Park Terrace Care Center: Feeding Tube Safety Failures - NY
The nursing home's staff relied on listening for "gurgling sounds" through stethoscopes instead of checking for gastric residual volume, the standard safety practice that involves drawing back stomach contents to confirm proper tube positioning before administering nutrition.
Resident 52, who suffered a diffuse traumatic brain injury with loss of consciousness, receives all nutrition through a percutaneous endoscopic gastrostomy tube. The resident has severely impaired cognition and gets 51 percent or more of daily feedings through the tube, along with more than 501 milliliters of fluids.
On September 4, Licensed Practical Nurse 2 administered the resident's 4:00 PM feeding of Jevity 1.5 at 65 milliliters per hour. The nurse verified tube placement by pushing air into the resident's stomach and listening with a stethoscope for gurgling sounds.
During an interview 20 minutes later, the same nurse acknowledged that feeding tube placement should be checked using gastric residuals. But the nurse defended skipping this step, stating "the resident had not been fed since this morning so there was no need to check for residuals."
This reasoning contradicts established medical practice. Gastric residual checks verify tube position regardless of when the patient last ate, preventing potentially fatal complications if nutrition enters the lungs instead of the stomach.
Registered Nurse 1 told inspectors they received no training on checking gastric residual volume to verify tube placement. The nurse said staff were instructed only to introduce air and listen for gurgling sounds using a stethoscope.
The Director of Nursing revealed during a September 9 interview that the facility had been using the inferior auscultation method as standard practice. She admitted changing the policy "last week" and starting competencies and in-services on checking residuals by aspirating gastric contents.
The timing raises questions about whether the policy change occurred in response to the complaint that triggered the federal inspection. The Director of Nursing stated that checking for placement isn't documented in physician orders because "it is considered a standard of care."
But the inspection found this standard of care wasn't being followed. Multiple nurses demonstrated unfamiliarity with proper gastric residual procedures, suggesting the training gap extended beyond individual staff members to systemic facility practices.
Improper feeding tube verification can have devastating consequences. When nutrition enters the respiratory system instead of the digestive tract, patients can develop aspiration pneumonia, a potentially fatal condition. Brain-injured residents like Resident 52 face heightened risks because cognitive impairment may prevent them from showing obvious signs of distress.
The facility's physician orders specified precise feeding instructions for Resident 52: 1000 milliliters of Jevity 1.5 administered at 65 milliliters per hour starting at 4:00 PM. But without proper tube placement verification, even perfectly followed orders could deliver nutrition to the wrong location.
Federal regulations require nursing homes to ensure residents receive treatment and care in accordance with professional standards of practice. The auscultation method Park Terrace nurses were using has been largely superseded by gastric residual checks in modern medical practice.
Licensed Practical Nurse 2's statement that residual checks weren't needed because the resident "had not been fed since this morning" suggests fundamental misunderstanding of the procedure's purpose. Gastric residuals don't just measure leftover food - they confirm the tube remains properly positioned in the stomach rather than having migrated to the lungs or other organs.
The September 9 inspection occurred during a week when the facility was implementing new training on proper residual checking procedures. This timing indicates the nursing home may have been aware of deficient practices before federal investigators arrived.
Resident 52's medical record shows admission diagnoses including gastrostomy status and unspecified protein-calorie malnutrition alongside the traumatic brain injury. Proper nutrition delivery through the feeding tube is essential for recovery and preventing further complications in patients with such complex medical needs.
The Director of Nursing's acknowledgment that placement verification represents a "standard of care" underscores the significance of the violation. Standards of care in medical settings exist to prevent patient harm through established, evidence-based practices.
Park Terrace Care Center's shift from auscultation to gastric residual checking brings the facility in line with current medical standards. But the inspection reveals how long residents like Resident 52 received feedings through tubes verified using outdated methods that increased their risk of serious complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Terrace Care Center from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PARK TERRACE CARE CENTER in CORONA, NY was cited for violations during a health inspection on September 9, 2025.
The resident has severely impaired cognition and gets 51 percent or more of daily feedings through the tube, along with more than 501 milliliters of fluids.
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.