Inspection Reports for Spring Grove Rehabilitation And Healthcare Center

144 Gales Drive, NJ, 07974

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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)
DescriptionSeverity
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)
DescriptionSeverity
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
NameTitleContext
CNA 4Certified Nursing AssistantNamed in incident involving Resident #8 where care was provided without required assistance; discharged due to violation of company policy.
LPN 3Licensed Practical NurseEntered room during Resident #8 incident and assessed the resident.
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)
DescriptionSeverity
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
NameTitleContext
RN/UMRegistered Nurse/Unit ManagerNamed in findings related to Broda chair use and resident supervision
CNA #1Certified Nursing AideNamed in mechanical lift transfer finding
CNA #2Certified Nursing AideNamed in mechanical lift transfer finding
Physical TherapistPhysical TherapistNamed in Broda chair assessment and restorative nursing program
Occupational TherapistOccupational TherapistNamed in Broda chair assessment and wheelchair management
Regional Director of Risk ManagementRegional Director of Risk ManagementNamed in multiple findings including Broda chair use and staffing
Director of NursingDirector of NursingNamed in staffing and medication administration findings
Licensed Nursing Home AdministratorLicensed Nursing Home AdministratorNamed in staffing and Broda chair findings
Registered Nurse SupervisorRegistered Nurse SupervisorNamed in medication administration and mechanical lift findings
Consultant PharmacistConsultant PharmacistNamed in medication accountability findings
Speech Language PathologistSpeech Language PathologistNamed in activity and Broda chair findings
Director of TherapyDirector of TherapyNamed in restorative nursing program and Broda chair findings
Registered NurseRegistered NurseNamed in Broda chair and toileting findings
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.
Report Nov 20, 2025
File
20251120-REPORT-notice_of_privacy_practices.pdf
Report Jan 30, 2025
File
20250130-COMPLAINT-HZ2W11.pdf
Report Nov 13, 2024
File
20241113-COMPLAINT-4YKZ11.pdf
Report Nov 1, 2023
File
20231101-COMPLAINT-PCER11.pdf
Report Aug 15, 2023
File
20230815-ROUTINE-YYJL11.pdf
Report Dec 3, 2022
File
20221203-ROUTINE-5HHB11.pdf
Report Oct 3, 2022
File
20221003-ROUTINE-Z4TU11.pdf
Report Oct 3, 2022
File
20221003-ROUTINE-Z4TU21.pdf
Report Jul 23, 2021
File
20210723-COMPLAINT-ZZZI11.pdf
Report Jun 3, 2021
File
20210603-ROUTINE-ZN2W21.pdf

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