Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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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 | — | 1 | 0 |
| Sterling Manor | 1.9 mi | — | 0 | 0 |
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