Plaza Healthcare & Rehabilitation Center

Inspectors wroteBased on observation, interview, and a review of facility documentation, it was determined that the facility failed to ensure laundry staff had the proper personal protection equipment (PPE) necessary to handle linens to prevent the spread of infection. This deficient practice was evidenced by the following: On 6/4/25 at 11:10 AM, the surveyor toured the laundry room along with the Infection Preventionist (IP). Upon entry to the clean laundry area, two laundry aides were emptying a dryer. The laundry room consisted of an area with two front loading washers, both which were running. There was another area with three dryers and room for folding laundry. The surveyor asked the laundry aides, what they needed to do when loading the dirty laundry into the washers. The aide explained that sometimes she finds disposable briefs in the wash when emptying the washer into the dryer. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have an ongoing monitoring of bed side rails as part of their routine maintenance program for one of one resident (Resident (R)71) of 35 sample residents and 86 of 87 occupied beds reviewed for side rails.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to inform the New Jersey Department of Health (NJDOH) of one of two abuse allegations reviewed for Resident (R)73 and R41 on 05/20/23 within the mandated two-hour period of 35 sample residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of five residents (Residents (R) 46) reviewed for Pre-admission Screening and Resident Review (PASARR) had a PASARR level one updated upon receipt of a new serious mental health diagnoses not previously identified of 35 sample residents. This failure placed residents at risk for unmet care needs and not receiving appropriate and necessary mental health support/services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan with goals and approaches for three of three residents (Residents (R) 32, R33, and R71) reviewed for side rail use; and one of three residents (R71) reviewed for limited range of motion of 35 sample residents.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure that three of three residents (Resident (R) 32, R33, and R71) reviewed for bed rail use of 35 sample residents had attempted alternatives documented, quarterly and annually side rail screen assessments completed according to facility policy, and the Resident or Resident Representative (RR) were advised of the risks and/or benefits of rail use with an informed consent signed prior to the installation of the bed rails. This failure had the potential for the resident, or the RR be uninformed of the risks associated with bed rail use and could put the residents at risk for injury or entrapment.

Inspectors wroteBased on interviews, record review, and document review, it was determined that the facility failed to ensure: 1.) the emergency response system was activated to call a code, 2.) 911 was enacted, 3.) the automatic external defibrillator (AED) was utilized for a resident who was found unresponsive (Resident #7) and was a full code status (all resuscitation procedures will be provided when a person stops breathing or heart stops beating). This deficient practice occurred for 1 of 3 residents (Resident #7) reviewed for unexpected deaths and 4.) failed to ensure a system was in place to appropriately track and maintain cardiopulmonary resuscitation (CPR) certifications to ensure that staff maintain the appropriate CPR certification. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility 1.) failed to ensure: that the facility policy for Accident/Incident Reports was followed to determine the causal factor and to update interventions to prevent recurrent falls, for a visually impaired ambulatory resident who was identified as a high fall risk, and sustained multiple falls, including a fall that resulted in a head injury on [DATE], and 2.) failed to ensure; that the emergency crash cart (a set of trays /drawers /shelves on wheels) used for transportation and dispensing of emergency medications and equipment, was secured and not easily accessible to residents and non-licensed staff. The deficient practice occurred for 1 of 2 residents (Resident #57) reviewed for falls and for 1 of 2 crash carts inspected (2nd floor). [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the facility visitation process did not restrict visitation as per executive directive from Center for Medicare Services (CMS) QSO-20-39-NH revised 11/12/2021. This deficient practice was identified for 1 of 18 residents (Resident #5) reviewed. The deficient practice was evidenced by the following: On 02/28/22, at 9:45 AM the surveyor toured the second floor of the facility. Resident #5 approached the surveyor and requested information regarding visitation. On 02/28/22 at 10:28 AM, during the entrance conference with the Administrator (LNHA) and the Director of Nursing (DON), the DON stated that visitors must be tested for COVID-19. The LNHA interjected, and stated, that the visitor was not forced to test. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, it was determined that the facility failed to conduct performance evaluations in a timely manner and to provide documented education for areas of improvement identified on the performance evaluations, for 4 of 5 Certified Nursing Assistants (CNA #1, #2, #3, and #5) reviewed. This deficient practice was evidenced by the following: On 03/02/22 at 8:13 AM, the Surveyor requested the CNA performance evaluations and education information from the Registered Nurse (RN) Staff Educator. On 03/02/22 at 10:11 AM, the RN Staff Educator provided the Surveyor with some CNA competencies and nothing else. The RN Staff Educator stated that the in-services she had provided the surveyor are the yearly education for all CNAs. The Surveyor explained there was missing information. [...]

Inspectors wroteBased on observation, interview, and policy review it was determined that the inactions in administration of the facility contributed to the facility failure to ensure: a.) the visitation process did not restrict visitation and complied with executive directive from Center for Medicare Services (CMS) QSO-20-39-NH revised [DATE], b.) allegations of abuse were investigated and reported to the State Survey Agency (SSA), c.) the facility followed the facility Policy and Procedure (P&P) for Abuse Identification and Prevention, d.) a system for staff education and monitoring for Basic Life Support/CPR was in place after an adverse resident event occurred, e.) that nurse aides received the minimum required number of in-service hours and annual performance evaluations, f.) the facility developed quantitative and measurable goals for Quality Assessment and Performance Improvement (QAPI) , and [...]

Inspectors wroteBased on interview, clinical record review and review of other pertinent facility documentation it was determined that the facility Medical Director (MD) failed to provide clinical oversight and guidance regarding resident care policies and procedures that affect resident care, medical care, and resident quality of life related to 1.) laboratory results 2.) staff training and certifications for basic life support/cardiopulmonary resuscitation (CPR) and 3.) antibiotic stewardship. This deficient practice was evidenced by the following: 1.) On [DATE] at 12:51 PM, the Surveyor reviewed the closed medical record for Resident #7 which revealed: A Licensed Practical Nurse (LPN #1) documented a Nurses Note (NN) on [DATE] at 16:05 (4:05 PM). [...]

Inspectors wroteBased on interview and document review, it was determined that the Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the Facility Performance Improvement Plan to; a.) ensure a system for staff training and monitoring for Basic Life Support/CPR was in place after an adverse resident event occurred, and b.) follow the facility process to measure the utilize data acquired for pressure ulcer quality improvement and develop quantitative and measurable goals. This deficient practice was evidenced by the following: a.) (Refer to 678 L) b.) On 03/11/22 at 9:08 AM, the Surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the facility process for QAPI. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to monitor and track resident antibiotic use for 3 of 3 months (January 2022, February 2022, and March 2022) reviewed for Antibiotic Stewardship. This deficient practice was evidenced by the following: The survey team entered the facility on 02/28/22. The facility was asked to provide information for review which included the Antibiotic Stewardship tracking. The survey team was provided daily with an Antibiotic Stewardship log book dated 2021. On 02/28/22 at 10:15 AM, Surveyor #2 observed Resident #206 lying in bed and a yellow container of Personal Protective Equipment (PPE) hanging on the door. [...]

Inspectors wroteBased on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to consistently perform interventions designed by an Occupational Therapist to promote range of motion and positioning for 2 of 2 residents (Resident #159 and #259) who were reviewed for positioning and mobility. The deficient practice was evidenced by the following: On 02/28/22 at 10:16 AM during tour, the Surveyor interviewed Resident #159 who was sitting up in bed. Resident #159 stated that he/she wanted to be able to walk, however he/she did not receive rehabilitation and wanted to know why. He/she stated that he/she got of bed to chair daily and did not walk. The surveyor reviewed Resident # 159's medical record which revealed the following: [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to: a.) administer medications in accordance with physician orders to coordinate with dialysis days, and b.) follow-up on recommendations from the hemodialysis center for 1 of 2 residents who received dialysis treatments (Resident #3). The deficient practice was evidenced by the following: On 03/01/22 at 10:08 AM, the Surveyor conducted an interview with Resident #3 in the resident's room. The resident stated that he/she attended dialysis on Monday, Wednesday and Friday at 1:45 PM. Resident #3 stated he/she had been going to the dialysis center on Monday, Wednesday and Friday a few months ago. Resident #3 stated that prior to that, he/she used to go to dialysis on Tuesday, Thursday and Saturday. The Surveyor reviewed the medical record for Resident #3 and the following was revealed: [...]

Inspectors wroteBased on observation, interview and review of other pertinent facility documentation, it was determined that the facility failed to: 1.) ensure that expired medications and supplies were removed from two medication rooms and two unit emergency carts, and 2.) ensure the temperatures were monitored daily for 1 of 2 unit (1st floor) medication refrigerators. This deficient practice was identified for 2 of 2 units and was evidenced by the following: 1) On 03/01/22 at 9:01 AM, Surveyor #1 inspected the medication storage room on the 2nd floor. The surveyor observed that there were plastic bins in the medication storage room filled with supplies. [...]

Inspectors wroteBased on interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the mandatory 12 hours of in-service education. This deficient practice was identified for 4 of 5 Certified Nursing Assistants (CNA #1, #2, #3, and #4) reviewed. This deficient practice was evidenced by the following: A review of the facility provided, CNA Certification Log, dated 02/28/22, included a list of the employed CNAs and their hire dates. The log revealed the following hire dates: CNA #1 09/14/2018 CNA #2 08/27/1987 CNA #3 03/05/2001 CNA #4 09/01/2008 On 03/01/22 at 1:39 PM, the Registered Nurse (RN) Staff Educator provided the requested CNA in-services. The RN Staff Educator stated that the in-services she had provided were the yearly education for all the CNAs. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to maintain resident call bells that were accessible and within reach of all residents. This deficient practice occurred for 1 of 18 residents reviewed (Resident #259) and was evidenced by the following: On 02/28/22 at 10:48 AM, the Surveyor observed Resident #259 lying in bed with heel booties on. The surveyor observed a flat tap call bell draped over the resident's bed side rail and was within the resident's reach. On 03/01/22 at 8:36 AM, the Surveyor observed Resident #259 lying in bed and was wearing heel booties. The Surveyor interviewed Resident #259 at that time who stated that he/she was not good because he/she could not reach the remote control for the bed. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) report to the New Jersey Department of Health (NJDOH) an allegation of resident to resident abuse, and b.) develop the facility's Policy on Resident Abuse policy in accordance with federal and state requirements for the timing of reporting such allegations of abuse to the state agency. The deficient practice was identified for 1 of 2 investigations of reportable incidents reviewed (Resident #258) and was evidenced by the following: On 02/28/22 at 11:34 AM, the Surveyor reviewed Resident #258's electronic Progress Notes (ePN) which included the following note dated 02/08/22 at 6 PM: [...]

Inspectors wroteBased on interview, record reviews and review of pertinent documents, it was determined that the facility failed to complete a thorough and timely investigation for an allegation of abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and Resident #258). The deficient practice was evidenced by the following: During the initial tour of the facility on 02/28/22 at 10:23 AM, the Surveyor observed Resident #60 who was awake and alert and was lying in bed. The Surveyor observed a reach extender (handheld mechanical tool used to increase the range when grabbing objects) located on the bed and was next to the resident. Resident #60 stated that he/she was moved to that room last night following an altercation with the former roommate. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to review and revise a resident's Care Plan for antibiotic use with infection. This deficient practice was identified for 1 of 20 residents (Resident #208) reviewed for Care Plans and was evidenced by the following: 1) On 02/28/22 at 9:41 AM, the Surveyor toured the first floor unit and observed Resident #208 lying in bed. Resident #208 pulled up his/her bed sheet and pointed at their feet. The Surveyor observed both feet were swollen and red in color. On 03/03/22 at 8:22 AM, Resident #208's direct care Licensed Practical Nurse (LPN) stated the resident needed help with getting to the bathroom, care, tube feeding, also was ordered pleasure foods, and encouragement to keep feet elevated because of swelling. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to: 1.) follow professional standards of practice and facility policy when altering a Medication Administration Record (MAR) and Physician's Order (PO) sheet, and 2.) ensure physician ordered medications were administered and entered correctly into the MAR. This deficient practice was identified for 2 of 7 residents (Resident #258 and #5) reviewed during a medication administration observation and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to a) provide a resident a physician ordered routine pain medication within the acceptable time; b) administer a routine pain medication as ordered by the physician, and c) accurately document the administration of narcotic medication for 1 of 18 sampled residents (Resident #258). This deficient practice was evidenced by the following: On 03/02/22 at 8:27 AM, the Surveyor observed Resident #258 seated in a wheelchair in the resident's room. Resident #258 was moaning. Resident #258 stated that he/she did not receive the pain medication that was ordered for 8 AM. Resident #258 stated that the facility ran out of the medication and that the medication was supposed to come last night from the pharmacy. [...]

Inspectors wroteBased on observation, interview, clinical record review, and review of other pertinent facility documentation it was determined that the facility failed to provide consistent behavioral health services for attainment or maintenance of a resident's highest practicable well-being. This deficient practice was identified for 1 of 2 residents reviewed (Resident #61) and was evidenced by the following: On 02/28/22 at 12:20 PM, the Surveyor observed Resident #61 on the 2nd floor unit. The resident was agitated and loudly yelled for someone to get out of his/her room. On 02/28/22 at 12:21 PM, the Surveyor reviewed Resident #61's clinical record which revealed the following information: -The physician order sheet reflected that the Resident #61 was on the antipsychotic medication Risperdal 0.25 mg (milligram) at HS (night) for agitation. [...]

Inspectors wroteBased on interview, and closed record review it was determined that the facility failed to order the appropriate physician ordered laboratory test for 1 of 2 closed medical records reviewed for physician orders (Resident #7) and was evidenced by the following: On 03/02/22 at 12:51 PM, the Surveyor reviewed the closed medical record for Resident #7 which revealed: A Licensed Practical Nurse (LPN #1) documented a Nurses Note (NN) on 02/12/22 at 16:05 (4:05 PM). The admission record for Resident #7 revealed the resident was admitted to the facility with diagnoses which included, but were not limited to, hyperkalemia (high potassium level) and malignant neoplasm of the prostate (prostate cancer). [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure: 1.) staff wore the required personal protective equipment (PPE) in resident rooms that required transmission-based precautions (TBP), and 2.) staff performed hand hygiene in accordance with the Centers for Disease Control and Prevention (CDC) and per the facility policy. This deficient practice was identified for 2 of 2 residents (Resident #206 and #209) reviewed for TBP, and identified for one staff member during the medication pass administration. The evidence was as follows. 1. a.) On 02/28/22 at 10:15 AM, Surveyor #1 observed Resident #206 lying in bed and a yellow pocket holder with personal protective equipment (PPE) was hanging on the door. There was no signage on the door to see the nurse or what type of TBP was in place. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure that the Mandatory COVID-19 Vaccine Policy and Procedure was implemented to track and document the vaccination status for all facility staff. The deficient practice was evidenced by the following: On 03/01/22 at 9:40 AM, the Surveyor reviewed the National Healthcare Safety Network (NHSN) data regarding the facility reported percentage of fully vaccinated staff for the week ending 02/06/22. The facility reported the percentage of staff fully vaccinated was 94.2 %. On 03/01/22 at 12:30 PM, the Registered Nurse, Infection Preventionist (RNIP), confirmed she was responsible for the facility vaccination process. At that time the RNIP provided the surveyor with the COVID-19 Staff Vaccination Status for Providers. [...]