Park Terrace Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Park Terrace Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Apr 11, 2025

  Based on observation, medical record review, review of a fire and rescue run report, review of hospital documentation, review of narcotic/controlled drug records, staff interviews, interview with the pharmacist, and review of the policy on controlled substances, the facility failed to ensure Resident #86 was free from a significant mediation error, failed to report missing Fentanyl medication patches, failed to accurately assess the resident, and failed to immediately investigate and implement immediate interventions to ensure an accurate system was in place for monitoring Fentanyl patch placement. […]

• Immediate jeopardy, isolatedF695Dec 28, 2023

  Based on observation, medical record review, staff interview, review of the emergency cart checklist and review of facility policy, the facility failed to ensure necessary supplies and life sustaining equipment was available for staff to immediately respond to a medical emergency. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or negative health outcomes when Resident #93, who had a tracheostomy, did not have suction catheters available at her bedside or on the emergency cart. The lack of equipment at bedside and on the emergency cart delayed the clearing of secretions to maintain a patent airway when Resident #93 experienced shortness of breath, loss of consciousness, loss of respirations, and loss of pulse. […]

• Immediate jeopardy, isolatedF689Aug 25, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of a facility investigation, review of staff statements, review of a facility timeline, review of an emergency medical services (EMS) run report, review of hospital reports, staff interview, family member interview, and review of the facility's policy on elopement, the facility failed to provide adequate supervision to prevent Resident #96, who had moderately impaired cognition and a diagnoses of Alzheimer's disease, dementia, and chronic obstructive pulmonary disease, from eloping from the facility's secured memory care unit unsupervised and without staff knowledge. […]

• Actual harm, isolatedF700Dec 4, 2025

  Based on closed medical record review, staff interviews, review of staff witness statements, review of the hospital notes, and review of the facility policy, the facility failed to ensure bed rails were properly installed. This resulted in Actual harm to Resident #89 when on 10/11/25 the facility applied bed rail broke off during resident care, causing the resident to roll out of bed, be lowered to the floor by staff, and maneuvered onto a Hoyer pad. Consequently, Resident #89 sustained a displaced fracture of the right humeral neck (upper arm). This affected one (#89) of three residents reviewed for falls. The facility census was 86.Findings include:Review of the closed medical record revealed Resident #89 was admitted on [DATE] and discharged on 10/25/25. […]

• Actual harm, isolatedF686Jun 27, 2024

  Based on observation, interviews with facility staff and the nurse practitioner, review of open and closed medical records, review of skin assessments, review of wound assessment reports, review of physician orders, review of treatment administration records, and policy review, the facility failed to ensure a resident's skin impairment was timely identified and treatment provided. This resulted in Actual harm to Resident #88 on 05/13/24 when the facility failed to develop and implement a care plan that included skin integrity monitoring with the use of an abdominal binder and failed to assess and monitor the resident's skin every shift that resulted in Resident #88 developing a Stage 3 pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and… […]