The Plaza Rehab and Nursing Center

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (2622908), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one 1(Resident #1) out of 3 residents reviewed for accidents. Specifically, Resident #1 complained of pain to their right arm on 09/18/2025 and Xray results showed a non-displaced fracture of the right proximal humeral shaft. Resident #1 was unable to explain the occurrence. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification survey from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. This was evident in 1 (Resident #106) of 1 resident of reviewed for Tube Feeding. Specifically, tube feedings were not appropriately labelled with the resident's name, the flow rate, the time, and the date of the administration for Resident #106.

Inspectors wrote2. The New York State Complaint Intake Summary (#NY00351324) dated 01/14/2025 documented that a family representative stated that the residents' rooms were left with crumbs and garbage on the floor, and the Administrator was notified about their concerns and nothing was done about it. On 04/30/2025 at 01:08 PM, in room [ROOM NUMBER] on Unit 9 East, paper towels and old tissues of a brownish color were observed on the floor. Two trash cans by the bedside were nearly full of trash. The resident who resided in room [ROOM NUMBER] stated that the housekeeping staff do not come to clean very often, and they only come in one or two times a week. On 05/01/2025 at 11:37 AM, an interview was conducted with Housekeeper #1 who stated that they work five days a week on several units and come to work on Unit 9 East about three times a week. [...]

Inspectors wrote2. Resident #523 was admitted to the facility with diagnoses including Alzheimer's Disease, Insomnia, Diabetes and Spontaneous Ecchymoses. The Quarterly Minimum Data Set (a resident assessment tool) dated 11/04/2024 documented that Resident #523 as severely cognitively impaired but requiring only supervision or set up for all Activities of Daily Living. A Medical note dated 01/28/2025 at 1:07 PM states that Resident #523 was seen for multiple scratches and ecchymoses to the upper extremities and left breast. Resident #523 was unable to provide any relevant history in view of their cognitive deficits. The scratches were located on their left hand, left elbow, right wrist and mid forehead, and there were two large ecchymoses on the lateral and medial side of the left breast with a central abrasion. [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. This was evident for 1 (Resident #640) of 3 residents reviewed for Skin Condition out of total 38 sampled residents. Specifically, the medical record did not contain evidence that Resident #640 received wound treatment as ordered on multiple days.

Inspectors wroteThe New York State Complaint Intake Summary (#NY00351324) dated 01/10/2025, documented that a family representative stated that they witnessed a mouse running in the resident's room, and also saw a roach on the resident's sandwich. On 04/30/2025 at 12:56 PM, in room [ROOM NUMBER] P East, a sticky fly trap was observed on the bedside table with multiple flies stuck to the fly trapper. An interview was conducted with the resident who resided in room [ROOM NUMBER] P who stated that there are flies everywhere in the room, and when they have complained about it, all the facility does is to replace the sticky fly trap. On 04/30/2025 at 01:08 PM, the resident who resided in room [ROOM NUMBER] East stated that they have seen cockroaches and mice in the room, and they informed staff but could not recall if the exterminator had been to their room. [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00356446), the facility did not ensure that each resident received adequate supervision to prevent an elopement. This was evident for one (1) out of four (4) residents (Resident #2) sampled for elopement. Specifically, the facility Elopement/Unauthorized Leave Incident Report dated 10/04/2024 documented that the surveillance video footage showed at 11:09 AM on 10/04/2024 Resident #2 exited the unit unsupervised. At 11:15 AM, the East COVID entrance door alarm was activated, and Security Officer #3 deactivated the alarm. The investigation documented that it was confirmed at 11:47 AM Resident #2 was missing. Resident #2 was located by the police and was taken to the emergency room on [DATE] without injury.

Inspectors wroteBased on observation, record review and interviews conducted during an abbreviated survey (Case NY 00324036), the facility did not ensure the resident's right to be free from physical abuse by nursing home staff. This was evident for one out of six residents (Resident #1) sampled for abuse. Specifically, on 09/15/23 at 12:30 PM, Resident #1 stated Certified Nursing Assistant (CNA) #1 punched them twice in the nose after they refused personal care. Nurse Manager (RM) #1 assessed Resident #1 and observed that the nose was bleeding with slight swelling, and seem shifted to the left. Emergency Medical Services (911) and the Attending Doctor was called. CNA #1 was removed from the nursing unit. At 1:55 PM, Resident #1 was transferred to the Hospital Emergency Room.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey of 5/9/23 to 5/16/23, the facility did not ensure that person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's medical needs. This was evident for 2 (Resident #351 and #232) of 39 total sampled residents. Specifically, 1) a CCP related to tracheostomy care was not developed for Resident #351, and 2) a CCP related to oxygen use was not developed for Resident #232.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 5/09/2023 through 5/16/2023, the facility did not ensure Comprehensive Care Plans (CCP) were reviewed and revised after each assessment. This was evident for 2 (Residents #87 and #351) of 39 sampled residents. Specifically, (1) the care plan for Tube Feeding was not reviewed for Resident #87, and 2) the care plan for abuse was not revised for Resident #351.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #385) of 4 residents reviewed for Positioning/Mobility, out of a sample of 39 residents. Specifically, Resident #385 was observed on several occasions, without bilateral elevating leg rests as per physician's order.

Inspectors wroteBased on observation and staff interviews during a Recertification survey, the facility did not ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illness was followed. Specifically, the cook did not perform hand hygiene during food preparation, after handling of food with gloved hands and after touching the garbage can. This was evident during the Kitchen Observation facility task.

Inspectors wroteBased on observation, record review, and interviews the facility did not maintain an effective pest management program so the facility was free of pests and rodents. Specifically, residents reported mice sightings on the units, mice droppings were observed on several units, and review of the exterminator log documented there was no exterminator service for one week during the period of mouse infestation. This was evident on 5 of 17 units (W6, W7, W9, W10, and 11) The finding is: The facility policy and procedure titled Pest Control dated 8/22/18 and revised 3/2020 documented the facility maintains an effective pest control program to ensure that the building is kept free of insects and rodents. The policy also documented maintenance services assist, when appropriate and necessary, in providing pest control services. [...]

Inspectors wroteBased on record review and interviews the facility did not ensure care and services provided met professional standards of quality. Specifically, nurses failed to document blood glucose monitoring for a resident who was prescribed insulin with parameters for which to notify the physician. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a final sample of 38 residents (Resident #207). The finding is: The facility policy and procedure titled Insulin Administration dated 4/2/2018 and revised 1/2020 documented that nurse documentation for insulin administration includes recording resident's blood glucose result, dose and concentration of insulin, size and gauge of the needle, site, and how the resident tolerated the procedure. [...]

Inspectors wroteBased on interview and record review, conducted during a Recertification survey, the facility did not ensure that residents received proper treatment and assistive devices to maintain vision abilities. Specifically, the resident did not receive Ophthalmology follow-up care as recommended. This was evident for 1 of 2 residents reviewed for Vision/Hearing out of a sample of 38 residents. (Resident #59)

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that the physician reviewed the resident's total program of care at each visit. Specifically, (1) the physician did not ensure that parameters were reviewed for a resident prescribed Insulin, and (2) the physician did not ensure that Ophthalmology consults were reviewed and follow-up provided. This was evident for 1 of 5 residents reviewed for Unnecessary Medication and 1 of 2 residents reviewed for Vision/Hearing out of a sample of 38 residents. (Resident #207 and # 59)

Inspectors wroteBased on observations, record review, and interviews during the re-certification survey, the facility did not ensure that a resident receiving an antipsychotic psychotropic drug received adequate monitoring and gradual dose reductions (GDR) in an effort to discontinue this drug. Specifically, a resident with a diagnosis of Schizoaffective Disorder had been prescribed the same dose of an antipsychotic medication since 2018 without a gradual dose reduction or monitoring for the effectiveness and continued need for the medication. This was evident for 1 of 5 residents reviewed for unnecessary medications out of a sample of 35 residents (Resident #207). The finding is: [...]