Palace Rehabilitation and Care Center, The

In the surveyor’s words

From the most serious findings on record at Palace Rehabilitation and Care Center, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 31, 2025

  Complaint #: NJ 185087 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain hot water temperatures at a safe level to protect residents from third degree burns and serious injury on 1 of 3 nursing units (C-Wing). Hot water temperatures obtained on 3/29/25, in both residents' rooms and in the resident shower room on the C-Wing nursing unit, registered between 137.1 degrees Fahrenheit (F) and 138.4 degrees F. Interviews with the Regional Licensed Nursing Home Administrator (RLNHA) and the Maintenance Director (MD) revealed that hot water temperatures should be maintained between 95 and 110 degrees F to prevent residents from being burned. […]

• Actual harm, isolatedF689Jun 5, 2023

  Based on observation, interview, record review, and review of pertinent documentation it was determined the facility failed to: a.) ensure the facility policy for Falls Management was followed to appropriately assess a resident and determine the causal factor of a fall and implement appropriate interventions to prevent recurrent falls for a cognitively impaired resident (Resident #23), who was identified as a high fall risk, required extensive assistance with bed mobility, and had a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency roiagnom on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones)… […]

• Actual harm, isolatedF692Jun 5, 2023

  This is a repeat deficiency from the Standard Survey Date: 03/31/22 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to identify and consistently comprehensively assess, implement, and modify interventions, consistent with professional standards of practice a.) in response to an unplanned significant weight loss of 16.38% in less than 6 months for (Resident #128), and b.) in response to a significant weight loss of 8.6 pounds (lbs) in four days for (Resident #51). This deficient practice occurred for 2 of 5 residents reviewed for nutrition. […]

• Actual harm, isolatedF686Jan 31, 2022

  Complaint Intake # NJ 0 Based on observations, interviews, and record reviews, it was determined that the facility failed to provide pressure ulcer treatment for 1 (Resident #1) of 3 residents reviewed with pressure ulcers. This deficient practice resulted in Resident #1 developing a stage 4 pressure ulcer which then got infected and resulted in the resident getting [CONDITION(S)] (bone infection). Findings included: 1. The facility admitted Resident #1 on 01/29/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital for a wound infection on 06/20/2021 and returned to the facility on [DATE]. […]

• Actual harm, isolatedF689Feb 4, 2021

  C#: NJ 0 Based on interviews, record reviews and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe environment for a severely cognitively impaired resident (Resident #3) with a roommate (Resident #2), who had a [DIAGNOSES REDACTED]. On 1/17/2021 at 7:45 a.m., Resident #2 physically assaulted Resident #3, sending that resident to the hospital. Resident #2 ,was refusing his medications that controlled his behaviors prior to this incident. The Pre-Admission Screening and Resident Review (PASRR) Level II was not followed, it indicated that Resident #2 needed to be seen for a psychiatric visit that was due upon re-admission on 12/23/2020 at the facility, however this visit was done on 1/12/2021, 15 days later. […]