Inspection Reports for Plaza Healthcare & Rehabilitation Center
456 Rahway Avenue, NJ, 07202
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Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform recipients about the privacy practices of NJDHSS, including how personal health information may be used and disclosed, and the rights individuals have concerning their health information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 4
Jun 5, 2025
Visit Reason
The inspection was conducted as a standard annual recertification survey to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with infection prevention and control requirements, specifically related to laundry staff's handling of linens and use of PPE. Additionally, deficiencies were noted in staffing ratios, employee health assessments, and emergency preparedness including generator fuel plans. Plans of correction were submitted and later found compliant.
Severity Breakdown
SS = F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure laundry staff had proper linen handling and use of PPE to prevent spread of infection. | SS = F |
| Failed to maintain required minimum direct care staff-to-resident ratios for 1 out of 14 shifts reviewed. | — |
| Failed to ensure newly hired employees received required physical examinations or nursing assessments within mandated timeframes. | — |
| Failed to ensure emergency preparedness plan included a plan to maintain fuel/operational power systems during an emergency. | SS = F |
Report Facts
Census: 88
Sample Size: 22
Staffing Deficiency: 1
Certified Nurse Aides (CNAs): 10
Residents: 87
Plan of Correction Completion Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist | Named in relation to infection control deficiencies and monitoring linen handling compliance | |
| Housekeeping Director | Involved in monitoring linen handling and infection prevention compliance | |
| Staffing Coordinator | In-serviced and responsible for staffing compliance and increasing staffing levels | |
| Administrator | Involved in staffing and employee health plan of correction and monitoring | |
| Director of Nursing | Involved in infection control, staffing, and employee health plan of correction and monitoring | |
| Human Resource Manager | Involved in auditing new hire health assessments and scheduling physicals | |
| Maintenance Director | Responsible for emergency preparedness and generator maintenance |
Inspection Report
Annual Inspection
Census: 89
Capacity: 89
Deficiencies: 13
Jan 25, 2024
Visit Reason
A Recertification and Complaint survey was conducted by the New Jersey Department of Health from 01/22/24 through 01/25/24 to assess compliance with federal and state regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to timely report alleged abuse, failure to update PASARR assessments, incomplete care plans, improper use and documentation of bedrails, lack of bed maintenance inspections, fire safety code violations including inadequate exits, sprinkler system deficiencies, corridor wall gaps, smoke barrier holes, laundry chute and incinerator safety issues, emergency electrical system deficiencies, and exit signage problems.
Complaint Details
The inspection included complaint investigations with complaint numbers NJ154369, NJ160128, NJ160566, NJ164368, and NJ169301.
Severity Breakdown
SS=D: 5
SS=E: 3
SS=F: 5
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to report alleged abuse to the New Jersey Department of Health within the mandated two-hour period. | SS=D |
| Failure to update PASARR assessments upon receipt of new serious mental health diagnosis. | SS=D |
| Failure to develop comprehensive person-centered care plans with measurable goals for residents, including care plans for side rail use and limited range of motion. | SS=D |
| Failure to ensure appropriate alternatives to bedrails were attempted, obtain informed consent, and document risks and benefits of bedrail use. | SS=D |
| Failure to conduct ongoing monitoring and maintenance inspections of beds and bedrails, resulting in loose and unsafe bedrails. | SS=D |
| Failure to install a supervisory electronic device or tamper switch on a sprinkler control valve. | SS=F |
| Corridor walls were not continuous from floor to ceiling due to large gaps and holes allowing passage of smoke. | SS=E |
| Laundry chute door latch was broken and incinerator door was not sealed to prevent use. | SS=F |
| Essential electrical system lacked emergency battery powered lighting above the generator transfer switch. | SS=F |
| Exit discharge stairs were obstructed by empty crates, blocking exit access. | SS=F |
| The facility failed to provide two acceptable exits from the 3rd floor; the secondary exit was a roof egress with an unenclosed exit path approximately 50 feet long. | SS=E |
| Exit directional signage was missing on the 3rd floor open roof pathway and within the 2 exit stairways from the 3rd floor to the exit discharge doors. | SS=F |
| The facility failed to maintain the required minimum direct care staff-to-resident ratios, specifically deficient CNA staffing on multiple day shifts. | — |
Report Facts
Survey Census: 89
Total Capacity: 89
Deficient CNA staffing days: 21
Generator KW: 151
Roof exit egress length: 50
Sliding glass window gap: 0.5
Smoke barrier holes: 4
Bed rail gap: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON)1 | Interviewed regarding care plan development and abuse reporting. | |
| Licensed Practical Nurse (LPN)1 | Interviewed regarding medication administration and resident care. | |
| Licensed Practical Nurse (LPN)4 | Interviewed regarding bedrail use during care. | |
| Nurse Aide (NA)2 | Interviewed regarding resident care and bedrail use. | |
| Maintenance Director | Interviewed regarding bed inspections and sprinkler valve supervision. | |
| Administrator | Interviewed and provided plan of correction responses. |
Inspection Report
Annual Inspection
Census: 87
Capacity: 128
Deficiencies: 17
Mar 17, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to have widespread system failures including Immediate Jeopardy related to emergency response and CPR certification, failure to maintain resident call bells within reach, visitation restrictions not compliant with CMS guidance, failure to report and investigate abuse allegations, incomplete care plan updates, medication administration errors, inadequate infection control practices, staffing shortages, and multiple life safety code violations.
Severity Breakdown
SS=L: 1
SS=F: 8
SS=E: 4
SS=D: 6
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to maintain resident call bells within reach and accessible. | SS=D |
| Visitation restrictions not compliant with CMS and NJDOH guidance. | SS=F |
| Failure to report and investigate resident abuse allegations timely and thoroughly. | SS=D |
| Failure to complete thorough and timely investigations of abuse allegations. | SS=D |
| Failure to review and revise care plans timely, including antibiotic use. | SS=D |
| Failure to follow professional standards in medication administration and documentation. | SS=D |
| Failure to ensure emergency response system activation, 911 call, and AED use for unresponsive resident; failure to maintain CPR certification for staff. | SS=L |
| Failure to provide restorative nursing program consistently and document interventions. | SS=E |
| Failure to provide resident activities two evenings per week. | SS=E |
| Failure to label and store drugs and biologicals properly, including expired medications and personal medications of discharged residents. | SS=E |
| Failure to provide timely physician ordered medications and document administration accurately. | SS=D |
| Failure to provide appropriate treatment and services for mental/psychosocial well-being. | SS=D |
| Failure to ensure infection prevention and control practices including PPE use and hand hygiene. | SS=D |
| Failure to implement and monitor antibiotic stewardship program. | SS=F |
| Failure to ensure mandatory COVID-19 vaccination policy and documentation for all staff including contractors and vendors. | SS=D |
| Failure to provide required in-service training for nurse aides including documentation of education. | SS=F |
| Failure to provide adequate fire safety including exit door accessibility, stairway markings, exit signage, hazardous area enclosures, fire alarm system testing, smoke detection maintenance, sprinkler system maintenance, HVAC ventilation, elevator inspections, emergency illumination, and electrical system maintenance. | SS=F |
Report Facts
Deficiencies cited: 29
Resident census: 87
Total licensed capacity: 128
Staffing ratios: 10
Staffing ratios: 11
Missing temperature log days: 14
Missing temperature log days: 6
Missing temperature log days: 8
Missing temperature log days: 6
Missing temperature log days: 8
Missing temperature log days: 7
Staff vaccination rate: 94.2
Number of staff on BLS log: 20
Number of staff with CPR cards: 8
Number of residents: 6
Number of expired items in crash cart: 11
Number of expired items in crash cart: 20
Number of expired items in medication room: 10
Number of missing CNA performance evaluations: 4
Number of missing CNA in-service trainings: 4
Number of stairwells missing marking stripes: 3
Number of exit signs missing directional indicators: 2
Number of hazardous areas with incomplete fire barriers: 3
Number of sprinkler logs missing transfer time data: 12
Number of resident rooms missing battery operated smoke detectors: 1
Number of resident bathrooms with non-functioning ventilation: 5
Number of elevators missing monthly firefighter service documentation: 2
Number of emergency lights missing bulbs or not on automatic circuit: 5
Number of exit doors with step or missing railing: 2
Number of exit doors with thumb turn locks: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in emergency response failure and medication administration issues |
| LPN #2 | Licensed Practical Nurse | Named in emergency response failure and medication administration issues |
| DON | Director of Nursing | Named in multiple findings including abuse reporting, emergency response, medication administration, infection control, and staff CPR certification |
| LNHA | Licensed Nursing Home Administrator | Named in findings related to visitation, abuse reporting, QAPI, and staff vaccination |
| RN/IP | Registered Nurse Infection Preventionist | Named in infection control and antibiotic stewardship findings |
| RCNA #1 | Restorative Certified Nursing Assistant | Named in restorative nursing program deficiencies |
| RCNA #2 | Restorative Certified Nursing Assistant | Named in restorative nursing program deficiencies |
| RN/UM | Registered Nurse Unit Manager | Named in medication storage and staff education findings |
| MD | Medical Director | Named in laboratory and antibiotic stewardship findings |
| RN/CN | Registered Nurse Charge Nurse | Named in laboratory order and documentation findings |
| PC | Pharmacy Consultant | Named in medication administration and antibiotic stewardship findings |
| RD | Recreation Director | Named in resident activities deficiency |
| CNA #1 | Certified Nursing Assistant | Named in resident call bell and infection control findings |
| CNA #2 | Certified Nursing Assistant | Named in infection control findings |
| RN/SON | Registered Nurse Supervisor of Nursing | Named in infection control and medication storage findings |
| Maintenance Director | Maintenance Director | Named in multiple life safety code deficiencies |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Jul 30, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ143076, NJ142922, and NJ142468.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ143076, NJ142922, and NJ142468 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Jan 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00140781.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint number NJ00140781 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control and Complaint Survey was conducted to assess compliance with Medicare regulations and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in substantial compliance with Medicare regulations at 42 CFR Part 483, Subpart B, and had implemented the CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
The survey was complaint-related and focused on COVID-19 infection control practices; the facility was found in substantial compliance.
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