Inspection Reports for Spring Grove Rehabilitation And Healthcare Center
144 Gales Drive, NJ, 07974
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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 contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Jan 30, 2025
Visit Reason
The inspection was conducted based on a complaint (Complaint #: NJ00182823) 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, and in compliance with New Jersey Administrative Code Chapter 8:39, based on this complaint visit.
Complaint Details
Complaint # NJ00182823 was investigated and the facility was found to be in substantial compliance with applicable federal and state standards.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Nov 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ00179501) to determine compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations, specifically failing to meet minimum staff-to-resident ratios on 4 of 14 day shifts.
Complaint Details
Complaint #: NJ00179501. The facility was found to be in substantial compliance with federal requirements based on this complaint visit. The complaint was substantiated with findings related to staffing deficiencies.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 4 of 14 day shifts. |
Report Facts
Census: 102
Deficient day shifts: 4
Staffing shortfall: 3
Staffing shortfall: 2
Staffing shortfall: 1
Staffing shortfall: 1
Residents: 97
Inspection Report
Routine
Census: 88
Capacity: 106
Deficiencies: 11
Oct 29, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
The facility was found to have multiple deficiencies including failure to maintain call bells within residents' reach, failure to issue required Medicaid notices, failure to meet professional standards in care plans and treatment orders, inadequate care for dependent residents, quality of care issues, respiratory care deficiencies, drug regimen review irregularities, and life safety code violations related to sprinkler system coverage.
Complaint Details
Complaint numbers NJ 172237, 172317, 172380, 174618, 175850, 176226, 176966, 177870 were investigated during this survey.
Severity Breakdown
Level E: 5
Level D: 5
Level F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to maintain the call bell within reach of residents. | Level E |
| Facility failed to issue required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) for 3 residents. | Level E |
| Facility failed to discontinue treatment orders and follow physician's treatment orders for 1 of 18 residents. | Level D |
| Facility failed to ensure dependent residents received timely care and fresh linen. | Level E |
| Facility failed to provide timely notification and discontinuation of treatment orders for resident wounds. | Level D |
| Facility failed to provide necessary care for residents unable to carry out activities of daily living. | Level E |
| Facility failed to provide timely physical examinations for newly hired employees. | Level E |
| Facility failed to ensure drug regimen review was conducted monthly and irregularities addressed for 1 of 5 residents. | Level D |
| Facility failed to ensure oxygen administration policy was followed and residents received oxygen as ordered. | Level D |
| Facility failed to ensure sprinkler system coverage on South and North nursing stations in accordance with NFPA 13 standards. | Level F |
| Facility failed to ensure sprinkler system supervisory signals were installed and monitored as required. | Level F |
Report Facts
Census: 88
Total Capacity: 106
Deficiencies cited: 12
Sample Size: 20
Date Survey Completed: Oct 29, 2024
Inspection Report
Routine
Census: 93
Deficiencies: 0
Aug 21, 2024
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 CDC recommended practices.
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: 7
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
May 10, 2024
Visit Reason
A complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of New Jersey Department of Health due to multiple complaint numbers listed, with survey dates from 05/08/24 to 05/10/24.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on a complaint visit. Key findings included failure to ensure one resident (Resident #8) remained safe with adequate supervision and assistance devices, resulting in an accident. Additionally, the facility failed to maintain required minimum direct care staff to resident ratios for day and evening shifts as mandated by New Jersey state law.
Complaint Details
The complaint investigation involved multiple complaint numbers and found the facility not in substantial compliance. Resident #8 was involved in an incident where a Certified Nursing Assistant (CNA 4) provided care without required assistance, resulting in a fall and injury. CNA 4 was discharged due to violation of company policy. Staffing deficiencies were documented over multiple weeks with insufficient CNAs on day and evening shifts.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure one resident remained safe with adequate supervision and assistance devices to prevent accidents. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios for day and evening shifts as mandated by the State of New Jersey. | — |
Report Facts
Survey Census: 97
Sample Size: 16
Deficient CNA staffing days: 38
Deficient CNA staffing days: 14
Required CNA staffing ratio: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Named in incident involving Resident #8 where care was provided without required assistance; discharged due to violation of company policy. |
| LPN 3 | Licensed Practical Nurse | Entered room during Resident #8 incident and assessed the resident. |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Nov 1, 2023
Visit Reason
The inspection was conducted in response to multiple complaints (NJ00153396, NJ00157178, NJ00157203, NJ00159672, NJ00159845) to investigate compliance with long-term care facility regulations.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards related to medication administration and care plans. Deficient practices were identified in administering medications according to physician orders and facility policy for 5 of 8 sampled residents, requiring a plan of correction.
Complaint Details
The investigation was triggered by multiple complaints. The facility was found non-compliant with medication administration standards. The facility must submit a plan of correction to address deficiencies. The report notes no negative outcomes identified from deficient practice for some residents, but counseling and re-education of nursing staff were required.
Deficiencies (1)
| Description |
|---|
| Failure to administer medications in accordance with physician orders and facility policy for 5 of 8 sampled residents. |
Report Facts
Complaint numbers: 5
Census: 93
Sample size: 8
Residents with deficient medication administration: 5
Medication pass observations: 3
Medication observations monthly: 2
Inspection Report
Annual Inspection
Census: 92
Capacity: 107
Deficiencies: 9
Aug 15, 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 deficient in multiple areas including safe and homelike environment, accuracy of assessments, professional standards of care, pressure ulcer treatment, mobility maintenance, sufficient nursing staff, dietary preferences, infection prevention and control, and environmental safety.
Complaint Details
Complaint numbers NJ00151595, NJ00159657, NJ00152188, NJ00152300, NJ00152562, NJ00159269, NJ00160307, NJ00164302 triggered the survey.
Severity Breakdown
SS=E: 2
SS=D: 5
SS=C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to ensure a safe, clean, comfortable, and homelike environment for residents and maintain central baths free of storage and safety hazards. | SS=E |
| Facility failed to accurately code the Minimum Data Set (MDS) for one resident. | SS=C |
| Facility failed to ensure staff consistently and accurately documented showers and medication indications. | SS=D |
| Facility failed to follow physician's orders and infection control standards for wound care for one resident. | SS=D |
| Facility failed to ensure a resident's splint was consistently applied according to physician's order. | SS=D |
| Facility failed to provide sufficient nursing staff to meet state mandated minimum direct care staff-to-shift ratios. | SS=E |
| Facility failed to ensure resident dietary preferences were collected, documented, and honored. | SS=D |
| Facility failed to maintain infection prevention and control standards including proper disposal of used COVID-19 test kits and timely replacement of sharps containers. | SS=D |
| Facility failed to maintain a safe and sanitary environment in the laundry room, including accumulation of lint and dust near clean linens and towels. | SS=D |
Report Facts
Resident census: 92
Total licensed capacity: 107
Sample size: 33
Deficiency counts: 9
Staff to resident ratio: 1
Staffing deficiency counts: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA#1 | Certified Nursing Aide | Named in environmental and staffing findings. |
| Director of Nursing | Director of Nursing | Informed surveyors of COVID outbreak and involved in staffing discussions. |
| Housekeeping Director | Housekeeping Director | Involved in cleaning deficiencies and environmental observations. |
| Maintenance Director | Maintenance Director | Responsible for maintenance issues and sharp container replacement. |
| MDS Coordinator | MDS Coordinator/Registered Nurse | Named in MDS coding deficiency. |
| Registered Dietician | Registered Dietician | Named in dietary preference deficiency. |
| Licensed Practical Nurse | Licensed Practical Nurse | Observed in wound care deficiency. |
| Regional Director of Operations | Regional Director of Operations | Involved in multiple findings and interviews. |
| Staffing/Ancillary Coordinator | Staffing/Ancillary Coordinator | Interviewed regarding staffing and scheduling. |
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 2
Dec 3, 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 and CMS/CDC recommended practices for COVID-19.
Findings
The facility failed to consistently implement infection control measures, including lack of proper signage for residents on transmission-based precautions and failure to ensure staff were fit-tested for the specific make, model, and size of N95 respirator masks in use.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents on transmission-based precautions had signage posted outside their rooms to inform staff and visitors of the need for precautions for 7 of 9 residents observed. | SS=E |
| Failed to ensure staff were fit-tested for the specific make, model, and size of N95 respirator masks that were in use. | SS=E |
Report Facts
Residents observed for transmission-based precautions: 9
Residents without proper signage: 7
Sample size: 5
Fit testing completion date: Dec 6, 2022
Audit duration: 12
Fit testing deadline: Jan 31, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed about knowledge of PPE and fit testing; stated not fit tested for the N95 mask in use |
| Director of Nursing | Director of Nursing | Placed transmission-based precaution signs; stated expectation that staff wear the N95 mask for which they were fit tested |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Interviewed about expectations for signage and fit testing; unaware of fit testing specifics; responsible for auditing and education |
| Regional Director of Operations | Regional Director of Operations | Interviewed about signage and fit testing expectations; confirmed fit testing must be specific to make, model, and size of mask |
| CNA #4 | Certified Nursing Assistant | Observed wearing N95 mask not fit tested for; unaware of mask stocking details |
| CNA #5 | Certified Nursing Assistant | Observed wearing N95 mask not fit tested for; unaware of mask stocking details |
| LPN #6 | Licensed Practical Nurse | Observed wearing N95 mask not fit tested for; unaware of mask stocking details |
Inspection Report
Life Safety
Deficiencies: 0
Oct 3, 2022
Visit Reason
A Life Safety Code Survey was conducted as part of a new construction and renovation project (Phase 2) involving administration offices, a lounge, nurse station, janitor's closet, and storage room.
Findings
Spring Grove Rehabilitation and Healthcare Center was found to be in compliance with Medicare/Medicaid participation requirements for Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 Existing Health Care Occupancies. The noted renovated areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Original Licensing
Deficiencies: 0
Oct 3, 2022
Visit Reason
The survey was conducted as part of a new construction and renovation project, specifically Phase 2 renovation involving administration offices, a lounge, nurse station, janitor's closet, and storage room.
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. The renovated areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Jul 23, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146040, NJ145908, and NJ144708 regarding compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to ensure resident participation in care planning, failure to notify resident representatives of changes in condition including medication changes, and failure to conduct scheduled resident-involved care conferences. Specific deficiencies involved one resident missing care conferences and another resident's family not being notified of medication discontinuation.
Complaint Details
The complaint investigation involved three complaint intakes (NJ146040, NJ145908, NJ144708). The facility failed to ensure resident participation in care planning for Resident #2 and failed to notify Resident #3's representative of medication changes, specifically discontinuation of a medication, which was not communicated to the family despite hospitalizations and significant health events.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure resident participation in the care planning process, including scheduled resident-involved care conferences. | SS=D |
| Failure to notify resident and/or representative of changes in condition, including medication changes. | SS=D |
Report Facts
Census: 83
Sample Size: 9
Residents affected: 1
Residents affected: 1
Audit frequency: 10
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Registered Nurse #3 | Regional Registered Nurse | Interviewed regarding missed care conferences for Resident #2 |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding missed care conferences and notification processes |
| Unit Manager | Unit Manager | Interviewed regarding notification of medication changes to resident representatives |
| Physician | Physician | Interviewed regarding discontinuation of medication and family notification |
Inspection Report
Routine
Census: 86
Deficiencies: 12
Jun 3, 2021
Visit Reason
A Recertification Survey and a Complaint Visit Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to physical restraints, ADL care, activities, mobility and positioning, complaint investigations, medication administration, psychotropic drug use, hydration, and staffing ratios. The facility failed to ensure appropriate use and assessment of Broda chairs, timely toileting, meaningful activities, restorative nursing programs, medication accountability, and compliance with staffing requirements.
Complaint Details
Complaint numbers NJ00141821 and NJ00144873 triggered the survey. The complaint involved issues with physical restraints, ADL care, activities, medication administration, and staffing.
Severity Breakdown
SS=D: 7
SS=E: 5
Deficiencies (12)
| Description | Severity |
|---|---|
| Resident #34 was improperly restrained in a locked Broda chair without assessment or consent, limiting mobility and posing safety risks. | SS=D |
| Resident #74 was not toileted timely after request, lacked appropriate care plan for incontinence, and was not provided skin barrier cream. | SS=D |
| Residents in Broda chairs were positioned at tables with inappropriate heights, causing feeding difficulties. | SS=D |
| Facility failed to provide meaningful activities based on resident preferences for Residents #32, #51, and #74. | SS=D |
| Residents in Broda chairs were not appropriately assessed or monitored, and restorative nursing programs were inconsistently implemented. | SS=E |
| Resident #38 was transferred using a mechanical lift by one staff member alone, risking resident safety. | SS=D |
| Resident #75's medication times were not adjusted to accommodate dialysis schedule, risking medication errors. | SS=D |
| Facility failed to maintain accurate accountability and reconciliation for controlled drugs for Residents #74 and #75. | SS=E |
| Resident #74 was administered psychotropic medication without documented rationale or trial of non-pharmacological interventions. | SS=E |
| Resident #74's nutritional supplement preferences were not honored, and inappropriate supplements were provided despite diabetes diagnosis. | SS=D |
| Resident #74 repeatedly spilled liquids during meals but was not assessed or provided adaptive drinking cups. | SS=D |
| Facility failed to meet New Jersey minimum staffing ratios for 55 of 66 shifts reviewed, potentially impacting resident care. | SS=E |
Report Facts
Resident census: 86
Staff to resident ratio: 12.3
Staff to resident ratio: 17.4
Staff to resident ratio: 21.8
Deficiency count: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN/UM | Registered Nurse/Unit Manager | Named in findings related to Broda chair use and resident supervision |
| CNA #1 | Certified Nursing Aide | Named in mechanical lift transfer finding |
| CNA #2 | Certified Nursing Aide | Named in mechanical lift transfer finding |
| Physical Therapist | Physical Therapist | Named in Broda chair assessment and restorative nursing program |
| Occupational Therapist | Occupational Therapist | Named in Broda chair assessment and wheelchair management |
| Regional Director of Risk Management | Regional Director of Risk Management | Named in multiple findings including Broda chair use and staffing |
| Director of Nursing | Director of Nursing | Named in staffing and medication administration findings |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Named in staffing and Broda chair findings |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Named in medication administration and mechanical lift findings |
| Consultant Pharmacist | Consultant Pharmacist | Named in medication accountability findings |
| Speech Language Pathologist | Speech Language Pathologist | Named in activity and Broda chair findings |
| Director of Therapy | Director of Therapy | Named in restorative nursing program and Broda chair findings |
| Registered Nurse | Registered Nurse | Named in Broda chair and toileting findings |
Inspection Report
Life Safety
Deficiencies: 1
May 27, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/27/21 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant due to failure to maintain smoke control systems in a safe operating condition. Specifically, 13 of 38 (34%) smoke dampers failed testing, posing a risk during a smoke event. The issue was verified by the corporate Vice President of Operations and communicated to the facility Administrator.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure smoke control systems were maintained in a safe operating condition; 13 of 38 smoke dampers failed testing. | SS=E |
Report Facts
Smoke dampers failed: 13
Total smoke dampers tested: 38
Percentage of smoke dampers failed: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vice President of Operations | Corporate Vice President of Operations | Verified the smoke damper failure finding in an interview |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Jan 5, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ140910.
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 #: NJ140910. The facility was found in compliance based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 78
Deficiencies: 0
Jan 5, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted at Spring Grove Rehabilitation and Healthcare Center to assess compliance with Medicare regulations and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in substantial compliance with Medicare regulations at 42 CFR Part 483, Subpart B, and had implemented the CMS and CDC recommended practices to prepare for COVID-19.
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