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Plaza Healthcare & Rehabilitation Center

456 Rahway Avenue, Elizabeth, NJ 07202 · For profit - Partnership · 128 certified beds · (908) 354-1300 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jan 20241 immediate-jeopardy citation1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
517 Rahway Ave · (908) 527-1247 · Call to confirm hours
Pharmacy
Walgreens0.1 mi
401 Rahway Ave · (908) 527-9203 · Call to confirm hours
Grocery
Erico ave · (908) 880-0376 · Call to confirm hours
Park
428 Murray St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.1%8.7%15.4%better
Long-stay residents who lose too much weight3.7%4.6%5.4%better
Long-stay residents with a catheter left in their bladder3.7%0.6%0.9%worse
Long-stay residents with a urinary tract infection0.9%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms11.5%12.1%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.2%2.3%3.3%better
Long-stay residents whose ability to walk worsened3.9%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.3%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%97.2%95.3%typical
Long-stay residents with pressure ulcers9.3%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control2.9%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table17.3%12.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication4.7%1.2%1.4%worse
Short-stay residents given the seasonal flu vaccine91.7%80.1%79.4%better
Short-stay residents rehospitalized after admission26.9%24.9%22.6%worse
Short-stay residents with an outpatient ER visit0.0%8.1%12.0%check this — see note marked star below the table
Long-stay hospitalizations per 1,000 resident days2.742.071.67worse
Long-stay outpatient ER visits per 1,000 resident days0.711.111.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.1%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
80.0%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 80.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 45 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.1%CMS range 33.8–67.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.7–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge80.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge71.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge64.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 4.5–14.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.421.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.50
RN hours/ resident / day
0.79
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.30
Total nurse hours/ resident / day
0.45
RN hoursweekends
30.7%
Total nursing turnover
43.8%
RN turnover

How full it usually is: this home is certified for 128 beds and averages 104.1 residents a day — about 81% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.44 on weekdays — 14% thinner on weekends. RN hours go from 0.51 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

1
deficiencies at the latest standard inspection (2025-06-05)
5
at the previous standard inspection (2024-01-25)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · L2022-03-17 · tag F0678 — failed to provide CPR when needed — widespread
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility's system wide failure to appropriately track and maintain appropriate cardiopulmonary resuscitation certifications, and provide the required emergency response, posed a serious and immediate threat to the health, safety, and wellbeing of all residents who resided in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2022-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The deficient practice was evidenced by the following: 1. On [DATE] at 10:41 AM, the Surveyor observed a resident wandering unassisted in the hallway, holding on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-06-05 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. She further stated that if a brief was found, she removed them and disposed of them in the garbage. The surveyor asked if she needed to wear anything to protect her when handling the dirty linens. She repeated her…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-25 · tag F0909 — failed to maintain a comfortable temperature — pattern
    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: 1. Review of R71's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/23, located in the MDS tab of the electronic medical report (EMR), revealed R71 had an admission date of 07/07/22. There was no Brief Interview for Mental Status (BIMS) score conducted and R71 had severely impaired cognition, R71 had impairment on one side to the upper extremity (shoulder, elbow, wrist, hand) and on the lower extremity (hip, knee, ankle, foot) R71 was dependent with mobility when lying to sitting on the side of the bed. Side rails were not used and R71 had diagnoses of epilepsy and cerebrovascular accident (CVA). Review of R71's side rail assessment provided by the facility, dated 07/07/22, revealed 3. Does the resident has [sic] alternation of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the Investigation Summary provided by the facility, dated 05/23/23, revealed the incident occurred on 05/20/23. The residents were questioned on 05/22/23. R41 had no recollection of the event and stated, I can't fight anybody. How can I hit him? R73 stated he slammed the bathroom door shut, and R41 took offense and began yelling. R73 stated he [R73] opened the door and R41 hit him [R73] in the face. The investigation concluded there was not sufficient evidence to sustain the allegation stating, No visible injury to both residents, and no witness to this incident and therefore unable to determine that there was evidence of any physical altercation. The summary was signed by the then Director of Nursing (DON)2 [no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: Review of R46's undated admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 01/21/21 with medical diagnoses of bipolar disorder and acquired absence of limb. Review of R46's undated admission Record from the EMR Diagnosis tab revealed a diagnosis of insomnia was added on 03/10/21; bipolar disorder in partial remission, most recent episode mixed was added on 01/23/23; the diagnosis unspecified psychosis was added on 10/30/23; and the diagnosis of schizoaffective disorder depressive type was added on 12/08/23. Review of R46's EMR Miscellaneous tab…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of R32's undated admission Record from the electronic medical record (EMR) under the Profile tab, showed a facility admission date of 10/02/19, readmission on [DATE], with medical diagnoses that included bilateral below knee amputation, dementia, macular degeneration, peripheral vascular disease, and anxiety disorder. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/23, located in the MDS tab of the EMR, showed R32 was rarely or never understood and was totally dependent on staff for bed mobility. Review of R32's Care Plan from the EMR Care Plan tab, showed bed rails were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-25 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of R32's undated admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 10/02/19 and readmission on [DATE], with medical diagnoses that included bilateral below knee amputation, dementia, macular degeneration, peripheral vascular disease, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-03-17 · tag F0563 — failed to protect the right to visitors — widespread
    Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. On 03/03/22 at 8:08 AM, upon the Survey team entrance to the facility, the Receptionist was interviewed regarding the process for a visitor upon entrance.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-03-17 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. The Surveyor explained to the RN Staff Educator that the survey team needed to review the performance evaluations and the educational information for the CNAs. On 03/03/22 at 8:35 AM, the facility had not provided the information on the CNA performance…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-03-17 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 g.) Antibiotic Stewardship was being conducted to track and monitor antibiotic use. This deficient practice was evidenced by the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-03-17 · tag F0841 — widespread
    Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). 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). A Doctor's Progress note, dated [DATE] was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · F2022-03-17 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. The LNHA stated that the facility QAPI meeting is held quarterly, and attendance included the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the LNHA, Medical Director (MD), department heads, and vendors such as lab, x-ray, pharmacy consultants etc. He stated that concerns were brought to the QAPI committee's attention by conducting environmental rounds, department…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-03-17 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. A review of the admission Record revealed Resident #206 had been admitted to the facility with diagnoses which included but were not limited to an open wound of the abdominal wall. A review of the admission Minimum Data Set (MDS - an assessment tool), dated 2/28/22, revealed a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-03-17 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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: The admission Record (AR) indicated that Resident #159 was admitted to the facility with the diagnoses which include but not limited to, multiple sclerosis (MS), depression, and seizures. The quarterly Minimum Data Set (MDS) an assessment tool dated 01/06/22, indicated that Resident #159 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-03-17 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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: A physician order script dated 12/22/21 revealed an order for Midodrine (used to increase blood pressure), 5 MG (milligram), 1 tab by mouth twice daily on hemodialysis days. A Pharmacist Note dated 02/24/22 at 10:13 AM,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-03-17 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Upon further inspection of the plastic bins, the surveyor observed that the bins had multiple individual bags of resident personal medications from multiple un-sampled residents who either discharged to home or who were deceased and were mixed in with with intravenous (IV) tubing supplies and dressings. The surveyor found the following: 1.) .9% sodium chloride (NaCl) IV 100…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-03-17 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. The in-services provided did not include the in-service length of time or who presented the in-services. The in-services were as follows: 1/13/21: Infection control, handwashing, standard & transmission base precautions, isolation, PPE [personal protective equipment]. 2/10/21: pain management,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. The surveyor observed that Resident #259's bed remote that was hanging off of the bed and it was touching the floor. The surveyor then asked Resident #259 where his/her call bell was so he/she could call the nurse for help. Resident #259 then shrugged his/her shoulders. The Surveyor…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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: Resident reported to writer that resident across the hall from his/her room hit him/her on the left forehead with a cane when he/she went to the residents' room at 5pm to approach him for taking his snacks from the TV room. On 03/01/22 at 11:00 AM, the Surveyor requested the Director of Nursing (DON) provide the Surveyor with any incidents that were required to be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Resident #60 stated, [referred to the roommate] touched me inappropriately, and I hit him/her with the reacher on the shoulder. On 02/28/22 at 12:50 PM, the Surveyor reviewed the nurse Progress Notes and was unable to locate documentation…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. On 03/03/22 at 9:10 AM, the direct care Certified Nursing Assistant (CNA) stated the resident needed total care, was incontinent, and that his/her feet were swollen and dent when they are touched. A review of the resident's medical record revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Resident #258 then stated that the nurse was going to call the pharmacy at 8 AM and get the medicine stat (at once). At 8:41 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that she called the pharmacy at 8 AM…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. -The admission Record (AR) indicated that Resident #61 was admitted to the facility with the diagnoses that included but were not limited to diabetes mellitus (DM), anxiety disorder, and unspecified psychosis. -The quarterly Minimum Data Set (MDS) and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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). A Doctor's Progress note, dated 02/02/22 was reviewed which revealed K+ 6.2? (elevated blood potassium level and a Plan Continue Monitor, Repeat CMP (Comprehensive Metabolic Panel) and PTH (Para-Thyroid Hormone). The Physician's Orders dated 02/02/22 revealed an order for a CMP and PTH on Friday and the order was noted on 02/02/22 and signed by a Registered Nurse. A NN dated 02/03/22, at 15:21…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-03-17 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. A review of Resident #206's medical records revealed the following: An admission Record revealed Resident #206 had been admitted to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-17 · tag F0888 — isolated
    Ensure staff are vaccinated for COVID-19
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. The documents revealed a total of 101 staff designated as Direct Facility Hires which the surveyor observed did not include the name of the facility medical director and other providers. At that time the RNIP stated she wanted to review the list. On 03/01/22 at 1:37 PM, the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2024-04-25 for 7 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
FISHMAN GROUP LLCOrganizationDIRECT OWNERSHIP INTERESTsince 01/01/2024
FISHMAN, BENZIONIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
FISHMAN, MORDECHAIIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
FISHMAN, ZEVIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNFsince 12/01/2013
PLAZA NURSING & CONVALESCENT CENTER INC.Organization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2004
KARELITZ, SHLOMOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2024
SALUJA, RUBYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2004
FISHMAN, NATHANIndividualADP OF THE SNFsince 01/01/2004

CMS files one row per role, so the 17 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$10.0M
Net patient revenuemost recent cost report
-19.5%
Operating marginrevenue minus expenses
$1.7M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 88%Medicare 8%Other / private 4%

About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$390per resident / day
operating cost
$11,841per month
≈ monthly operating cost
$326per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315483. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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