Deficiencies (last 5 years)
Deficiencies (over 5 years)
13.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
159% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Dec 9, 2025
Visit Reason
The visit was conducted as an abbreviated survey to assess compliance with reporting requirements related to suspected abuse, neglect, or injury of unknown source in the facility.
Findings
The facility failed to report a suspected injury of unknown source involving Resident #1 within the required 2-hour timeframe to the New York State Department of Health. Resident #1 sustained a non-displaced fracture of the right proximal humeral shaft, which was not reported timely despite facility policy requiring immediate reporting of such incidents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or injury of unknown source to the New York State Department of Health within 2 hours as required. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accidents: 3
Hours delay in reporting injury: 48
Medication dosage: 650
Medication dosage: 5
Days medication prescribed: 10
Follow-up appointment date: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Ordered X-ray and transfer of Resident #1 to emergency room | |
| Certified Nursing Assistant #1 | Reported Resident #1's complaints of pain on 09/18/2025 | |
| Registered Nurse #3 | Supervisor on duty | Reported X-ray results revealing fracture on 09/19/2025 |
| [NAME] President of Clinical Services | President of Clinical Services | Interviewed regarding delay in reporting injury to Department of Health |
| Administrator | Administrator | Interviewed regarding reporting procedures and incident details |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
May 6, 2025
Visit Reason
Inspection revealed 5 standard health and 5 life safety code citations, all corrected by mid-2025.
Findings
Inspection revealed 5 standard health and 5 life safety code citations, all corrected by mid-2025.
Deficiencies (10)
| Description | Severity |
|---|---|
| Maintains effective pest control program | Level 2 |
| Reporting of alleged violations | Level 2 |
| Resident records - identifiable information | Level 2 |
| Safe/clean/comfortable/homelike environment | Level 2 |
| Tube feeding mgmt/restore eating skills | Level 2 |
| Corridor - doors | Level 2 |
| Corridors - areas open to corridor | Level 2 |
| Hazardous areas - enclosure | Level 2 |
| Portable fire extinguishers | Level 2 |
| Stairways and smokeproof enclosures | Level 2 |
Inspection Report
Complaint Investigation
Deficiencies: 4
May 6, 2025
Visit Reason
The inspection was conducted as a Recertification and Abbreviated survey including complaint investigations related to concerns about cleanliness, pest control, injury reporting, and medical record documentation at The Plaza Rehab and Nursing Center.
Findings
The facility failed to maintain a clean and homelike environment in multiple resident rooms, did not timely report injuries of unknown origin, had incomplete wound treatment documentation, and did not maintain an effective pest control program. Pest sightings and rodent activity were reported on multiple units, and several resident rooms showed signs of dirt, damage, and pest presence.
Complaint Details
The complaint investigation was triggered by family representatives reporting unclean resident rooms with crumbs and garbage, pest sightings including mice and roaches, and concerns about injury reporting and medical record accuracy. The investigation found substantiated issues with cleanliness, pest control, injury reporting, and documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Residents' rooms were left with crumbs, garbage, dust, dirt buildup on radiators and vent grills, peeling nonslip stickers, stained window shades, broken furniture handles, and other maintenance issues. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or injuries of unknown origin to proper authorities for two residents with injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Medical records for Resident #640 did not contain documentation that wound treatment was administered as ordered on multiple days. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not maintain an effective pest control program; multiple reports of mice, roaches, flies, and other pests were documented in resident rooms and units. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Accidents: 6
Total sampled residents: 38
Resident units inspected: 20
Pest control service visits: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Interviewed regarding Resident #523 injury and history | |
| Director of Nursing | Interviewed regarding injury reporting policies and wound treatment documentation | |
| Registered Nurse #6 | Interviewed regarding wound treatment for Resident #640 | |
| Registered Nurse #5 | Interviewed regarding wound treatment documentation and pest control treatments | |
| Assistant Director of Nursing | Interviewed regarding wound treatment documentation and staff education | |
| Director of Environmental Services | Interviewed regarding housekeeping tasks and pest control program | |
| Administrator | Interviewed regarding environmental rounds, pest control program, and quality assurance | |
| Director of Plant Operations | Interviewed regarding maintenance responsibilities and pest control program |
Inspection Report
Annual Inspection
Deficiencies: 1
May 6, 2025
Visit Reason
The inspection was conducted as a Recertification survey from 04/29/2025 to 05/06/2025 to assess compliance with regulations related to care for residents with feeding tubes.
Findings
The facility failed to ensure that a resident fed by enteral means received appropriate treatment and services to prevent complications. Specifically, tube feedings for Resident #106 were not properly labeled with the resident's name, flow rate, time, and date of administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Tube feedings were not appropriately labeled with the resident's name, the flow rate, the time, and the date of the administration for Resident #106. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Interviewed regarding feeding tube procedures and responsibilities. | |
| Director of Nursing | Interviewed regarding labeling responsibilities for feeding tube formula containers. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Apr 16, 2025
Visit Reason
One standard health citation related to accident hazards was identified and corrected by June 2025.
Findings
One standard health citation related to accident hazards was identified and corrected by June 2025.
Deficiencies (1)
| Description | Severity |
|---|---|
| Free of accident hazards/supervision/devices | Level 2 |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Apr 16, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to investigate an elopement incident involving Resident #2 who exited the facility unsupervised on 10/04/2024.
Findings
The facility failed to ensure adequate supervision to prevent elopement of Resident #2, who was identified as at risk and on hourly visual monitoring with a functional wander guard. The resident exited the unit and the facility without authorization, triggering alarms that were improperly handled by security staff, resulting in a delayed response and the resident being found offsite by police without injury.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision to prevent elopement of Resident #2. | Level of Harm - Minimal harm or potential for actual harm |
| Security Officer #3 deactivated the exit door alarm without investigating or notifying the Director of Security as required by policy. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Incident times: 11.09
Incident times: 11.15
Incident times: 11.47
Incident times: 13.4
Incident times: 11.49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | Monitored Resident #2 and reported leaving for break prior to elopement | |
| Registered Nurse #1 | Provided medications to Resident #2 and monitored wandering behavior | |
| Unit Manager #1 | Reported Resident #2 missing and conducted rounds | |
| Associate Director of Nursing | Coordinated search and investigation of elopement incident | |
| Security Officer #3 | Deactivated alarm without following protocol | |
| Security Officer #4 | Relieved Security Officer #3 and notified Director of Security about alarm | |
| Director of Security | Reviewed video footage and reported on security failures | |
| Administrator | Notified of incident and described corrective actions taken |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Oct 10, 2023
Visit Reason
One standard health citation for abuse and neglect was identified and corrected by November 2023.
Findings
One standard health citation for abuse and neglect was identified and corrected by November 2023.
Deficiencies (1)
| Description | Severity |
|---|---|
| Free from abuse and neglect | Level 2 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 10, 2023
Visit Reason
The inspection was conducted as an abbreviated survey triggered by a complaint regarding physical abuse of a resident by nursing home staff.
Findings
The facility failed to ensure the resident's right to be free from physical abuse. On 09/15/2023, a Certified Nursing Assistant (CNA #1) punched Resident #1 twice in the nose, causing bleeding, swelling, and misalignment. The resident was transferred to the hospital emergency room for evaluation. The facility has a zero tolerance policy for abuse and initiated a care plan for potential abuse risk on admission. The investigation included interviews with involved staff and medical evaluations confirming no new fractures but noting old nasal bone deformity.
Complaint Details
The complaint investigation found substantiated physical abuse by CNA #1 against Resident #1. The CNA was removed from the nursing unit and law enforcement was involved. The resident was transferred to the hospital for treatment of nose injury. Interviews and medical records supported the findings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect resident from physical abuse by nursing home staff, resulting in injury to resident's nose. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for abuse: 6
Police Officers involved: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in physical abuse incident against Resident #1. |
| CNA #2 | Certified Nursing Assistant | Assigned to Resident #1 and involved in incident observation. |
| RM #1 | Nurse Manager | Assessed Resident #1 after incident and provided first aid. |
| MD #1 | Attending Physician | Notified of incident and involved in resident's medical evaluation. |
| Medical Director | Provided follow-up information on resident's condition and investigation. | |
| Associate Director of Nursing | ADON | Conducted investigation and provided interview regarding incident. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 30
May 16, 2023
Visit Reason
Multiple standard health and life safety code citations were identified, including care plan issues and physical environment concerns, all corrected by mid-2023.
Findings
Multiple standard health and life safety code citations were identified, including care plan issues and physical environment concerns, all corrected by mid-2023.
Deficiencies (30)
| Description | Severity |
|---|---|
| Care plan timing and revision | Level 2 |
| Develop/implement comprehensive care plan | Level 2 |
| Quality of care | Level 2 |
| Cooking facilities | Level 2 |
| Corridors - construction of walls | Level 2 |
| Discharge from exits | Level 2 |
| Egress doors | Level 2 |
| Electrical equipment - other | Level 2 |
| Electrical equipment - power cords and extens | Level 2 |
| Electrical equipment - testing and maintenanc | Level 2 |
| Emergency lighting | Level 2 |
| Exit signage | Level 2 |
| Fire alarm system - testing and maintenance | Level 2 |
| Fundamentals - building system categories | Level 2 |
| Hazardous areas - enclosure | Level 2 |
| Horizontal sliding doors | Level 2 |
| Hvac | Level 2 |
| Illumination of means of egress | Level 2 |
| Maintenance, inspection & testing - doors | Level 2 |
| Means of egress - general | Level 2 |
| Means of egress requirements - other | Level 2 |
| Multiple occupancies | Level 2 |
| Number of exits - story and compartment | Level 2 |
| Physical environment | Level 2 |
| Protection - other | Level 1 |
| Sprinkler system - installation | Level 2 |
| Sprinkler system - maintenance and testing | Level 2 |
| Standards of construction for new existing nh | Level 2 |
| Subdivision of building spaces - smoke barrie | Level 2 |
| Vertical openings - enclosure | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 5
May 16, 2023
Visit Reason
The inspection was a Recertification survey conducted from 5/9/2023 to 5/16/2023 to assess compliance with regulatory requirements for The Plaza Rehab and Nursing Center.
Findings
The facility failed to develop and implement complete person-centered care plans with measurable goals and timely updates for residents, including care plans related to tracheostomy care, oxygen use, tube feeding, and abuse prevention. Additionally, the facility did not ensure a resident received treatment and care according to physician orders, specifically regarding the use of bilateral elevating leg rests on a wheelchair.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop a person-centered care plan related to tracheostomy care for Resident #351. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop a person-centered care plan related to oxygen use for Resident #232. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to review and revise the care plan for tube feeding for Resident #87 after MDS assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to review and revise the care plan related to abuse prevention for Resident #351 upon each MDS assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide treatment and care according to physician orders for Resident #385, who was observed without bilateral elevating leg rests on their wheelchair as ordered. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 39
Residents reviewed for Positioning/Mobility: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #5 | Registered Nurse Manager | Interviewed regarding responsibility for initiating and updating care plans and care plan deficiencies for Residents #351 and #87 |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding oxygen saturation monitoring and care plan initiation for Resident #232 |
| Dietician | Dietician | Interviewed regarding failure to update Resident #87's tube feeding care plan |
| MDS Senior Manager | MDS Senior Manager | Interviewed regarding responsibility for care plans and monitoring linked to MDS |
| VP of Clinical Services | Vice President of Clinical Services | Interviewed regarding care planning policies and procedures |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding Resident #385's wheelchair leg rests usage |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding Resident #385's wheelchair leg rests usage and refusal |
| Rehab Director | Rehabilitation Director | Interviewed regarding Resident #385's assessment and leg rests order |
| Director of Nursing | Director of Nursing | Interviewed regarding responsibility for wheelchair leg rests and resident usage |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Mar 9, 2022
Visit Reason
One standard health citation related to pharmacy services was identified and corrected by April 2022.
Findings
One standard health citation related to pharmacy services was identified and corrected by April 2022.
Deficiencies (1)
| Description | Severity |
|---|---|
| Pharmacy srvcs/procedures/pharmacist/records | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Feb 10, 2022
Visit Reason
Two standard health citations related to abuse and reporting of alleged violations were identified and corrected by March 2022.
Findings
Two standard health citations related to abuse and reporting of alleged violations were identified and corrected by March 2022.
Deficiencies (2)
| Description | Severity |
|---|---|
| Free from abuse and neglect | Level 2 |
| Reporting of alleged violations | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Oct 26, 2021
Visit Reason
One standard health citation for reporting of alleged violations was identified and corrected by December 2021.
Findings
One standard health citation for reporting of alleged violations was identified and corrected by December 2021.
Deficiencies (1)
| Description | Severity |
|---|---|
| Reporting of alleged violations | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 6
Oct 9, 2020
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with professional standards of quality, medication management, vision and hearing services, physician oversight, psychotropic medication use, food safety, and pest control.
Findings
The facility was found deficient in multiple areas including failure to document blood glucose monitoring for a resident on insulin, lack of ophthalmology follow-up care for a resident with vision impairment, inadequate physician review of residents' care and medication parameters, failure to implement gradual dose reductions for psychotropic medications, improper food handling and sanitation practices by kitchen staff, and ineffective pest control program evidenced by mice sightings and droppings in multiple units.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Nurses failed to document blood glucose monitoring for a resident prescribed insulin with parameters for physician notification. | Level of Harm - Minimal harm or potential for actual harm |
| Resident did not receive recommended ophthalmology follow-up care; no active order for ophthalmology consult and no documented evaluation since 6/18/19. | Level of Harm - Minimal harm or potential for actual harm |
| Physician did not review resident's total program of care at each visit, including parameters for insulin and ophthalmology consults. | Level of Harm - Minimal harm or potential for actual harm |
| Resident receiving antipsychotic medication since 2018 without documented gradual dose reduction or monitoring for effectiveness and continued need. | Level of Harm - Minimal harm or potential for actual harm |
| Cook did not perform hand hygiene during food preparation, after handling food with gloved hands, and after touching the garbage can. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not maintain an effective pest control program; mice sightings and droppings observed on multiple units, with gaps in exterminator service. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 38
Residents reviewed for unnecessary medications: 5
Residents reviewed for vision/hearing: 2
Residents affected by mice infestation: 5
Antipsychotic medication dose: 10
Glucose monitoring order date: Jul 22, 2020
Last blood sugar reading date: Jan 24, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding blood glucose monitoring and documentation practices |
| Director of Nursing | DON | Interviewed regarding nursing documentation and order reconciliation |
| Attending Physician #1 | AP | Interviewed regarding review of blood sugar monitoring and ophthalmology consults |
| Attending Physician #2 | AP | Interviewed regarding ophthalmology consult follow-up and resident coverage |
| Medical Director | MD | Interviewed regarding physician oversight and GDR requirements |
| Nurse Practitioner | NP | Interviewed regarding follow-up on physician concerns and ophthalmology |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding resident behavior and cooperation |
| [NAME] #1 | Cook | Observed and interviewed regarding food handling and hygiene practices |
| Food Service Manager | FSM | Interviewed regarding food safety policies and staff training |
| Food Service Director | FSD | Interviewed regarding food safety and sanitation procedures |
| Housekeeper | HSK | Interviewed regarding pest control and mice sightings |
| Exterminator | Interviewed regarding pest control visits and rodent issues | |
| Director of Environmental Services | DES | Interviewed regarding pest control program and supervision |
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