Palace Rehabilitation And Care Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Maple Shade, New Jersey.
- Location
- 315 West Mill Road, Maple Shade, New Jersey 08052
- CMS Provider Number
- 315263
- Inspections on file
- 23
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Palace Rehabilitation And Care Center, The during CMS and state inspections, most recent first.
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.
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.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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