Inspection Reports for Plaza Healthcare & Rehabilitation Center
456 Rahway Avenue, Elizabeth, NJ, 07202
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed some recurring issues, particularly with infection prevention and control practices, staffing ratios, and emergency preparedness. Prior reports also noted deficiencies related to timely reporting of abuse allegations, care planning, bedrail safety, and fire safety code compliance. Complaint investigations were mostly unsubstantiated, though one substantiated finding involved delayed reporting of suspected abuse without evidence of harm. The facility’s inspection record shows some improvement over time, with fewer and less extensive deficiencies in the most recent reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
88 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (4)
Failed to ensure laundry staff had proper linen handling and use of PPE to prevent spread of infection.
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.
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
Routine
Deficiencies: 1
Date: Jun 4, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on the laundry staff's use of personal protective equipment (PPE) when handling linens to prevent the spread of infection.
Findings
The facility failed to ensure laundry staff wore proper PPE when handling soiled linens, as evidenced by observations of laundry aides not wearing gowns or aprons and the absence of a formal infection control policy in the laundry area. Facility staff acknowledged the need for PPE but lacked proper policies and training.
Deficiencies (1)
Failed to ensure laundry staff had the proper personal protection equipment (PPE) necessary to handle linens to prevent the spread of infection.
Report Facts
Date of survey: Jun 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director/Housekeeping Director | FSD/HD | Interviewed regarding PPE use in laundry |
| Licensed Nursing Home Administrator | LHNA | Notified of concerns in laundry room |
| Director of Nursing | DON | Notified of concerns in laundry room |
Inspection Report
Annual Inspection
Census: 89
Capacity: 89
Deficiencies: 13
Date: 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.
Complaint Details
The inspection included complaint investigations with complaint numbers NJ154369, NJ160128, NJ160566, NJ164368, and NJ169301.
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.
Deficiencies (13)
Failure to report alleged abuse to the New Jersey Department of Health within the mandated two-hour period.
Failure to update PASARR assessments upon receipt of new serious mental health diagnosis.
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.
Failure to ensure appropriate alternatives to bedrails were attempted, obtain informed consent, and document risks and benefits of bedrail use.
Failure to conduct ongoing monitoring and maintenance inspections of beds and bedrails, resulting in loose and unsafe bedrails.
Failure to install a supervisory electronic device or tamper switch on a sprinkler control valve.
Corridor walls were not continuous from floor to ceiling due to large gaps and holes allowing passage of smoke.
Laundry chute door latch was broken and incinerator door was not sealed to prevent use.
Essential electrical system lacked emergency battery powered lighting above the generator transfer switch.
Exit discharge stairs were obstructed by empty crates, blocking exit access.
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.
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.
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
Complaint Investigation
Deficiencies: 1
Date: Jan 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected resident-to-resident abuse to the New Jersey Department of Health within the mandated two-hour period.
Complaint Details
The complaint investigation focused on an incident on 05/20/23 involving alleged resident-to-resident abuse between residents R73 and R41. The facility did not notify the New Jersey Department of Health within the mandated two-hour period. The investigation concluded there was insufficient evidence to substantiate the abuse allegation.
Findings
The facility failed to inform the New Jersey Department of Health of one of two abuse allegations involving residents R73 and R41 on 05/20/23 within the required two-hour timeframe. The investigation found insufficient evidence to sustain the abuse allegation, with no visible injuries or witnesses. Interviews revealed delays in reporting and notification processes.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents in sample: 35
Date of incident: May 20, 2023
Date of investigation summary: May 23, 2023
Date report faxed to NJDOH: May 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Called the Director of Nursing immediately after the incident |
| Director of Nursing 2 | Director of Nursing | Signed the investigation summary and was called after the incident |
| Social Service Director | Social Service Director | Began abuse protocol on 05/22/24 after hearing about the incident |
| Administrator | Administrator | Not informed of the incident on the night it occurred; agreed NJDOH should have been notified within two hours |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse and neglect, and to ensure compliance with care planning, PASARR screening, side rail use, and bed maintenance policies.
Complaint Details
The complaint investigation was triggered by an allegation that the facility failed to report suspected abuse within the required two-hour timeframe. The investigation found the facility delayed reporting the incident to the New Jersey Department of Health and had deficiencies in abuse investigation and reporting protocols.
Findings
The facility failed to timely report an abuse allegation to the New Jersey Department of Health within the mandated two-hour period. The facility also failed to update PASARR screening for a resident with new mental health diagnoses, develop comprehensive person-centered care plans for residents with side rails and limited range of motion, ensure informed consent and proper assessment for side rail use, and maintain bed rails safely with ongoing inspections.
Deficiencies (5)
Failed to timely report suspected abuse to the New Jersey Department of Health within the mandated two-hour period.
Failed to update PASARR level one screening upon receipt of new serious mental health diagnoses for a resident.
Failed to develop a comprehensive person-centered care plan with goals and approaches for residents reviewed for side rail use and limited range of motion.
Failed to document alternatives attempted prior to bed rail use, complete quarterly and annual side rail assessments, and obtain informed consent for side rail use for three residents.
Failed to have ongoing monitoring and maintenance of bed side rails, resulting in loose and unsafe side rails for a resident.
Report Facts
Residents reviewed: 35
Residents affected: 2
Residents affected: 5
Residents affected: 3
Occupied beds with side rails: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director (SSD) | Interviewed regarding abuse protocol and investigation timing. | |
| Licensed Practical Nurse (LPN)2 | Reported calling Director of Nursing immediately after abuse incident. | |
| Administrator | Interviewed about knowledge and reporting of abuse incident. | |
| Director of Nursing (DON)2 | Signed abuse investigation summary; no longer employed. | |
| MDS Coordinator (MDSC) | Interviewed about care plan development and side rail care planning. | |
| Director of Rehabilitation (DOR) | Interviewed about resident's hand splint and side rail use. | |
| Nurse Aide (NA)2 | Observed and interviewed about resident's refusal to wear splint. | |
| Licensed Practical Nurse (LPN)1 | Interviewed about medication administration record and splint use documentation. | |
| Maintenance Supervisor (MS) | Interviewed about bed and side rail inspections and maintenance. | |
| Director of Nursing (DON)1 | Interviewed about splint refusals and side rail assessments. | |
| Licensed Practical Nurse (LPN)4 | Interviewed about side rail use during care. |
Inspection Report
Annual Inspection
Census: 87
Capacity: 128
Deficiencies: 17
Date: 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.
Deficiencies (17)
Failure to maintain resident call bells within reach and accessible.
Visitation restrictions not compliant with CMS and NJDOH guidance.
Failure to report and investigate resident abuse allegations timely and thoroughly.
Failure to complete thorough and timely investigations of abuse allegations.
Failure to review and revise care plans timely, including antibiotic use.
Failure to follow professional standards in medication administration and documentation.
Failure to ensure emergency response system activation, 911 call, and AED use for unresponsive resident; failure to maintain CPR certification for staff.
Failure to provide restorative nursing program consistently and document interventions.
Failure to provide resident activities two evenings per week.
Failure to label and store drugs and biologicals properly, including expired medications and personal medications of discharged residents.
Failure to provide timely physician ordered medications and document administration accurately.
Failure to provide appropriate treatment and services for mental/psychosocial well-being.
Failure to ensure infection prevention and control practices including PPE use and hand hygiene.
Failure to implement and monitor antibiotic stewardship program.
Failure to ensure mandatory COVID-19 vaccination policy and documentation for all staff including contractors and vendors.
Failure to provide required in-service training for nurse aides including documentation of education.
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.
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
Deficiencies: 15
Date: Mar 1, 2022
Visit Reason
The inspection was conducted based on observation, interview, record review, and review of pertinent facility documentation to assess compliance with regulatory requirements including resident care, abuse investigations, medication administration, infection control, emergency response, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to maintain accessible call bells for residents, failure to ensure visitation rights in accordance with CMS directives, failure to report and investigate allegations of abuse timely and thoroughly, failure to properly administer and document medications, failure to maintain emergency response readiness including CPR certification and AED use, failure to provide consistent restorative nursing care, failure to ensure safe environment and supervision to prevent accidents, failure to provide appropriate behavioral health services, failure to monitor antibiotic use, failure to ensure staff vaccination documentation, and failure to conduct timely performance evaluations and staff education.
Deficiencies (15)
Facility failed to maintain resident call bells accessible and within reach for all residents.
Facility failed to ensure visitation process did not restrict visitation as per CMS executive directive.
Facility failed to timely report and thoroughly investigate allegations of resident-to-resident abuse.
Facility failed to properly administer and document medications including narcotics and antibiotics.
Facility failed to activate emergency response system, call 911, and utilize AED for resident found unresponsive; failed to maintain CPR certification tracking.
Facility failed to provide consistent restorative nursing care including range of motion and bed mobility as ordered.
Facility failed to ensure safe environment and supervision to prevent accidents and failed to secure emergency crash cart.
Facility failed to provide consistent behavioral health services and psychotherapy as ordered.
Facility failed to ensure proper hand hygiene and use of personal protective equipment in transmission-based precaution rooms.
Facility failed to ensure expired medications and supplies were removed from medication rooms and emergency carts; failed to monitor refrigerator temperatures.
Facility failed to ensure staff vaccination status was accurately tracked and documented for all staff including contractors.
Facility Medical Director failed to provide clinical oversight regarding laboratory testing, staff CPR certification, and antibiotic stewardship.
Facility failed to monitor and track resident antibiotic use for multiple months.
Facility failed to conduct timely performance evaluations and provide education for Certified Nursing Assistants.
Facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize performance improvement plans to monitor and improve care.
Report Facts
Residents reviewed: 20
Residents reviewed: 18
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 2
Residents reviewed: 2
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Residents reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in emergency response and medication administration findings |
| LPN #2 | Licensed Practical Nurse | Named in emergency response and medication administration findings |
| DON | Director of Nursing | Named in multiple findings including abuse investigation, medication administration, emergency response, infection control, and QAPI |
| LNHA | Licensed Nursing Home Administrator | Named in multiple findings including abuse investigation, emergency response, staff vaccination, and QAPI |
| RN/IP | Registered Nurse Infection Preventionist | Named in antibiotic stewardship and infection control findings |
| RN/S | Registered Nurse Supervisor | Named in emergency response and QAPI findings |
| RN Staff Educator | Registered Nurse Staff Educator | Named in CNA education and performance evaluation findings |
| RCNA #1 | Restorative Certified Nursing Assistant | Named in restorative nursing findings |
| RCNA #2 | Restorative Certified Nursing Assistant | Named in restorative nursing findings |
| MD | Medical Director | Named in medical oversight and antibiotic stewardship findings |
| RN/CN | Registered Nurse Charge Nurse | Named in laboratory testing and medication administration findings |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Jul 30, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ143076, NJ142922, and NJ142468.
Complaint Details
Complaint numbers NJ143076, NJ142922, and NJ142468 were investigated and found to be unsubstantiated as the facility was in compliance.
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.
Report Facts
Sample Size: 6
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00140781.
Complaint Details
Complaint number NJ00140781 was investigated and found to be unsubstantiated as the facility was in compliance.
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.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: 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.
Complaint Details
The survey was complaint-related and focused on COVID-19 infection control practices; the facility was found in substantial compliance.
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.
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