Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palace Rehabilitation And Care Center, The during CMS and state inspections, most recent first.
Kitchen Sanitation and Food Storage Deficiencies: The FSD and RLNHA were observed with multiple sanitation issues in the kitchen, including red and brown substance on the ice machine guard, a scoop stored inside a bin of rice, a flour bin lid smeared with black and brown substance, a dented can of cranberry sauce, black debris on a can opener blade, and pasta with yellow brown sediment in the steam table water. The FSD stated the steam table needed to be emptied, and no kitchen cleanliness policy was provided when requested.
Uncovered dumpsters and debris were observed in the garbage area behind the kitchen. During a kitchen tour, a surveyor found 2 of 4 dumpsters with open lids, cardboard boxes on the ground, and papers and paper cups scattered in the grassy area behind the building. The FSD and RLNHA stated that dietary and housekeeping staff were responsible for keeping the area clean, and no policy for the outside dumpster area was provided.
Delayed Records and Inaccurate Staffing Documentation: The LNHA, DON, and other leadership staff failed to provide immediate access to employee personnel and medical files and repeatedly submitted inaccurate AAS-11 and AAS-12 staffing forms. The survey team initially received only the personnel portion of the files, later found missing reference checks, background checks, license verification, and incomplete health physicals in new hire records, and continued to receive forms with inconsistent numbers and missing daily census information despite multiple corrections.
A facility failed to provide written notice to residents with PNA balances nearing the Medicaid/SSI resource limit. Eleven residents had balances ranging from about $1,877 to $2,316, and staff said they reviewed statements quarterly and used purchases or prepaid funeral arrangements to spend down funds, but there was no documentation of written notification when balances were approaching $2,000. The DSS and LNHA acknowledged that written notice should have been provided, while the facility policy did not include that requirement.
Survey results were not readily accessible to residents, families, or the public. During a resident council meeting, alert and oriented residents said they did not know where the State survey results were located and had not been told about them. On unit tours, staff had difficulty locating the survey books, one unit had no book available, the books that were found were outdated, there were no signs directing residents to them, and the lobby copy was behind a locked door requiring a code to enter.
Bathroom Light Out for Resident Room: A resident in a semiprivate room on the C Wing reported that the bathroom light was not working, and the surveyor observed the light switch did not turn on the ceiling light and there was no cover on the fixture. The resident, who used a rolling walker, said maintenance knew about the issue but had not fixed it, and later stated it was hard to use the bathroom at night. The maintenance log documented the problem, but the repair section was blank, and staff could not provide documentation of the ordered light or a homelike environment policy.
Pre-employment screening records were missing for multiple newly hired staff members. Review of personnel files found that several CNAs, RNs, the LNHA, a smoke aide, and a housekeeper lacked evidence of required reference checks, license or certification verification, or criminal background checks before starting work. The LNHA stated onboarding was supposed to include these checks before orientation, and the facility policy required review of past histories through registry, licensing, and reference checks.
Inaccurate MDS Fall Assessment: A resident with dementia, severe cognitive impairment, abnormal gait, and a history of falls had a quarterly MDS that recorded zero falls despite multiple documented falls in the look-back period. A CNA was observed providing doorway observation due to the fall history, and the MDSC acknowledged the falls should have been included on the quarterly MDS but were missed.
Care Plan Not Revised After Tube Feedings Ended: A resident with dx including dementia, bipolar disorder, anxiety, failure to thrive, and a gastrostomy tube was observed not receiving tube feedings and had no feeding pump in the room. Although active orders showed a regular diet and oral supplement, the ICCP still listed tube feeding-related interventions and a feeding tube focus. The MDS still indicated a feeding tube and therapeutic diet, and an LPN stated resolved care focuses should be revised in the care plan.
The facility did not ensure the daily nurse staffing sheet was updated and posted each day in a public area. Surveyors observed the lobby staffing sheet was outdated, and both the SC and LNHA stated the sheet was required to reflect changes and be posted daily. The facility could not provide a written staffing policy for daily postings.
An LPN dispensed the wrong calcium medication for a resident during med pass after only reading part of the physician order. The resident had dementia and severely impaired cognition, and the ordered medication was calcium citrate-vitamin D, but the LPN gave calcium citrate 200 mg instead. The error was identified before the medication was administered, and the LPN could not initially locate the correct OTC medication in the cart.
A resident with COPD and intact cognition had a nebulizer medication vial left on the bedside table, where it was accessible outside of a locked compartment. The resident stated he/she gave breathing treatments after nurses left the medication, while the RN/UM and LPN acknowledged the resident was not care planned to self-administer medications and that the medication should not have been left at the bedside.
Failure to Follow Planned Menus: Staff did not follow the posted meal menus for lunch and breakfast. The lunch menu called for baked chicken, macaroni and cheese, and roasted zucchini, but staff prepared fried chicken and different vegetables. The breakfast menu posted on the units listed orange juice, farina, an egg and spinach frittata, an apple cinnamon muffin, whole milk, and coffee, but staff and a resident reported scrambled eggs, bacon, an English muffin, coffee, and milk instead. The RD stated menu changes may affect nutritional analysis, and the RLNHA said the facility found a kitchen fault causing incorrect meals/menus.
Licenses Not Visibly Posted: Surveyors found that the current MD and LNHA licenses were not visibly displayed in the main hallway as required. Staff, including the DON, DSS, and LNHA, acknowledged the licenses were not posted at the time of the tour, and a copy of a previous MD's license was instead seen on a bulletin board in the copier room. The LNHA stated the bulletin with the licenses had been taken down for a new time clock installation and confirmed the licenses should have been visible to the public before surveyor inquiry.
An LPN failed to perform hand hygiene before and after administering medications to three residents during a med pass, despite facility policy requiring hand hygiene before preparing medications and after resident contact. The facility also left a resident's nebulizer mask exposed on a bedside table instead of storing it in a labeled plastic bag as required by policy. Staff interviews confirmed the expected infection control practices, and the resident involved in respiratory care had COPD and intact cognition.
Hot water temperatures in one unit were found to be dangerously high, with measurements between 137.1°F and 138.4°F in resident rooms and the shower room. Staff confirmed the excessive heat, and residents reported using the water to make hot beverages and instant soup. The unit included cognitively impaired residents, and temperature logs were incomplete, with no written policy in place. The deficiency was identified after a recent fire and utility restoration, with staff denying prior issues.
The facility was cited for deficiencies in food storage, preparation, and labeling, which could lead to food-borne illnesses. Observations included improperly dated produce, unclean kitchen equipment, incomplete dishwashing logs, expired and infested food items, and unlabeled resident food in the pantry. The FSD and staff acknowledged these issues, which were not in compliance with the facility's policies.
A surveyor found a black substance on the ceiling of the Central Supply room, which the RLNHA and Maintenance Assistant attempted to cover with paint. The staff responsible were unaware of the issue, and the facility lacked a specific policy for maintaining a safe and sanitary environment.
The facility failed to report an alleged misappropriation of resident property to the NJDOH. Two residents had discrepancies in their medication records, with pain medications signed out but not documented as administered. An investigation involving three LPNs found the drug diversion allegations unsubstantiated, but the facility did not report the investigation to the NJDOH. Facility leadership assumed the issue was resolved and believed the ombudsman had informed the state.
A facility failed to investigate an allegation of misappropriation of a resident's pain medication. The resident, with moderately impaired cognition, reported consistent access to pain medication, but records showed discrepancies. On a specific date, two Percocet tablets were signed out without proper documentation or investigation. The facility's policy mandates investigation of such allegations within 24 hours, which was not adhered to, resulting in a deficiency.
A facility failed to maintain accurate medical records for two residents regarding pain medication administration. One resident's MAR lacked documentation of pain levels and medication administration for several dates, and the Individual Patient's Controlled Drug Record was incomplete. Another resident's records showed similar issues, with missing documentation for Oxycodone administration. Facility staff confirmed the policy to maintain records per regulations, but acknowledged missing records, leading to a deficiency citation.
A resident with a history of tobacco use and cognitive impairment repeatedly violated the facility's smoking policy, but their care plan was not updated to reflect these incidents. The resident was observed smoking unsafely, sharing cigarettes, and possessing unauthorized smoking materials. Despite these violations, the care plan was not revised, contrary to the facility's protocol requiring updates after each infraction.
The facility failed to provide adequate supervision during resident smoking sessions, leading to safety concerns for two residents. A resident with cognitive impairment and physical limitations was observed smoking without proper safety measures, resulting in a burn hole in their clothing. Smoking aides lacked clear guidance and documentation on resident needs, leading to violations of the facility's smoking policy.
A resident with renal dialysis dependence experienced incomplete documentation in their dialysis communication book. The facility's protocol required the dialysis center to fill out a communication tool, and nurses were to follow up if it was not completed. However, on several occasions, the dialysis center did not complete their section, and the facility staff failed to document any follow-up actions to obtain the necessary information.
A resident with paroxysmal atrial fibrillation was administered Cardizem despite physician orders to hold the medication if systolic blood pressure (SBP) was below 130 mm Hg. The medication was given multiple times with SBP readings below the threshold, even after a pharmacy consultant noted the error. Interviews with the DON and RDON confirmed the need to follow medication orders.
A facility failed to maintain infection control practices for a resident on Enhanced Barrier Precautions (EBP) due to staff not donning appropriate PPE. The resident had pressure ulcers and required staff to wear a gown and gloves during wound care. However, an RN entered the room without a gown, citing the absence of a PPE supply bin as a reason for the oversight. The DON confirmed the RN should have worn a gown, as per the facility's EBP policy.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain kitchen and equipment areas in a manner to prevent microbial growth and cross contamination. During a kitchen tour with the Food Service Director (FSD) and the Regional Licensed Nursing Home Administrator (RLNHA), the surveyor observed red and brown substance on the white plastic ice guard in the ice machine, and the paper towel used to wipe it also had red and brown substance on it. The ice machine cleaning log showed the machine was cleaned weekly, with the last cleaning documented on 2/9/26, and the RLNHA stated that weekly cleaning was not sufficient based on what was observed. Additional observations in the kitchen and dry storage area included a large bin of rice with the scoop stored inside the rice, a large flour bin lid with a large amount of black and brown substance smeared on top, a 7-pound can of cranberry sauce with a large dent, and a can opener blade with a large amount of black debris when lifted from its holder. During tray line temperature checks, the surveyor also observed a large amount of rectangular shaped pasta and yellow brown sediment in the water of the steam table, even though pasta was not being served that day. The FSD stated, "We have to empty that," and no policy regarding kitchen cleanliness was provided when requested.
Uncovered Dumpsters and Debris in Garbage Area
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public by not keeping the garbage container area free of debris and by leaving 2 of the 4 outside dumpsters uncovered. During a kitchen tour with the Food Service Director and the Regional Licensed Nursing Home Administrator present, the surveyor observed four dumpsters located behind the kitchen, with two lids open. The surveyor also observed multiple cardboard boxes on the ground in front of the dumpsters and multiple debris items, including papers and paper cups, scattered on the ground in the grassy area to the right of the dumpsters and behind the building. The Regional Licensed Nursing Home Administrator and the Food Service Director stated that both dietary staff and housekeeping staff were responsible for keeping the area clean, and no policy regarding the outside dumpster area was provided.
Delayed Records and Inaccurate Staffing Documentation
Penalty
Summary
The facility failed to provide immediate access to records and requested information necessary to conduct the survey. During the entrance conference, the LNHA, in the presence of the DON, Regional LNHA, and Regional DON, was informed that the survey team required all employee personnel and medical files for staff hired or terminated since the last recertification, and the LNHA was also asked to complete and return the AAS-11 and AAS-12 staffing forms by the next day. When the survey team began reviewing the employee files, the medical files were not available, and the DSS stated that the IP kept the health files and that the survey team had only received the personnel portion of the employee files. The full employee files were later reviewed, and the survey team found missing reference checks, background checks, license verification, and incomplete health physicals in new hire records. The staffing forms were also repeatedly inaccurate. The AAS-11 and AAS-12 forms submitted by the SC and signed by the DON contained inconsistent numbers, were returned for correction, and were resubmitted multiple times with continued data-entry errors. Even after the surveyor met with the LNHA, DON, and SC to identify the inconsistencies and the SC corrected the data in the surveyor’s presence, the emailed forms were still inaccurate. The final version was returned with the DON’s signature, but the daily census was missing from the forms. The LNHA stated that she was responsible for everything and the overall function of the facility, and the Administrator job description identified responsibility for directing day-to-day functions, representing the facility to outside agencies, making routine inspections, and ensuring appropriate employee documentation was filed.
Failure to Provide Written Notice for PNA Balances Near Medicaid/SSI Limit
Penalty
Summary
The facility failed to ensure that all residents with a Personal Needs Account (PNA) received a written notification when their balances were approaching the limit that could affect Medicaid or SSI eligibility. This deficiency involved 11 of 11 residents reviewed for PNA, whose quarterly statement balances ranged from $1,877.71 to $2,316.28, with pending balances on the facility’s trial balance ranging from $1,800.25 to $1,800.71. The facility’s Director of Social Services stated that quarterly PNA statements were provided to residents and/or representatives and that the facility used resident funds to purchase clothing or prepay funeral arrangements to spend down balances, but there was no documentation showing that written notifications were provided when balances were nearing the limit. During interviews, the Director of Social Services stated she did not document written notification in the resident chart and that she simply reviewed the statements quarterly and purchased items when the balance was approaching $2,000.00. The Regional LNHA stated he was unsure whether written notification existed and later acknowledged that a written notification should have been provided when the balance was approaching $2,000.00. The facility’s PNA policy, revised July 2025, did not include a written notification requirement, although the regulations provided by the facility stated that when the NF is handling the PNA, it must closely monitor the account and inform the beneficiary and/or representative when the amount comes within $200.00 of the resource eligibility cap.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to residents, families, and the public. During the Resident Council Meeting on 2/18/26, five alert and oriented residents stated they were not aware of the location of the State Survey results, had not been spoken to about the results, and were interested in reading the reports. On 2/19/26, the surveyor toured the A-Wing, B-Wing, and C-Wing units and found that the State Survey Book was not readily accessible on the units. Staff had difficulty locating the book on the A-Wing and B-Wing, and UM/LPN #1 and staff on the C-Wing were unable to locate it. When the books were found, the most recent survey results were not current and were dated 6/5/23. There were no signs posted to direct residents to the location of the State Survey results, and the survey book in the front lobby was not readily accessible because the door between the lobby and residents' units was locked and required a four-digit code. During an interview on 2/24/26, the LNHA was informed that the survey results were behind the nurse's station and not readily accessible without asking staff, and that only two of the three units had survey result books and they were not current.
Bathroom Light Out for Resident Room
Penalty
Summary
The facility failed to maintain a resident bathroom in a safe, clean, comfortable, and homelike environment by not providing adequate lighting in a semiprivate room on the C Wing. During an initial tour, the surveyor observed Resident #87 sitting on the side of the bed and was told the bathroom light did not work. The surveyor entered the bathroom, observed there was no cover on a ceiling light, and found that turning on the switch did not activate the light. Resident #87 used a rolling walker to ambulate and stated that maintenance was aware of the problem and had not fixed it yet, estimating the light had been out for about two weeks. On a later interview, Resident #87 stated the light still had not been fixed and said it was pretty hard going to the bathroom at night. Facility staff described a maintenance log process in which issues were written down and checked daily, and the maintenance technician stated he reviewed the book each morning and several more times each day. The maintenance book showed an entry from 2/9/26 documenting the bathroom light being out in Resident #87's room, but the repair/sign-off column was blank. The maintenance technician stated the facility was waiting on an order for the light and that the plan was to get another light in the meantime, but no order was provided to the surveyor. The LNHA stated the facility did not have a policy for homelike environment, and the facility was unable to provide an invoice for the light ordered on 2/9/26.
Pre-employment screening records missing for newly hired staff
Penalty
Summary
The facility failed to ensure newly hired employees were properly screened for a history of abuse, neglect, exploitation, or misappropriation, and failed to follow its pre-employment screening policies and procedures. During review of 55 personnel files for employees hired since the last annual recertification survey, surveyors found that 10 files lacked evidence that required license verifications, reference checks, or criminal background checks were completed before the employees started work. The missing documentation involved CNAs, RNs, the LNHA, a smoke aide, and a housekeeper, with deficiencies noted for Employees #1 through #10. The surveyor requested personnel files and related hiring documentation, including department of hire, date of hire, license verification, reference checks, criminal background checks, and pre-employment medical records. The LNHA stated that onboarding was supposed to include employment application review, verification of references, vaccination records, applicable licenses, and a criminal background check before orientation, and that all documentation had to be completed before an employee worked on the floor. The facility policy titled Residents/Patient rights-Abuse, Neglect, Mistreatment, or Misappropriation of Resident/Patient's Property, revised July 2025, stated that the facility would be thorough in investigating past histories of individuals hired through inquiry of the State Aide Registry, licensing authorities when appropriate, and reference checks.
Inaccurate MDS Fall Assessment
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for a resident with a history of falls. Resident #79 was admitted with diagnoses including dementia, chronic kidney disease, abnormal gait and mobility, and falls, and had a BIMS score of 00 out of 15, indicating severe cognitive impairment. The quarterly MDS documented zero falls since admission in section J1800, even though the resident had documented falls on 4/5/25, 4/18/25, 5/2/25, 11/12/25, 12/20/25, and 1/8/26. The resident also had an ICCP focus for falls that was initiated after the first fall and revised after each subsequent fall with new fall-prevention interventions. During observation, the resident was seen in bed with a fall mat on one side of the bed and the other side against the wall. Later, a CNA was observed sitting in a chair in the doorway and stated she was there to observe the resident because of the fall history. When the MDS Coordinator reviewed the record, she stated that falls should be included on the quarterly MDS as a quarter look-back and acknowledged that falls should have been included on the 12/24/25 quarterly MDS, but said she did not know how she missed them. The facility did not have an MDS policy available for review.
Care Plan Not Revised After Tube Feedings Ended
Penalty
Summary
The facility failed to revise an Individual Comprehensive Care Plan for a resident who was no longer receiving tube feedings. Resident #164 had diagnoses including bipolar disorder, gastrostomy tube, dementia, anxiety, and failure to thrive. On observation, the resident was in bed in the room and was not receiving tube feeding, and there was no feeding pump in the room. The Physician Order Summary Report showed active orders for a regular diet, regular texture, thin consistency, super cereal at breakfast, and Ensure Plus by mouth three times daily, but no orders for tube feeding formula. There was also an active order to cleanse the feeding tube site daily and cover it with a drain sponge. The ICCP still contained a focus for the need for a feeding tube and resident refusal of feedings at times. The care plan, initiated on 5/15/23 and last revised on 10/22/24, continued to include interventions for administering tube feeding formula, hydration, and flushes per orders, and encouraging compliance with tube feedings, hydrations, and flushes as ordered. The quarterly MDS dated 12/7/25 indicated severe cognitive impairment, and Section K marked that the resident had a feeding tube and received a therapeutic diet. During interview, the UM/LPN stated that when a care focus was resolved, such as a completed tube feeding, the care plan would be revised to include it as resolved. The facility's Interdisciplinary Care Planning Protocol policy stated that nursing provides overview of medical and nursing care regimes and problems established by the team with resident/family input must be specific and individualized, but the policy did not address care plan revisions.
Failure to Post Updated Daily Staffing Information
Penalty
Summary
The facility did not ensure that the daily nurse staffing report was updated and posted each day in a location accessible to the public. During surveyor observation on 2/17/26 at 8:56 AM, the staffing sheet posted in the lobby was dated 2/5/26. In interviews on 2/20/26, the Staff Coordinator stated that staffing information was required to be updated to reflect any changes and posted daily in the facility lobby in a location accessible to the public, and the LNHA stated that the daily staffing sheet was required to be updated to reflect any changes and posted each day in the lobby in a location accessible to the public. When asked for the facility's staffing policy, the LNHA stated that the facility followed state staffing regulations and did not maintain a separate written staffing policy, and the facility was unable to provide a written policy regarding daily staffing postings.
Incorrect Calcium Medication Dispensed During Medication Pass
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when an LPN dispensed the wrong calcium medication for a resident during medication pass. The resident had diagnoses including dementia and disorders of bone density and structure, and the quarterly MDS dated 11/18/25 showed a BIMS score of 5 out of 15, indicating severely impaired cognition. During the 2/18/26 medication pass, the LPN pulled medications from the cart and handed an OTC bottle of calcium citrate 200 mg to the surveyor, then dispensed one pill from that bottle into the medication cup for the resident. Before entering the resident's room, the surveyor asked the LPN to review the medications, and the LPN verified the physician's order was for calcium citrate-vitamin D 315-5 mg-mcg, one tablet by mouth daily. The LPN acknowledged she had dispensed the incorrect calcium citrate medication and used a drug buster to destroy it. She could not locate the correct medication in the medication cart and asked another LPN/unit manager to find it in the facility's OTC supply. The LPN later stated she had only read the part of the order that said calcium citrate, and the DON stated nurses should read the order and check the medication against it three times to prevent a medication error.
Unsecured Nebulizer Medication Left at Bedside
Penalty
Summary
A medication was found unsecured in Resident #143’s bedroom when a nebulizer medication vial was observed on the bedside table during surveyor observation. Resident #143 was seated in a wheelchair and stated that he/she administered breathing treatments after nurses left the medication for him/her. The resident’s record showed diagnoses including COPD, a BIMS score of 15 out of 15, and a care plan focus for respiratory impairment with interventions to administer medications and treatments as ordered. The medical record included physician orders for Albuterol Sulfate Nebulization Solution as needed, Budesonide inhalation suspension twice daily, and Ipratropium-Albuterol inhalation solution three times daily for COPD. During interview, the RN/UM stated the nebulizer medication should not have been left on the bedside table because the resident was not care planned to self-administer medications. The LPN stated she usually left the nebulizer medication vials at the bedside for the resident to place into the nebulizer mask and start the machine, then returned in 10 to 15 minutes to check completion, and acknowledged that if the resident was not care planned to self-administer medications, the medication should not have been left at the bedside.
Failure to Follow Planned Menus
Penalty
Summary
The facility failed to follow the planned written menu for 2 of 2 meals observed. During lunch preparation, the posted menu called for crispy baked chicken, macaroni and cheese, and roasted zucchini, but the surveyor observed a vegetable mix of cauliflower, carrots, and zucchini simmering on the stove, and a staff member stated the lunch was chicken with glazed ham as the alternate. The surveyor also observed chicken being placed in a deep fryer, and when asked whether the chicken was baked or fried, the staff member stated that all the chicken was fried. For breakfast, the menu posted on the units listed orange juice, farina, egg and spinach frittata, apple cinnamon muffin, whole milk, and coffee, but a CNA on C wing, a CNA on B wing, and an unsampled resident on A wing all stated that scrambled eggs, bacon, English muffin, coffee, and milk were served instead. The Regional Dietician stated that menus are developed with a nutrient analysis and changing the menu may mean it does not meet residents’ nutritional needs. The Regional Licensed Nursing Home Administrator stated the facility found a fault in the kitchen that caused incorrect meals/menus, and the facility did not provide documentation on meal substitutions or menu changes.
Licenses Not Visibly Posted
Penalty
Summary
The facility failed to ensure that the Licensed Nursing Home Administrator (LNHA) and the Medical Director (MD) licenses were visibly displayed. During a tour, surveyors observed that there was no evidence the current MD's license or the LNHA's license was posted in a visible location. A copy of a previous MD's license was seen on a bulletin board in the copier room, but the current MD's license was not visibly displayed at that time. During interviews, the DON, Regional DON, DSS, and LNHA acknowledged that the current MD and LNHA licenses were not posted where they should have been. The DSS stated that a bulletin board had fallen and the licenses were put somewhere, and the LNHA stated she kept her license and that the MD's license was in the DON's office. The LNHA later stated the MD's license was posted visibly in the main hallway, and on a later date her own license was also shown posted there. She stated the bulletin with the licenses had been taken down to install a new time clock and acknowledged the licenses should have been visible to the public before surveyor inquiry.
Hand Hygiene and Nebulizer Storage Deficiencies
Penalty
Summary
The facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. During a medication pass observation, an LPN exited a resident's room and returned to the medication cart, then prepared and administered medications to three residents without performing hand hygiene before or after the medication administration. The LPN dispensed medications into medicine cups, administered them, and returned to the cart without using hand sanitizer or washing hands between residents. During interview, the LPN acknowledged that hand hygiene should be performed before and after administering medications to prevent the spread of germs, and the LPN/UM stated nurses should use hand sanitizer between each resident. The DON stated nurses should perform hand hygiene before dispensing medications and after administering medications by either washing hands with soap and water or using hand sanitizer. The facility's medication administration and hand hygiene policies stated staff shall follow infection control procedures and that alcohol-based hand rub is preferred in most situations, including before and after direct contact with residents and before preparing or handling medications. The facility also failed to properly store a nebulizer mask for a resident with COPD. The resident was seated in a wheelchair in the bedroom waiting to go to therapy, and the nebulizer mask was observed left on the bedside table exposed to air. The resident had diagnoses including COPD, a BIMS score of 15 out of 15 indicating intact cognition, and physician orders for nebulized respiratory medications. RN/UM #2 and the LPN stated the nebulizer mask should not have been left at bedside exposed to air and should have been placed in a plastic bag for infection control purposes. The facility's oxygen therapy policy stated that when not in use, the nasal cannula or oxygen mask will be placed in a plastic bag labeled with the resident's name and dated.
Failure to Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to maintain hot water temperatures at a safe level on one of its nursing units, specifically the C-Wing, resulting in water temperatures ranging from 137.1°F to 138.4°F in resident rooms and the shower room. These temperatures were significantly above the safe range of 95°F to 110°F, as acknowledged by both the Regional Licensed Nursing Home Administrator (RLNHA) and the Maintenance Director (MD). The C-Wing unit, which included cognitively impaired residents, was serviced by a separate boiler that lacked a temperature gauge and was found set to high. Multiple staff, including the RLNHA, confirmed the excessive temperatures and agreed that such conditions could cause burns. Residents on the C-Wing reported that the hot water was so hot it could be used to make tea or instant noodle soup, indicating prolonged exposure to unsafe water temperatures. One resident with fully intact cognition and another with moderately impaired cognition both confirmed the water had been excessively hot for some time. The surveyors directly measured the high temperatures in the presence of facility staff, who acknowledged the findings. Despite daily water temperature checks being claimed by the MD, the temperature logs for C-Wing were incomplete and did not show any recent entries, nor did they specify the locations where temperatures were taken. The facility did not have a written water temperature policy and relied on regulatory standards. The lack of documentation and monitoring, combined with the absence of a temperature gauge on the C-Wing boiler, contributed to the failure to detect and address the hazardous water temperatures. The issue was identified during a survey following a recent fire that had affected utilities, but the facility's staff denied any prior issues with high water temperatures. The deficiency was found to have placed residents, including those with cognitive impairments, at risk of serious injury from scalding.
Removal Plan
- The Maintenance Director lowered the hot water temperature on the boiler.
- Water temperatures were obtained throughout every residents' room in the facility.
- The facility initiated water temperatures to be taken every two hours for three days.
- All residents on C-Wing were assessed for skin damage.
- The facility conducted a resident council meeting to discuss safe water temperatures with the residents.
- The Director of Nursing/designee initiated a house-wide staff in-service on safe water temperatures, the process of taking water temperatures, and any staff not in-serviced would be prior to their next shift.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility was found to have several deficiencies related to food storage, preparation, and labeling, which could potentially lead to food-borne illnesses. During an inspection, the surveyor observed that in the walk-in cooler, bok choy and lemongrass were not properly dated, and the Food Service Director (FSD) was unsure of their discard dates. Additionally, a commercial blender in the food preparation area was found with hardened food stains and discoloration, indicating inadequate cleaning. The pellet heater used to keep food warm was also noted to have food particles and a sticky residue, and the FSD admitted that the cleaning process had not been completed after breakfast service. Further inspection revealed that the dishwashing machine logs were incomplete, with missing entries for temperature and chlorine levels on specific dates. The Dietary Aide confirmed that these checks were performed but not documented, and the FSD acknowledged that the logs should have been filled out. In the food storage area, expired barley and green split peas were found, with some packages infested with bugs. The FSD confirmed these findings and stated that he was responsible for ensuring no expired foods were on the shelves. In the B Wing pantry, the surveyor found several unlabeled food items in the refrigerator and freezer, which were designated for resident use. A Certified Nursing Aide (CNA) stated that these items belonged to residents but were not labeled with their names or use-by dates. The Regional Director of Nursing confirmed that all items should have been labeled according to the facility's policy. The facility's policies on labeling, dating, and dishwashing procedures were reviewed, revealing that these practices were not consistently followed, contributing to the deficiencies observed.
Deficiency in Maintaining Sanitary Environment in Central Supply Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the Central Supply room, as observed during a survey. A black substance, approximately 24 inches in length, was found adhered to the wall board ceiling near the pipes in the Central Supply room. This was discovered during a tour of the facility's basement by a surveyor, accompanied by the Regional Licensed Nursing Home Administrator (RLNHA) and the staff member in charge of Central Supply. The staff member in charge was unaware of the black substance, citing that she was covering for a prior staff member who had resigned. The Maintenance Director was also unaware of the issue. Upon revisiting the room, the surveyor observed the RLNHA and a Maintenance Assistant attempting to cover the black substance with white paint. The RLNHA later stated that the substance was dirt and that it was cleaned and painted over following the surveyor's inquiry. The facility was unable to provide a policy specifically related to maintaining a safe and sanitary physical environment, although the RLNHA mentioned following their Infection Control policy. This deficiency had the potential to affect all three nursing units within the facility.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged violation of misappropriation of resident property to the New Jersey Department of Health (NJDOH). This deficiency was identified during a survey for two residents who were reviewed for unnecessary medications. Resident #58, who had a moderately impaired cognition, reported that pain medications were always available when requested. However, a review of the resident's medication records revealed discrepancies in the administration of Percocet, with multiple instances where the medication was signed out but not documented as administered, and no pain evaluations were recorded. Similarly, for Resident #365, who had intact cognition, the records showed that Oxycodone was signed out on several occasions without corresponding documentation of administration or pain evaluation. The facility conducted an investigation involving three LPNs regarding alleged drug diversion, but the investigation concluded that the allegations were unsubstantiated. Despite this, there was no evidence that the facility reported the investigation to the NJDOH as required by regulation. During an interview with the surveyor, facility leadership, including the Regional Director of Nursing and the Licensed Nursing Home Administrator, acknowledged that the concerns of alleged drug diversion were not reported to the NJDOH. They believed the issue was resolved through resident interviews and assumed the ombudsman had informed the state. The facility's Incident/Occurrence Investigation Procedure did not specify the requirement to report such allegations to the NJDOH, contributing to the oversight.
Failure to Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of property concerning a resident's pain medication. The resident, who had a moderately impaired cognitive status, reported that pain medications were always available when requested. However, a review of the medication records revealed discrepancies. On a specific date, two Percocet tablets were signed out at 8 PM, but there was no documentation of pain level, pain evaluation, or a signature confirming the administration of the medication at that time. Additionally, the destroyed/wasted medication doses section was left blank, indicating a lack of proper documentation and investigation into the potential misappropriation of medication. The facility's investigation summary for three LPNs involved in the incident concluded that the alleged drug diversion was unsubstantiated. However, the investigation for one LPN included a suspension notice pending further investigation. The President of Clinical Services admitted that the duplicate dose was not investigated because it was not brought to their attention. The facility's policy requires all allegations of misappropriation to be investigated within 24 hours, but this procedure was not followed, leading to the deficiency.
Deficiency in Medical Record-Keeping for Pain Medication Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to a deficiency in accordance with accepted professional standards. For one resident, the surveyor found discrepancies in the documentation of pain medication administration. The resident had physician's orders for Percocet to be administered as needed for moderate to severe pain. However, the Medication Administration Record (MAR) for February 2024 showed no recorded pain levels, evaluations, or signatures indicating that the medication was administered on multiple dates. Additionally, the Individual Patient's Controlled Drug Record for January 2024 was not provided, and there was missing documentation for several dates in February 2024. Another resident's records also showed similar issues. The resident had a physician's order for Oxycodone to be administered as needed for severe pain. The MAR for December 2023 lacked documentation of pain levels, evaluations, or signatures for medication administration on specific dates. The Individual Patient's Controlled Drug Record for a portion of December 2023 was not provided to the surveyor, indicating incomplete record-keeping. Interviews with facility staff, including the Director of Nursing and the Regional Licensed Nursing Home Administrator, confirmed that the facility's policy was to maintain medical records in accordance with regulations. However, the Regional Director of Nursing acknowledged that the Individual Patient's Controlled Records for both residents could not be located. This failure to maintain accurate and complete medical records for the administration of controlled substances resulted in a deficiency citation.
Failure to Update Care Plan for Smoking Policy Violations
Penalty
Summary
The facility failed to revise a resident's care plan each time the resident violated the smoking policy. This deficiency was identified for a resident who was observed self-propelling in a wheelchair with a flaccid left upper extremity and a swollen left hand, without the use of a splint or sling. The resident had a history of tobacco use, nicotine dependence, and hemiplegia following a stroke, with a moderately impaired cognitive status. Despite these conditions, the resident's care plan, which was last revised on 10/11/24, did not adequately address the resident's noncompliance with the smoking policy. The resident was observed smoking multiple times a day, with staff holding their cigarettes and lighter. During an observation, the resident was seen with a long ash falling onto their clothing, resulting in a burn hole. The resident also shared a cigarette with another resident, which was against facility policy. The resident had previously been found with cigarettes and a lighter in their possession, leading to suspensions from smoking privileges. However, these incidents were not documented in the resident's electronic health record or care plan. Interviews with facility staff, including a Licensed Practical Nurse, Social Worker, and MDS Coordinator, revealed that the care plan should have been updated after each smoking violation. The facility's Interdisciplinary Care Planning Protocol required that care plans be specific and individualized, but this was not adhered to in the case of the resident's repeated noncompliance with the smoking policy. The lack of updates to the care plan after each infraction was a significant oversight in the facility's management of the resident's care.
Inadequate Supervision During Resident Smoking Sessions
Penalty
Summary
The facility failed to provide adequate supervision during resident smoking sessions and did not consistently follow and implement the facility's smoking policy, leading to safety concerns for two residents. Resident #72, who had a history of cognitive impairment and physical limitations due to a stroke, was observed smoking without proper supervision or safety measures in place. The resident was seen using a makeshift sling and had a burn hole in their clothing, indicating a lack of appropriate protective equipment such as a smoking apron. Additionally, the resident was observed passing a lit cigarette to another resident, which is against the facility's policy. The smoking aides responsible for supervising the residents during smoking sessions did not have a clear understanding of the residents' needs or the facility's smoking policy. Smoking Aide #1, who had been working at the facility for one month, was not provided with a list of residents requiring smoking assistance or protective equipment. The aide failed to intervene when Resident #72's cigarette ash became too long and fell onto their clothing, and did not ensure that cigarette butts were disposed of properly. The aide also allowed residents to light each other's cigarettes, which is prohibited by the facility's policy. The facility's staff, including the Social Worker and nursing staff, were not effectively communicating or documenting smoking infractions and resident needs. The Social Worker admitted to verbally communicating resident needs and infractions without maintaining a written record or binder accessible to the smoking aides. This lack of documentation and communication contributed to the inadequate supervision and safety measures during smoking sessions, resulting in multiple safety violations and potential hazards.
Incomplete Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure the completion of the dialysis communication book for a resident who required dialysis services. This deficiency was identified for a resident with a diagnosis of dependence on renal dialysis, who had a moderately impaired cognitive status. The resident's care plan indicated dialysis treatment three times a week, and physician orders required checking the hemodialysis binder upon the resident's return from dialysis. However, on multiple occasions, the dialysis center did not complete their portion of the Dialysis Communication Tool, and there was no documentation that the facility's nurses contacted the dialysis center to obtain the necessary post-dialysis information. Interviews with facility staff, including a registered nurse, a licensed practical nurse/unit manager, and the director of nursing, revealed that the facility's protocol required the dialysis communication tool to be completed by the dialysis center and for nurses to follow up if it was not. Despite this protocol, the communication tool was not completed on several dates, and the nurses did not document any follow-up actions to obtain the missing information. The facility's policy on Dialysis Management emphasized the importance of completing the communication tool and following up on any special instructions from the dialysis center, which was not adhered to in this case.
Failure to Adhere to Physician's Medication Orders
Penalty
Summary
The facility failed to administer medication in accordance with the physician's orders for a resident diagnosed with paroxysmal atrial fibrillation. The physician's order specified that Cardizem, a medication prescribed for atrial fibrillation, should be held if the resident's systolic blood pressure (SBP) was less than 130 mm Hg. However, the Medication Administration Record (MAR) for June and July 2024 showed that the medication was administered on multiple occasions when the resident's SBP was below the specified threshold, with readings as low as 96 mm Hg. Despite a pharmacy consultant's recommendation noting the medication errors, the nursing staff continued to administer Cardizem outside the prescribed SBP parameters. Interviews with the Director of Nursing (DON) and the Regional Director of Nursing (RDON) confirmed that the medication order should have been followed, and any necessary changes should have been communicated to the physician. The facility's policy on administering medications, which requires adherence to physician orders, was not followed in this instance.
Infection Control Deficiency: Failure to Don PPE for Resident on EBP
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident on Enhanced Barrier Precautions (EBP) due to staff not donning appropriate Personal Protective Equipment (PPE) before providing care. The resident, who had pressure-induced deep tissue damage and an unstageable pressure ulcer, was on EBP as per the individualized comprehensive care plan. The plan required staff to wear a gown and gloves during wound care. However, during an observation, a registered nurse (RN) entered the resident's room without donning a gown, only wearing gloves during the wound care treatment. The RN acknowledged the oversight, attributing it to the absence of a PPE supply bin outside the resident's room, which was supposed to serve as a reminder. The Director of Nursing (DON) confirmed that the RN should have worn a gown during the procedure and that a flower next to the resident's name indicated EBP status. The facility's EBP policy required the use of gown and gloves during high-contact care activities to prevent the transfer of multi-drug resistant organisms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Maple Shade
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Premier Cadbury Of Cherry Hill | 1.2 mi | ★★★★★ | 27 | 0 |
| Dwellside Care And Rehab | 1.2 mi | ★★★★★ | 2 | 1 |
| Laurel Brook Rehabilitation And Healthcare Center | 1.6 mi | ★★★★★ | 9 | 0 |
| Aristacare At Cherry Hill | 1.9 mi | ★★★★★ | 21 | 0 |
| Sterling Manor | 1.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.