Inspection Reports for The Palace Rehabilitation and Care Center

NJ, 08052

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Deficiencies per Year

24 18 12 6 0
2021
2022
2023
2024
2025
High Moderate Unclassified

Census Over Time

140 147 154 161 168 175 Jan '21 Jul '21 Sep '22 Jun '23 Feb '25 Jun '25
Census Capacity
Notice Deficiencies: 0 Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
NameTitleContext
Devon L. GrafDirector, NJDHSS Privacy OfficerContact person for privacy practices and rights
Inspection Report Complaint Investigation Census: 153 Deficiencies: 0 Jun 12, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00187009 and NJ186183.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities and the New Jersey Administrative Code, 8:39 standards for licensure of Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ00187009 and NJ186183 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 5
Inspection Report Abbreviated Survey Census: 157 Deficiencies: 0 Feb 12, 2025
Visit Reason
A Focused Infection Control survey was conducted on 02/12/25 to assess compliance with infection control regulations.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the focused infection control survey.
Report Facts
Sample Size: 7
Inspection Report Routine Census: 161 Capacity: 165 Deficiencies: 7 Oct 29, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and life safety code survey.
Findings
The facility was found to be noncompliant with multiple regulatory requirements including failure to report alleged violations, inadequate medication administration documentation, deficient care plan revisions, unsafe physical environment conditions, and infection control deficiencies. Corrective actions and systemic changes were required.
Complaint Details
The survey included investigations of multiple complaints (NJ164832, 165602, 167382, 168691, 168917, 172102, 175383, 175570, 175710, 175725, 175728, 176593, 176873). Some allegations were substantiated, including failure to report and investigate abuse and misappropriation, medication errors, and unsafe environment issues.
Severity Breakdown
SS=E: 3 SS=D: 3 SS=F: 3
Deficiencies (7)
DescriptionSeverity
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment in a timely manner.SS=E
Failure to thoroughly investigate allegations of abuse and misappropriation of resident property.SS=E
Failure to maintain accurate and complete medication administration records with signatures for administered medications.SS=E
Failure to revise resident care plans timely and adequately to reflect current needs and interventions.SS=D
Failure to maintain a safe environment including fire safety issues such as lack of emergency diagrams, blocked fire doors, and unsecured oxygen cylinders.SS=F
Failure to maintain proper food safety and sanitation in kitchen and food storage areas.SS=F
Failure to maintain infection prevention and control practices including PPE use and isolation procedures.SS=D
Report Facts
Census: 161 Total Capacity: 165 Deficiencies cited: 9 Staffing ratios: Certified Nurse Aide staffing ratios required by state law (e.g., 1 CNA per 8 residents day shift). Fire extinguishers inspected: 25 Emergency generator load test interval: 10
Employees Mentioned
NameTitleContext
Regional Director of Nursing (RDON) #1 and #2Interviewed during investigation and survey.
Licensed Practical Nurse (LPN) #1Named in investigation related to employee suspension and medication errors.
Vice President of Clinical Services (VPCS) #1Interviewed regarding medication administration.
Licensed Practical Nurse/Unit Manager (LPN/UM) #1 and #2Interviewed regarding medication administration and communication.
Registered Nurse (RN) #1 and #2Interviewed regarding resident care and PPE use.
Certified Nursing Assistant (CNA) #1Observed food labeling and storage issues.
Maintenance Director/DesigneeResponsible for audits and corrective actions related to fire safety and environment.
Food Service Director/DesigneeResponsible for food safety audits and corrective actions.
Inspection Report Complaint Investigation Census: 156 Deficiencies: 1 Sep 4, 2024
Visit Reason
The inspection was conducted in response to complaint NJ00175122 to investigate staffing ratio compliance at the facility.
Findings
The facility was found to be in substantial compliance with federal requirements but failed to meet New Jersey staffing ratio standards for certified nursing assistants on 9 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint #: NJ00175122. The facility failed to meet minimum staffing requirements for certified nursing assistants on 9 of 14 day shifts prior to the survey. No residents were affected by this negative outcome. The facility identified all residents as potentially at risk and implemented systemic changes including recruitment efforts, expedited onboarding, additional staffing agencies, weekly staffing meetings, and quality assurance audits.
Deficiencies (1)
Description
Failed to ensure staffing ratios were met for 9 of 14 day shifts reviewed, with fewer CNAs than required on multiple days.
Report Facts
Deficient CNA staffing days: 9 Census: 156 Required CNAs per day shift: 19 Actual CNAs on deficient days: Range from 11 to 18 CNAs on deficient days as detailed in the report
Inspection Report Annual Inspection Census: 157 Capacity: 165 Deficiencies: 23 Jun 5, 2023
Visit Reason
Annual recertification survey to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint survey NJ 00160152.
Findings
The facility was found deficient in multiple areas including resident rights violations, environmental safety and cleanliness, complaint follow-up, nutrition and hydration, infection control, staffing, and life safety code compliance. Deficiencies included failure to protect resident belongings, inadequate response to complaints, poor food quality and temperature control, insufficient staffing, unsafe environment, and incomplete investigations of incidents.
Complaint Details
Complaint # NJ 00160152 was investigated and found to be substantiated related to resident rights violations and other deficiencies.
Severity Breakdown
SS=F: 18 SS=D: 4 SS=E: 2
Deficiencies (23)
DescriptionSeverity
Failure to protect resident rights and dignity, including failure to provide clothing and protect belongings from theft for Resident #8.SS=D
Failure to ensure resident council grievances and recommendations were addressed and followed up.SS=F
Failure to maintain a safe, clean, comfortable, and homelike environment with multiple environmental deficiencies observed throughout the facility.SS=F
Failure to report and investigate an injury of unknown origin for Resident #23 and failure to report to the NJ Department of Health.SS=D
Failure to conduct thorough investigations of alleged abuse and injuries of unknown origin.SS=D
Failure to complete accurate and timely comprehensive assessments and care plans reflecting resident status and needs, including weight loss and communication needs.SS=D
Failure to provide adequate ADL care including nail care and shaving for dependent residents.SS=D
Failure to ensure residents received prescribed respiratory care and oxygen therapy as ordered.SS=D
Failure to provide each resident with a nourishing, palatable, well-balanced diet that meets preferences and clinical needs, and failure to maintain proper food temperatures.SS=E
Failure to maintain kitchen and food service areas in a clean, sanitary, and safe manner including soiled equipment, rust, pest infestation, and improper food storage.SS=F
Failure to properly dispose of contaminated personal protective equipment in isolation rooms and failure to perform hand hygiene during meal tray delivery.SS=F
Failure to provide two remote exits for the second floor; waiver in place until 12/7/23.SS=F
Failure to provide emergency illumination that operates automatically along the means of egress in resident day rooms.SS=F
Failure to provide smoke barrier doors that fully close and resist passage of smoke in multiple resident room corridors.SS=F
Failure to maintain kitchen hood system and repair deficiencies as required by NFPA 96.SS=F
Failure to ensure dietitian was qualified and available to provide nutritional assessments and care plans.SS=F
Failure to maintain proper isolation procedures for residents under investigation for communicable diseases and failure to maintain clean respiratory equipment.SS=F
Failure to maintain minimum required direct care staffing ratios for CNAs on day shifts.SS=F
Failure to provide adequate furniture including chairs, bedside tables, and closet space for residents in multiple rooms.SS=F
Failure to maintain smoking areas with proper ashtray containers and safe disposal of cigarette butts.SS=F
Failure to maintain electrical equipment and generator documentation including transfer times and natural gas reliability letter.SS=F
Failure to ensure oxygen therapy equipment was administered and documented per physician orders.SS=D
Failure to maintain power cords and prohibit use of extension cords beyond temporary use.SS=D
Report Facts
Deficiencies cited: 18 Deficiencies cited: 4 Deficiencies cited: 2 Resident census: 157 Total licensed capacity: 165 CNA staffing shortfall: 1 Weight loss: 10 Weight loss: 15 Fire safety waiver expiration: 2023 Generator load tests missing transfer times: 3
Employees Mentioned
NameTitleContext
LPN UM #1Licensed Practical Nurse/Unit ManagerNamed in respiratory care and care plan deficiencies
DONDirector of NursingNamed in multiple findings including failure to investigate injury, staffing, and dietitian oversight
LNHALicensed Nursing Home AdministratorNamed in oversight deficiencies and environmental issues
FSDFood Service DirectorNamed in food service and kitchen sanitation deficiencies
RA #2Regional AdministratorNamed in oversight and QAPI deficiencies
MDMaintenance DirectorNamed in multiple environmental and life safety deficiencies
RPODRegional Plant Operations DirectorNamed in multiple environmental and life safety deficiencies
CNA #2Certified Nursing AssistantNamed in ADL care and hand hygiene deficiencies
RNRegistered NurseNamed in respiratory care and injury investigation deficiencies
LPNLicensed Practical NurseNamed in respiratory care and injury investigation deficiencies
Hospitality AideHospitality AideNamed in injury investigation deficiencies
Infection PreventionistInfection PreventionistNamed in infection control deficiencies
Inspection Report Complaint Investigation Census: 159 Deficiencies: 1 Mar 23, 2023
Visit Reason
The inspection was conducted based on a complaint visit to investigate allegations related to medication administration practices at the facility.
Findings
The facility failed to follow a physician's order and facility policies on medication administration for one resident, as evidenced by undocumented medication administration and lack of physician notification. Licensed nursing staff did not document medication administration properly, and the facility was found not in substantial compliance with professional standards.
Complaint Details
Complaint # NJ162163. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
DescriptionSeverity
Failure to follow physician's order and facility policies on medication administration for Resident #2, including undocumented medication administration and lack of physician notification.SS=D
Report Facts
Census: 159 Sample size: 5 Dates of missed medication documentation: 26
Employees Mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding medication administration protocol and education of licensed nursing staff
LPN #1Licensed Practical NurseInterviewed regarding medication administration documentation expectations
LPN #2Licensed Practical NurseInterviewed regarding medication administration documentation expectations
Inspection Report Complaint Investigation Census: 157 Deficiencies: 0 Sep 22, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint numbers NJ 155053, 158102, and 158372.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ 155053, 158102, and 158372 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 5
Inspection Report Routine Census: 155 Deficiencies: 0 Sep 12, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Document Deficiencies: 0 Mar 31, 2022
Visit Reason
This document is an instruction page advising to open the PDF portfolio in Acrobat X or Adobe Reader X or later for best experience.
Findings
No inspection or regulatory information is present in this document.
Inspection Report Life Safety Deficiencies: 8 Mar 31, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 03/30/2022 and 03/31/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including insufficient number of exits on a floor, non-functioning emergency lighting, penetrations in fire barriers, improperly installed fire extinguishers, smoke barrier doors with excessive gaps, inadequate bathroom ventilation, malfunctioning laundry chute door, and lack of GFCI protection on electrical outlets near water sources.
Severity Breakdown
SS=D: 5 SS=E: 3
Deficiencies (8)
DescriptionSeverity
Failed to ensure two acceptable exits remote from each other on a floor; only one exit provided with a time-limited waiver requested.SS=D
Failed to provide functioning battery backup emergency light above emergency generator's transfer switch.SS=D
Failed to provide fire barriers with one-hour fire resistance rating to hazardous areas; penetrations in plaster ceiling of boiler room.SS=E
Failed to install 8 of 26 portable fire extinguishers within required height and failed to document monthly visual inspections on 3 extinguishers.SS=E
Failed to maintain smoke barrier doors to resist transfer of smoke; metal door sweeps allowed excessive gap.SS=D
Failed to ensure proper maintenance and provision of exhaust ventilation in resident bathrooms; one exhaust fan not functioning and one bathroom window screwed shut.SS=D
Failed to maintain one-hour fire-resistive construction for corridor linen chute door; door did not close and latch properly.SS=E
Failed to ensure electrical outlet near water source was equipped with proper working GFCI protection.SS=D
Report Facts
Deficiencies cited: 8 Fire extinguishers installed too high: 8 Fire extinguishers without monthly inspection documented: 3 Smoke barrier doors tested: 5 Smoke barrier doors with excessive gap: 2 Resident bathrooms inspected: 10 Resident bathrooms with ventilation issues: 2 Laundry chute door inspections: 1 Electrical outlets inspected near water source: 4 Electrical outlets lacking GFCI protection: 1
Employees Mentioned
NameTitleContext
Regional AdministratorPresent during observations and interviews confirming findings.
Director of MaintenancePresent during observations and interviews confirming findings and responsible for corrective actions.
Inspection Report Complaint Investigation Census: 151 Deficiencies: 6 Jan 31, 2022
Visit Reason
Complaint survey based on multiple complaint intakes regarding compliance with long term care facility regulations, including infection control, notification of changes, environment, quality of care, pressure ulcer treatment, incontinence care, and medical record documentation.
Findings
The facility was found non-compliant with several regulatory requirements including failure to notify resident representatives of changes in condition, inadequate environmental cleanliness and maintenance, failure to provide prescribed pain medication timely, inadequate treatment and documentation of pressure ulcers, improper incontinent care, unsecured suprapubic catheters, and incomplete medical record documentation.
Complaint Details
Complaint Intake #NJ151090, NJ150740, NJ149627, NJ149574. The survey was triggered by multiple complaints alleging failures in notification, infection control, environment, medication administration, pressure ulcer care, incontinent care, and medical record keeping.
Severity Breakdown
SS=D: 4 SS=E: 1 SS=G: 1
Deficiencies (6)
DescriptionSeverity
Failure to notify resident representative of changes in resident's treatment orders, medication changes, appointments, and presence of wounds or incidents.SS=D
Failure to maintain a safe, clean, comfortable, and homelike environment including plumbing, walls, floors, furniture, and equipment.SS=E
Failure to provide pain medication as prescribed and document administration accurately.SS=D
Failure to provide timely and appropriate treatment for pressure ulcers, including documentation and reporting.SS=G
Failure to provide appropriate incontinent care and secure suprapubic catheters as per resident preference and policy.SS=D
Failure to maintain complete, accurate, and organized medical records including treatment and medication administration documentation.SS=D
Report Facts
Census: 151 Sample Size: 13 Missed medication/treatment counts: 124 Missed treatment counts: 93
Employees Mentioned
NameTitleContext
LPN #2Licensed Practical NurseInterviewed regarding notification of resident representative and medication administration.
RN #2Registered NurseInterviewed regarding medication administration and telephone orders.
DONDirector of NursingInterviewed regarding notification requirements, medication administration, pressure ulcer care, and medical record documentation.
AdministratorInterviewed regarding facility policies and agreement with DON statements.
CNA #1Certified Nursing AssistantObserved and interviewed regarding incontinent care.
UM #1Unit ManagerInterviewed regarding incontinent care observations and staff education.
LPN #3Licensed Practical NurseInterviewed regarding securing suprapubic catheters.
RN #1Registered NurseObserved providing care and interviewed regarding securing suprapubic catheter.
Inspection Report Complaint Investigation Census: 154 Deficiencies: 0 Aug 30, 2021
Visit Reason
The inspection visit was conducted in response to a complaint (Complaint#: NJ 146348) to assess compliance with long term care facility regulations.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint#: NJ 146348. The facility was found compliant based on this complaint visit.
Report Facts
Sample Size: 4
Inspection Report Complaint Investigation Census: 158 Deficiencies: 0 Jul 27, 2021
Visit Reason
The inspection visit was conducted as a complaint investigation to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report Life Safety Deficiencies: 1 Jun 3, 2021
Visit Reason
The inspection was conducted to assess compliance with the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, specifically focusing on fire safety maintenance and retrofit requirements under the Uniform Fire Safety Code.
Findings
The facility failed to ensure that the building was inspected by a local fire code official on a quarterly basis for the last five quarters, with only one inspection documented during that period. This was due to a change in local fire inspection staffing, which the facility could not document. The deficiency was communicated to the Administrator during the Life Safety Code survey exit conference.
Deficiencies (1)
Description
Failure to ensure quarterly fire code inspections by a local fire code official for the last five quarters, with only one inspection documented.
Report Facts
Number of quarters without inspection: 4 Date of last inspection: Feb 18, 2020
Employees Mentioned
NameTitleContext
Maintenance DirectorInterviewed and confirmed inspection deficiency.
Regional Plant Operations DirectorInterviewed and confirmed inspection deficiency.
AdministratorInterviewed and informed of deficiency during exit conference.
Inspection Report Life Safety Deficiencies: 6 Jun 1, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found noncompliant with several life safety code requirements including egress door operation, number of exits per floor, illumination of means of egress, sprinkler system maintenance, smoke barrier door functionality, and electrical equipment wiring. Multiple deficiencies were identified related to door locking mechanisms, exit access, lighting, sprinkler escutcheon plates and ceiling integrity, smoke barrier door closure, and unsafe use of extension cords.
Severity Breakdown
SS=E: 2 SS=D: 4
Deficiencies (6)
DescriptionSeverity
Failed to maintain 3 of 3 means of egress double exit doors to operate free of obstructions or impediments; right-side door leafs were manually locked requiring manual unlocking.SS=E
Failed to ensure 2 acceptable exits, remote from each other, were provided for each floor/story; only one exit was available on a floor used for business offices.SS=D
Failed to ensure exit discharge areas were equipped with two sources of lighting; a single-bulb light fixture at the wing boiler room exit was missing a bulb.SS=D
Failed to maintain sprinkler system ceiling level smoke resistance; multiple sprinkler escutcheon plates missing and ceiling openings allowing smoke passage.SS=E
Failed to maintain 1 of 9 smoke barrier doors to automatically close with fire alarm activation; door remained open approximately 2 feet due to door sweep rubbing on floor.SS=D
Failed to maintain wiring in main egress corridor; an orange extension cord was used under a door, showing stress and potential hazard.SS=D
Report Facts
Number of deficient exit doors: 3 Number of deficient exit discharge areas: 1 Number of sprinkler observations with deficiencies: 9 Number of smoke barrier doors inspected: 9
Employees Mentioned
NameTitleContext
Maintenance DirectorPresent during observations and interviews related to deficiencies
Regional Plant Operations DirectorPresent during observations and interviews related to deficiencies
Inspection Report Complaint Investigation Census: 149 Deficiencies: 4 Feb 4, 2021
Visit Reason
The inspection was conducted based on complaint #NJ142500 regarding the facility's failure to provide a safe environment for residents, specifically concerning an incident of resident-to-resident physical assault.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to ensure a safe environment and adequate supervision for residents with behavioral issues. Resident #2 physically assaulted Resident #3, resulting in hospitalization. Resident #2 refused medications controlling behaviors and was not monitored or evaluated timely as required by PASRR Level II. The facility failed to follow its own policies on safety and supervision, and corrective actions were implemented including staff education and increased monitoring.
Complaint Details
Complaint #NJ142500 was substantiated. The complaint involved a physical assault by Resident #2 on Resident #3, with Resident #2 refusing medications and not being properly evaluated or supervised as required.
Severity Breakdown
SS=G: 4
Deficiencies (4)
DescriptionSeverity
Failure to provide a safe environment for an impaired resident leading to resident-to-resident physical assault.SS=G
Failure to follow PASRR Level II requirements for timely evaluation of a resident with behavioral issues.SS=G
Failure to provide adequate supervision and monitoring for a resident refusing medications and exhibiting aggressive behaviors.SS=G
Failure to follow facility policy titled 'Safety and Supervision of Residents' to prevent accidents and ensure resident safety.SS=G
Report Facts
Census: 149 Sample Size: 9 Medication refusal days: 5 Days delayed for PASRR evaluation: 15
Employees Mentioned
NameTitleContext
Licensed Practical Nurse (LPN #1)Responded to the resident room during the incident and assessed Resident #3.
Certified Nurse's Assistant (CNA #1)First staff to observe injuries on Resident #3 and questioned Resident #2 about the incident.
Registered Nurse (RN #1)Assessed Resident #3 after the incident and called emergency services.
Unit Manager (UM)Provided information about medication refusal protocols and monitoring of Resident #2.
Social Worker (SW)Acknowledged PASRR evaluation was not completed timely and advised staff on safety precautions.
Advanced Practice Nurse-Certified (APN-C)Recommended inpatient treatment for Resident #2 due to unsafe behaviors and medication refusal.
AdministratorProvided information about Resident #2's hospital admission and return to the facility.
Inspection Report Complaint Investigation Census: 148 Deficiencies: 0 Jan 12, 2021
Visit Reason
The inspection was conducted in response to complaint #NJ142225 to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #NJ142225 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report Routine Census: 149 Deficiencies: 0 Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8

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