Park Terrace Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews during the Recertification and Abbreviated Survey (Intake #797338), the facility failed to ensure Resident #199's representative was informed about a bed bug infestation in the resident's room. This was evident for one (1) (Resident #199) of one (1) resident reviewed for Notification of Change out of 40 total sampled residents. The findings include:The facility policy titled Notification of Changes with a revised date of 05/2025 documented the intent of the policy was to provide appropriate and timely information about changes relevant to a resident's condition or changes in room to the parties who will make decisions about care, treatment, and preferences to address the changes.Resident #199 had diagnoses of Vascular Dementia, Type 2 Diabetes Mellitus, and Malignant Neoplasm of Colon.The Annual Minimum Data Set assessment dated [DATE REDACTED] documented that Resident #199 had modified independence with their cognitive skills for daily decision making and a short/long-term memory problem.The Pest Elimination Division Service Requesting Log dated 06/10/2024 documented Resident #199's room had bed bugs.The Pest Control Service Report dated 06/10/2025 documented Resident #199's room was treated with Bedlam and Transport Mikron Pesticides for presence of bed bugs.There was no documented evidence that Resident #199's representative was notified.09/02/2025 at 2:18 PM, Resident #199's representative was interviewed and stated they were not notified of bed bugs in the resident's room. On 09/09/2025 at 12:05 PM, Registered Nurse #2 was interviewed and stated they were unaware Resident #199 had a past infestation of bed bugs in their room. Registered Nurse #2 stated when a resident has a bed bug infestation in their room, the Social Worker is responsible for notifying the family.On 09/09/2025 at 12:30 PM, the Director of Nursing was interviewed and stated the resident's family should be informed by their Social Worker when there is a bed bug infestation in the resident's room. The family is also encouraged to let the facility send out the resident's laundry so it can be washed in high temperatures in order to kill the bed bugs.On 09/09/2025 at 1:04 PM, the Director of Social Work was interviewed and stated either nursing or Social Service department notifies the family if bed bugs are present in a resident's room. They stated that at the time Resident #199 had bed bug infestation in their room, the social services department was short of a staff member, and they were covering 4 floors. However, the Director of Social Work stated this communication would not necessarily be documented in the progress notes. 10 NYCRR 415.3(d)(2)(ii)(c)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Terrace Care Center

59 20 Van Doren Street Corona, NY 11368

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584

room [ROOM NUMBER] – The bathroom heater had rusty brown color.

Level of Harm - Minimal harm or potential for actual harm

The resident's training bathroom and shower room had lots of dirt in between the floor tiles.

Residents Affected - Some

During an interview on 09/09/2025 at 10:51 AM, the Housekeeping Director stated that they will give an in-service education to all the housekeeping staff about room cleaning. They stated that all baseboards need to be cleaned and that the water for mopping the floor must be changed more often. The Director stated that the findings were well noted and that next year, the unit will be spotless.

1. 2. During multiple observations from 09/02/2025 through 09/05/2025, the following were observed in room

[ROOM NUMBER]: There was a brownish grime on the floor towards front of wardrobe closet D. There was dirt on the floor in between wardrobe closets B & C, where the baseboards and floor meet. There was also a large brown, round stain observed on the ceiling near the windows.

On 09/05/2025 at 10:15 AM, Housekeeper #3 was interviewed and stated they will ask the [NAME] to move

the wardrobe closets in order to clean the brown grime on the floor. They were unable to explain why the buildup of grime was not cleaned prior.

On 09/09/2025 at 10:03 AM, the Housekeeping Director was interviewed and stated closets are bolted to

the wall and maintenance can unbolt for the housekeeper to clean the grime from the floor. The housekeepers are instructed to pay attention to the edges and corners on the floors as they mop. They stated they have a foam spray that is designated for cleaning baseboards. The Housekeeping Director also stated there is no excuse why the floors near the wardrobe closets and baseboard areas were not cleaned properly.

On 09/09/2025 at 10:45 AM, the Director of Maintenance was interviewed and stated there was a leak on

the floor above from the last winter. The leak was fixed but they still have to prime and paint the stained area. The Director of Maintenance also stated they were unaware of the ceiling stain.

On 09/09/2025 at 1:23 PM, the Administrator was interviewed and stated there are daily environmental rounds where the Housekeeping and Maintenance Directors check areas for cleanliness and any repairs needed. The Administrator stated other staff should report areas that need attention as well. 10 NYCRR 415.5(h)(2)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Terrace Care Center

59 20 Van Doren Street Corona, NY 11368

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

introduce air and listen to gurgling sound using a stethoscope to ensure placement in the stomach.

Registered Nurse #1 also stated they were not instructed to verify tube placement buy checking for gastric residual volume.

1. 3. Resident #52 was admitted to the facility with diagnoses that included Diffuse Traumatic Brain Injury with

loss of consciousness of unspecified duration sequela, Gastrostomy status and Unspecified protein-calorie malnutrition.

The admission Minimum Data Set assessment dated [DATE REDACTED] documented that Resident #52 had severely impaired cognition, had no swallowing disorder and received 51 percent or more of feedings and 501 milliliters or more of fluids through a percutaneous endoscopic gastrostomy tube.

The physician's orders for Resident #52 included Jevity 1.5, 1000 milliliters to be administered at a rate of 65 milliliters per hour with a start time of 4:00 PM.

On 09/04/2025 at 4:01 PM, Licensed Practical Nurse #2 administered Resident #52's enteral feeding. The Licensed Practical Nurse verified the gastrostomy tube placement by introducing air to the resident's stomach and assessed the abdomen with a stethoscope; the Licensed Practical Nurse stated they heard a gurgling sound.

During an interview on 09/04/2025 at 4:20 PM, Licensed Practical Nurse #2 stated that feeding tube placement must be checked by gastric residuals, however, they stated that the resident had not been fed since this morning so there was no need to check for residuals.

On 09/09/2025 at 12:45 PM, the Director of Nursing was interviewed and stated nurses are instructed to check the placement of the gastrostomy tube by auscultating and listening for gurgling sound. They stated

they changed the policy last week and started doing competencies and in-services on checking residuals by aspirating gastric contents. The Director of Nursing further stated checking for placement is not documented in the physician orders as it is considered a standard of care. 10 NYCRR 415.12(g)(2)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Terrace Care Center

59 20 Van Doren Street Corona, NY 11368

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm

During an interview on 09/09/2025 at 1:23PM, Registered Nurse #3 stated they conduct daily rounds and had not observed any issues with the furniture. 10 NYCRR 415.29

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/09/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Park Terrace Care Center

59 20 Van Doren Street Corona, NY 11368

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm

On 09/09/2025 at 11:07 AM, Registered Nurse #1 was interviewed and stated they sometimes see roaches

in Unit 4 staff bathroom and reported this to Maintenance Department.

On 09/09/2025 at 12:30 PM, the Director of Nursing was interviewed and stated the exterminator visits the facility once a week and any pest sightings are addressed right away.

Residents Affected - Some

On 09/09/2025 at 1:23 PM, the Administrator was interviewed and stated they have the same exterminator for years and never had pest control issues. The Administrator stated they do not have an answer as to the recent roach sights but will be switching pest control companies. 10 NYCRR: 415.29(j)(5)

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet