Inspection Reports for
The Plaza Rehab and Nursing Center

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.

Inspection revealed 5 standard health and 5 life safety code citations, all corrected by mid-2025.

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.

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.

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.

One standard health citation related to accident hazards was identified and corrected by June 2025.

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.

One standard health citation for abuse and neglect was identified and corrected by November 2023.

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.

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.

Multiple standard health and life safety code citations were identified, including care plan issues and physical environment concerns, all corrected by mid-2023.

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.

One standard health citation related to pharmacy services was identified and corrected by April 2022.

Two standard health citations related to abuse and reporting of alleged violations were identified and corrected by March 2022.

One standard health citation for reporting of alleged violations was identified and corrected by December 2021.

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.