Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plaza Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Laundry staff handled soiled and clean linens without appropriate PPE, such as gowns or aprons, and demonstrated confusion about proper procedures for handling isolation and regular laundry bags. Facility policies required the use of gloves and gowns when handling soiled linens, but these practices were not followed or understood by staff.
The facility did not include a plan in its emergency preparedness policy for maintaining generator power and fuel during emergencies. Staff confirmed there was no documented procedure for ensuring emergency power systems would remain operational or for supplying power if the generator failed, as required by federal regulations and referenced standards.
The facility did not meet the required CNA-to-resident staffing ratio for one day shift, providing only 10 CNAs for 87 residents when at least 11 were required. This deficiency was identified through staffing records and confirmed during an interview with the Staffing Coordinator, who stated she was aware of the staffing requirements.
The facility did not ensure that new employees, including RNs, LPNs, and CNAs, received required health examinations by a physician, APN, or PA within the mandated timeframe, as shown by missing or incomplete documentation in 6 out of 10 newly hired staff files. The DON confirmed the lack of proper records and could not provide additional information to demonstrate compliance.
The facility failed to monitor and maintain bed side rails, resulting in a loose and leaning side rail for a resident with severely impaired cognition. The Maintenance Supervisor did not conduct regular bed checks or document side rail inspections, and the facility's policy did not address the risk of entrapment.
The facility failed to update a resident's PASARR level one screening upon receipt of new serious mental health diagnoses. The resident had additional diagnoses added over time, but the PASARR screening was not resubmitted or updated, placing the resident at risk for unmet care needs and not receiving appropriate mental health support.
The facility failed to develop comprehensive care plans for three residents reviewed for side rail use and one resident reviewed for limited range of motion. The care plans did not address the use of bed rails or document refusals to wear a hand splint, despite observations and staff confirmations.
The facility failed to document attempts of alternatives before using bed rails, complete quarterly and annual side rail assessments, and obtain informed consent from residents or their representatives. This deficiency involved three residents, leading to potential risks of injury or entrapment due to improper bed rail use.
The facility failed to inform the NJDOH of an abuse allegation within the mandated two-hour period. The incident involved two residents and occurred on a specific date. The investigation was delayed, and the report was faxed to the NJDOH beyond the required timeframe. Interviews indicated that the abuse protocol was initiated late, and the Administrator was not informed until the following Monday. The facility's policy mandates immediate reporting, but this was not followed, constituting a deficiency.
Failure to Ensure Proper PPE Use in Laundry Handling
Penalty
Summary
The facility failed to ensure that laundry staff had the proper personal protective equipment (PPE) necessary to handle linens in a manner that would prevent the spread of infection. During a survey, it was observed that laundry aides were emptying dryers and handling both clean and soiled linens without the use of gowns or aprons. When questioned, one laundry aide was unaware of any PPE requirements when handling dirty linens, and no gowns or aprons were observed in the laundry area. Another staff member, who was new to laundry and housekeeping, also did not know if PPE was required and attempted to look up the information online during the survey. Further interviews revealed inconsistencies in the use of laundry bags for soiled and isolation linens. While some staff described using water-soluble bags for isolation linens, others were observed using clear plastic bags that were not biodegradable for dirty laundry. There was confusion among staff regarding which bags should be used for isolation and whether PPE was necessary when handling soiled linens. Additionally, laundry aides were seen folding clean linens in a manner that allowed the linens to touch their clothing, and no PPE aprons were available in the area. A review of the facility's policies indicated that standard precautions, including the use of gloves and gowns when handling potentially infectious materials or soiled linens, were required. The policies also specified that soiled linen should be handled with gloved hands and an apron or gown, especially for residents on transmission-based precautions. Despite these written policies, the observed practices in the laundry area did not align with the facility's infection prevention and control program requirements.
Plan Of Correction
483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. Element #1. The Policy on Linen Management was updated on 6/4/2025. The laundry room personnel and the [R] were immediately in-serviced by the Infection Preventionist/Director of Nursing on the updated Linen Management Policy, especially regarding PPE and apron/gown use while handling soiled linens. Laundry personnel also received instructions on PPE supplies, gowns, and aprons. These items are readily available in the washing machine area for use by laundry personnel by the Infection Preventionist and the housekeeping director. Element #2 All residents have the potential to be affected by these deficient infection control practices. Element #3. All housekeeping and laundry personnel and the [R] were in-serviced on 6/19/2025 and educated by the Infection Preventionist on laundry and linen handling, and use of PPE/gowns/aprons. A PPE sign-off log will be present for the laundry staff to sign off daily that they are using proper PPE for infection control purposes. Element #4. For three (3) months (from 6/6/25 till 9/6/25), the Housekeeping Director and Infection Preventionist will monitor linen handling (3) times weekly for (4) weeks, then weekly for (2) months, then monthly thereafter for laundry personnel's compliance with infection prevention over the next two quarters. The Infection Preventionist and Nursing Director or designee will review the results of these audits, including any actions taken for correction. All findings to be reported and discussed by the next two QAPI meetings.
Deficiency in Emergency Generator Fuel and Power Maintenance Planning
Penalty
Summary
The facility failed to ensure that its emergency preparedness policy included a plan for maintaining generator power and fuel during an emergency. During a record review, it was found that the Emergency Preparedness Policy did not reference any procedures or strategies for keeping the emergency power systems operational in the event of a power outage or other emergency situations. This omission was specifically noted in the documentation provided by the facility. At the time of the survey, an interview with facility staff confirmed that there was no plan in place to maintain fuel sources for the emergency generator during an emergency. Additionally, there was no documented plan for supplying power to the building if the generator failed to operate during such an event. This lack of planning was acknowledged by the staff member interviewed by the surveyor. The deficiency was communicated to the facility's leadership during the Life Safety Code exit conference. The absence of a comprehensive emergency power and fuel maintenance plan was identified as a failure to meet the requirements set forth by federal regulations and referenced standards, including NFPA 99 and NFPA 110.
Plan Of Correction
Element #1 On 6/6/2025 the Administrator and the Maintenance Director went to do an audit on the facility contract and reports with our vendor Powerhouse, which services our generator. In the binder of contracts, we found the contract dated 1/1/2025, stating clearly that Powerhouse will service our facility with fuel throughout the time the generator is on during an emergency and will replace it with a rental if the current generator malfunctions (see policy attached). Element #2 All residents have the potential to be affected by this deficient practice when life safety reports and contracts are not handy and not in the right binder. Element #3 The administrator in-serviced the US FOIA (b)(6) the same day 6/6/25 about the importance of having all reports and contracts related to lift safety, to be stored in the emergency preparedness binder and to check monthly contract and report from the Vendor Powerhouse who services the generator, that they are up to date with life safety compliance. In addition, the administrator in-serviced the maintenance director on the responsibility of having a contracted vendor service the generator throughout the emergency and having a backup generator in case it malfunctions. Element #4 The Administrator will monitor the Maintenance Director for three (3) months starting 6/9/2025-9/9/2025 weekly on having all life safety reports and contracts handy and placed in the Emergency preparedness binder for all life safety compliance. All findings will be reviewed and discussed in the next Quarterly QAPI committee meeting.
Failure to Meet Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for one out of fourteen day shifts reviewed. Specifically, on one day shift, there were only 10 Certified Nurse Aides (CNAs) present for 87 residents, whereas the required minimum was 11 CNAs. This deficiency was identified through a review of the facility's "Nursing Staffing Report" for the specified weeks. During an interview, the Staffing Coordinator stated she was familiar with the CNA staffing ratios and believed the facility was able to meet them. The facility's staffing policy, reviewed in January 2025, indicated that staffing assignments were developed in accordance with resident needs and relevant regulations. However, the documentation and staffing records reviewed by the surveyor demonstrated that the facility did not meet the mandated CNA-to-resident ratio for at least one shift.
Plan Of Correction
Element #1 The staffing coordinator was in-serviced on 6/20/2025 by the Administrator and Nursing Director; education provided included the importance of meeting the minimum staffing requirements and utilizing all possible avenues to proactively increase staffing in the facility. Element #2 All residents have the potential to be affected by this deficient practice when staffing regulations are not met. Element #3 The staffing coordinator continues to utilize all possible means to increase facility staff, including offering bonuses to staff that refer to CNAs. The staffing coordinator will review the scheduled monthly staffing; any shift not adequately staffed, the staffing coordinator will reach out to our contracted staffing agencies, who assure us they will make all efforts to supply the necessary staff. In addition, the staffing coordinator can offer part-time/per-diem employment to our sister facility's CNA that may be seeking additional working hours. Staffing Coordinator, Nursing Director, and Administrator have listed job opportunities/openings on Indeed and Apploi for hiring nursing staff. Element #4 The Administrator or designee will monitor daily staffing levels with the staffing coordinator for the next 4 months (6/20/2025-10/20/2025). Weekly for the first 4 weeks and after 4 weeks, bi-weekly for 12 weeks. All findings to be reported and discussed by the next two QAPI meetings.
Failure to Ensure Timely Employee Health Examinations for New Hires
Penalty
Summary
The facility failed to ensure that newly hired employees received a required health examination by a physician, advanced practice nurse, or New Jersey licensed physician assistant within two weeks prior to employment or upon employment, or within thirty days if a registered nurse assessment was completed upon hire. During a review of 10 randomly selected newly hired employee files, it was found that 6 did not have documentation of a completed physical examination as required by regulation. Specifically, one LPN had no pre-employment health screen or documentation of a physical, and other staff had only partial or incomplete health reports. Interviews with the Director of Nursing (DON) confirmed that the facility's process was to have new hires receive a physical 1 to 2 weeks prior to starting work, typically performed by the facility's medical director. Upon review of the files, the DON acknowledged the missing or incomplete documentation and was unable to provide additional information to demonstrate compliance. The facility's policy also required a health review and physical examination for all new employees, but the records reviewed did not consistently meet these requirements.
Plan Of Correction
Element #1. On 6/5/2025 The facility Human Resource Manager (HR), Administrator and Director of Nursing began an audit on all new hire within the last (1) year to schedule date for each new hire to complete a Register Nurse (RN) assessment or physical examination. The Facility Administrator in-serviced on 6/6/2025 the director of nursing to follow the facilitys policy on completing an Registered Nurse assessment upon prior to hire date and schedule health physician exam with the facilitys medical director for all new employees in the required time frame. Element #2. All residents have the potential to be affected by this deficient practice by not completing registered nursing assessment or physician assessment within the required time frame. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting. Element #3. The Administrator on 6/20/2025 met with the Facility Medical Director and Human Resources Manager and Director of Nursing, in-service education the facilitys policy on the timely completion of all new hire health history and physicals within the required time frame. Element #4. The Administrator and the Director of Nursing will monitor and review on a weekly basis for 3 months (from 6/5/25 till 9/5/25), the monthly log for all new hire health history and physical to ensure compliance. The Nursing Director, Human Resources and the Administrator will review the results of these audits, including any actions taken for correction. All findings will be reported at the next two quarterly QAPI meeting.
Failure to Monitor and Maintain Bed Side Rails
Penalty
Summary
The facility failed to have an ongoing monitoring of bed side rails as part of their routine maintenance program for one resident and 86 of 87 occupied beds reviewed for side rails. Resident 71, who had severely impaired cognition and was dependent on mobility, was observed with a loose and leaning side rail that created a hand-size gap between the mattress and the rail. The Maintenance Supervisor confirmed that bed checks were not conducted regularly, and side rail inspections were not documented. The side rail was tightened only after the issue was pointed out by the surveyor. The facility's maintenance log for January 2024 did not include entries for bed rail maintenance, and the Maintenance Supervisor admitted to not checking for gaps between the side rail and mattress. The facility's policy on the use of side rails did not address the risk of entrapment, and the Administrator could not provide a bed maintenance/inspection policy. The facility's failure to properly monitor and maintain bed side rails was evident in the condition of Resident 71's bed and the lack of documented inspections. Additionally, the facility's review of a resident roster revealed that 86 of 87 occupied beds had side rails in use, yet there was no evidence of a systematic approach to ensure their safety. The facility's policy on side rails emphasized avoiding their use as physical restraints but did not include measures to prevent entrapment. The lack of proper maintenance and monitoring of bed side rails posed a significant risk to residents' safety, as demonstrated by the observations and interviews conducted during the survey.
Failure to Update PASARR Level One Screening
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening and Resident Review (PASARR) level one was updated upon receipt of new serious mental health diagnoses. Specifically, one resident, who was admitted with diagnoses of bipolar disorder and acquired absence of limb, had additional diagnoses of insomnia, bipolar disorder in partial remission, unspecified psychosis, and schizoaffective disorder depressive type added over time. However, the PASARR level one screening completed prior to admission did not identify any serious mental health diagnoses, and it was not resubmitted or updated to reflect the new diagnoses after admission. During interviews, both the Administrator and the Social Services Director acknowledged that the PASARR level one should have been resubmitted with the updated diagnoses. The facility's policy on PASARR did not address the procedure for correcting an incorrect admission screening or resubmitting the screening if a serious mental health diagnosis was received after admission. This oversight placed the resident at risk for unmet care needs and not receiving appropriate and necessary mental health support and services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan with goals and approaches for three residents reviewed for side rail use and one resident reviewed for limited range of motion. For Resident 32, the care plan did not address the use of bed rails despite the resident being totally dependent on staff for bed mobility and having bilateral full quarter upper rails in the up position during multiple observations. The MDS Coordinator confirmed that bed rails were not included in the care plan, which should have been addressed for safety and positioning in bed. Resident 33, who was cognitively intact and required staff supervision for bed mobility, also had bilateral upper full quarter bed rails that were not addressed in the care plan. The resident was not advised of the risks and benefits of side rails. The MDS Coordinator confirmed that bed rails were not included in the care plan, which should have been addressed for safety and positioning in bed. Resident 71, who had severe cognitive impairment and limited range of motion, had side rails included only as an intervention and not as a full care plan with goals and objectives. Additionally, the resident's refusal to wear a hand splint was not documented in the care plan, despite observations and staff interviews confirming the refusals. The MDS Coordinator and Director of Nursing confirmed that the refusals should have been care planned. The facility's policies on comprehensive care plans and side rail use were not followed, leading to these deficiencies.
Failure to Document Alternatives and Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that three residents (R32, R33, and R71) had documented attempts of alternatives before using bed rails, completed quarterly and annual side rail screen assessments according to facility policy, and informed consent from the resident or their representative regarding the risks and benefits of bed rail use. This deficiency was identified through observations, record reviews, interviews, and facility policy reviews. The lack of proper documentation and informed consent could potentially put residents at risk for injury or entrapment due to bed rail use. For Resident 32, the facility did not provide documentation of alternative measures utilized prior to the use of side rails. The resident had severe cognitive impairment and was observed with bed rails up on multiple occasions. The side rail assessment form dated 10/02/19 indicated the need for side rails but did not include any recent assessments or informed consent documentation. Similarly, Resident 33, who was cognitively intact, had been using bed rails for nine years without being informed of the risks and benefits. The side rail assessment form dated 08/14/15 was the only documentation provided, and no recent assessments or informed consent were available. Resident 71, who had severe cognitive impairment and physical limitations, was observed with loose and improperly installed side rails. The side rail assessment dated 07/07/22 did not include the risk of entrapment or the specific condition for side rail use. No informed consent was found in the resident's records. Despite the facility's policy requiring side rail assessments upon admission, quarterly, and annually, as well as informed consent, these procedures were not followed for the three residents reviewed, leading to the identified deficiency.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to inform the New Jersey Department of Health (NJDOH) of an abuse allegation within the mandated two-hour period. The incident involved two residents, R73 and R41, and occurred on 05/20/23. The investigation summary provided by the facility revealed that the residents were questioned on 05/22/23, and the investigation concluded on 05/23/23. The report was faxed to the NJDOH on 05/25/23, which was beyond the required reporting timeframe. Interviews with the Social Service Director (SSD) and the Licensed Practical Nurse (LPN) indicated that the abuse protocol was initiated on 05/22/23, and the Director of Nursing (DON) was informed immediately after the incident. However, the Administrator was not informed until the following Monday, and the NJDOH was not notified within the required two-hour window. The facility's policy on abuse and neglect, revised in December 2023, mandates immediate reporting of any abuse allegations to the appropriate authorities. Despite this policy, the facility did not adhere to the required reporting timeframe. The Administrator acknowledged that the NJDOH should have been informed within two hours of the accusation of physical contact between the residents. The reportable event record indicated that the alleged abuse occurred at 4:20 PM on 05/20/23, but the event was not deemed significant and was not called in immediately. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to regulatory requirements.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Elizabeth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elizabeth Nursing And Rehab Center | 0.2 mi | — | 0 | 0 |
| Elmora Hills Health & Rehabilitation Center | 0.5 mi | — | 7 | 0 |
| Trinitas Hospital | 1.6 mi | — | 0 | 0 |
| Cornell Hall Care & Rehabilitation Center | 2.3 mi | — | 0 | 0 |
| Aristacare At Parkside | 2.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.