regarding pest sightings in kitchen |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding pest sightings throughout facility |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding pest sightings in staff bathroom |
| Administrator | Administrator | Interviewed regarding environmental rounds, pest control, and overall facility issues |
Inspection Report — Aug 31, 2023
Complaint Investigation CMS
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.
Citations (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
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | CNA | Named in the fall incident and investigation for Resident #90 |
| Certified Nursing Assistant #7 | CNA | Assisted in transfer and involved in the fall incident |
| Registered Nurse #3 | RN | Initiated Accident/Incident Report and participated in investigation |
| Assistant Director of Nursing | ADNS | Conducted investigation and interviewed involved staff |
| Director of Nursing | DNS | Provided statements regarding the incident and staff in-service |
Inspection Report — Aug 31, 2023
Annual Inspection CMS
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.
Citations (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
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Named in dignity rights and medication administration findings. | |
| Licensed Practical Nurse #2 | Named in dignity rights and food handling findings. | |
| Certified Nursing Assistant #2 | Named in dignity rights and food handling findings. | |
| Certified Nursing Assistant #5 | Named 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 Therapy | Named in respiratory care findings. | |
| Acting Director Food and Nutrition Services (ADFN) | Named in food handling and trash disposal findings. | |
| Administrator | Named in trash disposal findings. |
Inspection Report — May 26, 2022
Annual Inspection CMS
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.
Citations (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
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed 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) #3 | Interviewed about use of wheelchair seatbelt restraint without physician order. | |
| Registered Nurse (RN) #1 | Interviewed 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) #5 | Interviewed about monitoring residents on wander guard devices. | |
| Certified Nursing Assistant (CNA) #4 | Interviewed about resident on wander guard device. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about wander guard device and physician orders. | |
| MDS Coordinator | Interviewed 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) #1 | Present during observation of expired medications. |
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