Inspection Reports for Grove Park Healthcare and Rehabilitation Center
NJ, 07017
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
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, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer and contact person for privacy practices |
Inspection Report
Routine
Census: 168
Deficiencies: 15
Oct 18, 2024
Visit Reason
A Recertification survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' rights and dignity, accuracy of assessments, professional standards in services provided, mobility support, nutrition and hydration status maintenance, pain management, psychotropic medication monitoring, and life safety code violations related to fire safety and emergency preparedness.
Complaint Details
Complaint investigation was part of the recertification survey with complaint numbers NJ177873, NJ173448, NJ171562, NJ170363, NJ169371.
Severity Breakdown
SS=F: 8
SS=D: 5
SS=B: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with dignity and respect by not removing weekly menus posted in residents' rooms who had a physician's order for NPO. | SS=F |
| Facility failed to accurately complete residents' status in the Minimum Data Set (MDS) for 1 of 33 residents reviewed. | SS=B |
| Services provided failed to meet professional standards of quality for 1 of 9 residents reviewed. | SS=D |
| Facility failed to ensure residents with limited mobility received appropriate treatment and services to increase range of motion or prevent decrease in range of motion. | SS=D |
| Facility failed to maintain acceptable nutritional and hydration status for 1 of 8 residents reviewed. | SS=D |
| Facility failed to ensure pain management was provided consistent with professional standards for 1 of 2 residents reviewed. | SS=D |
| Facility failed to monitor and document potential side effects of psychotropic medications for 1 of 5 residents reviewed. | SS=D |
| Facility failed to provide emergency illumination that would operate automatically along the means of egress in accordance with NFPA 101:2012 Edition. | SS=F |
| Facility failed to install and maintain supervised smoke/heat detection in accordance with NFPA 101:2012 Edition. | SS=F |
| Facility failed to maintain the fire sprinkler system by ensuring ceiling level was smoke resistant and maintaining sprinkler head escutcheon plates. | SS=F |
| Facility failed to maintain corridor doors to resist passage of smoke and maintain proper latching hardware. | SS=F |
| Facility failed to maintain ventilation in resident bathrooms and air conditioning filters in rooms. | SS=D |
| Facility failed to maintain electrical equipment, power cords, and extension cords in patient care areas. | SS=F |
| Facility failed to maintain electrical equipment testing and maintenance records and policies. | SS=F |
| Facility failed to maintain kitchen sanitation practices and ensure meals and snacks were provided at appropriate times. | SS=F |
Report Facts
Census: 168
Sample Size: 33
Deficiencies cited: 14
Residents reviewed: 33
Residents reviewed: 9
Residents reviewed: 8
Residents reviewed: 5
Inspection Report
Routine
Census: 159
Deficiencies: 0
Feb 11, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Routine
Census: 174
Deficiencies: 0
Aug 25, 2023
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 and preparedness for COVID-19.
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 to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 172
Capacity: 185
Deficiencies: 10
Jun 8, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with several federal regulations including issues with resident rights, staff qualifications, care planning, infection control, medication management, and safety. Multiple deficiencies were cited related to resident care, staff training, and facility policies.
Deficiencies (10)
| Description |
|---|
| Failure to provide residents reasonable access to communication and privacy. |
| Failure to implement policies to prevent abuse, neglect, and exploitation of residents. |
| Failure to verify nursing staff licenses and credentials prior to hire. |
| Failure to thoroughly investigate and report alleged abuse and neglect incidents. |
| Failure to provide timely and adequate nursing care and interventions for residents with injuries and health conditions. |
| Failure to accurately complete and maintain resident assessments and care plans. |
| Failure to provide adequate infection control and prevention measures including Legionella water management. |
| Failure to maintain accurate medication records and ensure proper medication administration. |
| Failure to maintain adequate staffing levels to meet resident needs. |
| Failure to maintain safe environment including emergency lighting and fire safety equipment. |
Report Facts
Census: 172
Total Capacity: 185
Deficiency Correction Due Date: 2023
Sample Size: 34
Additional Records Reviewed: 56
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
May 4, 2023
Visit Reason
A Complaint Survey was conducted on behalf of the New Jersey Department of Health due to complaints NJ00159769 and NJ00161160.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR 483 subpart B for Long Term Care Facilities.
Complaint Details
Complaint numbers NJ00159769 and NJ00161160 were investigated; the facility was found to be in substantial compliance.
Report Facts
Sample size: 7
Inspection Report
Complaint Investigation
Census: 177
Deficiencies: 1
Jun 29, 2022
Visit Reason
The inspection was conducted based on multiple complaints (NJ00153969, NJ00154606, NJ00154326, NJ00154860) alleging noncompliance with regulatory requirements at the facility.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically regarding the failure to perform comprehensive assessments upon admission or readmission for residents. The deficiency related to the governing body's responsibility to ensure proper management and operation was cited.
Complaint Details
The complaint investigation was based on four complaint numbers (NJ00153969, NJ00154606, NJ00154326, NJ00154860). The facility was found not in substantial compliance with regulatory requirements during this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to perform comprehensive assessments for residents upon admission/readmission as required by regulation. | SS=D |
Report Facts
Census: 177
Sample Size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the failure to perform comprehensive assessments upon admission/readmission |
Inspection Report
Routine
Census: 164
Capacity: 185
Deficiencies: 6
Feb 18, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were identified related to Activities of Daily Living (ADL) care, Respiratory/Tracheostomy Care and Suctioning, Pharmacy Services, Medication Administration, Infection Control, and Life Safety Code compliance. The facility was found not in compliance with several regulatory requirements.
Deficiencies (6)
| Description |
|---|
| ADL Care Provided for Dependent Residents was not met as evidenced by failure to provide necessary assistance with activities of daily living for a resident. |
| Respiratory/Tracheostomy Care and Suctioning deficiencies including failure to ensure proper oxygen and trach care. |
| Pharmacy Services deficiencies including failure to follow medication orders and hold medication as prescribed. |
| Medication Administration deficiencies including inaccurate medication administration records and failure to administer medications as ordered. |
| Infection Control deficiencies including failure to follow proper PPE use, hand hygiene, and infection prevention protocols. |
| Life Safety Code deficiencies including blocked egress doors, malfunctioning emergency lighting, and sprinkler system issues. |
Report Facts
Sample size: 32
Deficiencies cited: 6
Licensed beds: 185
Resident census: 164
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Named in medication administration and care findings |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Named in medication administration and care findings |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Named in medication administration and care findings |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Named in infection control and PPE use findings |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Named in infection control and PPE use findings |
| Certified Nursing Assistant (CNA) #3 | Certified Nursing Assistant | Named in infection control and PPE use findings |
| Director of Nursing (DON) | Director of Nursing | Named in medication administration and infection control findings |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in medication administration and infection control findings |
| Licensed Nursing Home Administrator (LNHA) | Licensed Nursing Home Administrator | Named in medication administration and infection control findings |
| Maintenance Director | Maintenance Director | Named in life safety code deficiencies related to doors, lighting, and sprinkler system |
Inspection Report
Complaint Investigation
Census: 166
Deficiencies: 3
Jan 27, 2022
Visit Reason
The inspection was conducted based on complaints NJ146235 and NJ150871 regarding allegations of verbal abuse and mistreatment of Resident #2 by staff members including the Social Worker, Director of Nursing, and a nurse.
Findings
The facility was found not in substantial compliance with requirements related to abuse and neglect. Resident #2 reported multiple incidents of verbal abuse and unprofessional behavior by staff. The facility failed to conduct thorough investigations and timely report these incidents to the New Jersey Department of Health. Staff were verbally counseled but documentation and formal corrective actions were lacking. The Administrator did not fully follow facility policies or regulatory requirements for abuse investigation and reporting.
Complaint Details
Complaint investigation based on allegations of verbal abuse and mistreatment of Resident #2 by three staff members. Resident reported feeling targeted, bullied, embarrassed, and unsafe. Incidents involved name-calling, profanity, and unprofessional conduct. Facility failed to report incidents timely and conduct thorough investigations.
Severity Breakdown
SS=G: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to prevent verbal abuse and neglect of Resident #2 by staff including Social Worker, Director of Nursing, and nurse. | SS=G |
| Failure to report alleged abuse and neglect incidents to the New Jersey Department of Health within required timeframes. | SS=D |
| Failure of facility administration to investigate, document, and take appropriate corrective action for verbal abuse incidents. | SS=D |
Report Facts
Census: 166
Sample size: 3
Dates of incidents: Incidents occurred between 12/27/2021 and 1/3/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #2 | Resident | Subject of abuse allegations and complaint |
| Social Worker | Social Worker (SW) | Involved in verbal abuse incidents with Resident #2 |
| Director of Nursing | Director of Nursing (DON) | Involved in verbal abuse incidents and failed to investigate properly |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Involved in verbal altercation with Resident #2 |
| Administrator | Facility Administrator | Failed to ensure proper investigation and reporting of abuse allegations |
| Receptionist | Receptionist | Witnessed part of incident between LPN and Resident #2 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assigned to interact with Resident #2 after DON was removed from floor |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Jul 1, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ140674, NJ140299, and NJ136490.
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 survey.
Complaint Details
Complaint numbers NJ140674, NJ140299, and NJ136490 were investigated and the facility was found compliant.
Report Facts
Sample Size: 8
Inspection Report
Original Licensing
Deficiencies: 0
Jun 29, 2021
Visit Reason
Initial inspection for licensure of new and/or renovated long term care facilities.
Findings
No deficiencies were noted during the inspection which involved 2 new bathrooms, a conference room wall, a glass wall, and cosmetic upgrades. The noted areas may not be occupied until formal notification by the Certificate of Need and Licensing Division has been received.
Report Facts
Number of new bathrooms: 2
Inspection Report
Abbreviated Survey
Census: 133
Deficiencies: 1
Feb 25, 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 related to COVID-19.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to provide services utilizing accepted infection control practices during food and drink service by Activity Aides. Deficiencies included improper hand hygiene and uncovered drink cups.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to perform proper hand hygiene after removing gloves and improper serving of uncovered drinks to residents. | SS=D |
Report Facts
Sample size: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA #1 | Activity Aide | Named in infection control deficiency related to hand hygiene and food service |
| AA #2 | Activity Aide | Named in infection control deficiency related to food service |
| Activity Director | Activity Director | Interviewed regarding infection control policies and training |
| Director of Nursing | Director of Nursing | Interviewed regarding staff training and infection control education |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Dec 15, 2020
Visit Reason
The inspection was conducted in response to complaints NJ 141738 and NJ 141847 regarding alleged resident-to-resident abuse and failure to provide consistent supervision to prevent further abuse.
Findings
The facility failed to ensure that Resident #1, who had a history of resident-to-resident abuse, was consistently monitored, resulting in Resident #1 entering another resident's room unsupervised and engaging in inappropriate behavior. The assigned CNA left Resident #1 unattended without coverage, violating facility policies and placing residents at immediate jeopardy. The facility implemented corrective actions including staff in-servicing and 1:1 supervision monitoring.
Complaint Details
Complaint # NJ 141738 and NJ 141847 involved allegations of resident-to-resident abuse by Resident #1. The investigation found that Resident #1 was left unattended by the assigned CNA and was able to enter another resident's room and engage in inappropriate behavior. The Immediate Jeopardy was identified on 12/18/2020 and was past non-compliance from 12/15/2020 10:15 a.m. to 12/15/2020 12:00 p.m. The facility provided an acceptable Removal Plan including staff in-servicing and 1:1 supervision.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure consistent monitoring and supervision of Resident #1 who had a history of resident-to-resident abuse, resulting in unsupervised entry into another resident's room and inappropriate behavior. | SS=J |
Report Facts
Census: 128
Sample size: 3
Immediate Jeopardy duration: 1.75
Monitoring interval: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Left Resident #1 unattended during 1:1 supervision, leading to resident entering another resident's room unsupervised |
| Unit Manager | Unit Manager | Observed CNA #1 leaving Resident #1 unattended and provided instructions on 1:1 supervision |
| Director of Nursing | Director of Nursing (DON) | Notified of Immediate Jeopardy situation and involved in investigation and corrective action |
| Administrator | Administrator (ADMIN) | Notified of Immediate Jeopardy situation and involved in investigation and corrective action |
| LPN #1 | Licensed Practical Nurse | Responded to incident involving Resident #1 and Resident #2 |
| LPN #2 | Licensed Practical Nurse | Responded to incident involving Resident #1 and Resident #2 |
| CNA #2 | Certified Nursing Assistant | Reported observing Resident #1 and Resident #2 in resident's room |
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