Inspection Reports for
Spring Grove Rehabilitation And Healthcare Center

Complaint 2613838 was substantiated based on interviews, record reviews, and facility documentation showing a breach of confidentiality involving Resident #4's medical information being discussed with Resident #3 present during a care conference.

The facility failed to keep resident medical information confidential when a care conference was held with the incorrect resident present, resulting in a privacy breach. The Unit Manager began reading Resident #4's medication information while Resident #3 was present, which was recognized by Resident #4's family member, leading to the meeting being stopped.

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.

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.

The investigation was complaint-driven, including complaints NJ 172317, NJ 172237, NJ 174618, and NJ 175890, focusing on resident care issues such as call bell accessibility, notification of Medicare coverage termination, wound care, incontinence care, injury treatment delays, oxygen therapy, and medication management.

The facility was found deficient in multiple areas including failure to keep call bells within residents' reach, failure to issue required Medicare/Medicaid notices, failure to follow physician orders for wound care, inadequate incontinence care, delayed assessment and treatment of a resident injury, failure to administer oxygen as ordered, and failure to identify medication irregularities during pharmacist review.

Complaint numbers NJ 172317, NJ 172237, NJ 174618, NJ 175890 were investigated. The incontinence care complaint was substantiated with findings of inadequate care for multiple residents. The injury and delayed treatment complaint was substantiated for Resident #101, with documented delays in nursing assessment and pain management following an injury sustained during therapy.

The facility failed to ensure timely incontinence care for 7 of 8 residents observed, with multiple residents found wearing two saturated incontinence briefs, causing potential skin breakdown. Additionally, the facility failed to provide timely assessment and treatment for a resident who sustained an ankle injury during therapy, resulting in a delayed diagnosis of a fracture and delayed pain management.

Complaint numbers NJ 172237, 172317, 172380, 174618, 175850, 176226, 176966, 177870 were investigated during this survey.

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.

The complaint investigation was substantiated based on observation, interviews, and record review. The fall incident occurred on 04/01/24 when CNA 4 was providing care alone to a resident requiring two-person assistance, resulting in the resident falling out of bed and sustaining a small abrasion. CNA 4 was suspended and discharged due to violation of company policy and code of conduct.

The facility failed to ensure one resident remained free from accident hazards, resulting in a fall with minimal harm. The investigation revealed inadequate supervision and failure to follow care protocols, including a staff member providing care alone despite the resident requiring two-person assistance.

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.

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.

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.

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 numbers NJ00151595, NJ00159657, NJ00152188, NJ00152300, NJ00152562, NJ00159269, NJ00160307, NJ00164302 triggered the survey.

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 investigations revealed issues with environmental cleanliness, medication management, staffing shortages, infection control, and dietary preferences. Specific complaints included unclean rooms, improper medication coding, insufficient shower documentation, and inadequate staffing ratios.

The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate resident assessments, medication management, infection control practices, sufficient staffing ratios, honoring resident dietary preferences, and environmental cleanliness. Specific issues included unclean resident rooms, improper storage of COVID test kits, full sharps containers, inaccurate MDS coding, failure to monitor medication indications, inconsistent shower documentation, improper wound care practices, insufficient CNA staffing, and accumulation of dust and lint in the laundry room.

The complaint investigation was triggered by reports of unclean resident rooms, improper use of central baths as storage, pest infestations, and insufficient nursing staff to meet residents' needs. The investigation included interviews, observations, and record reviews confirming these issues.

The facility failed to ensure a safe, clean, and homelike environment, evidenced by unclean resident rooms, improper storage in central baths, and pest issues. Additionally, the facility did not maintain the required minimum direct care staff-to-shift ratios, resulting in insufficient nursing staff to meet residents' needs, including toileting assistance and meal tray distribution.

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.

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.

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.

The facility was found deficient in multiple areas including improper use and assessment of Broda chairs as restraints, delayed toileting assistance, inadequate activity programming, failure to implement restorative nursing programs, medication administration discrepancies, failure to adjust medication times for dialysis, failure to provide adaptive eating equipment, and insufficient staffing ratios.

Complaint numbers NJ00141821 and NJ00144873 triggered the survey. The complaint involved issues with physical restraints, ADL care, activities, medication administration, and staffing.

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.

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.