Grove Park Healthcare and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) all emergency equipment was readily available at bedside for residents with tracheostomies (a surgical opening in the neck to provide an airway and remove secretions from the lungs), b.) staff were trained to use the emergency tracheostomy equipment, and c.) the primary care nurses were aware of the residents' inner cannula sizes for their tracheostomies. This deficient practice was identified for 2 of 3 residents reviewed for tracheostomy (Resident #6 and Resident #174). 1. Resident #174 was admitted to the facility on [DATE], and had a tracheostomy (trach). Observations and interviews on 02/17/26, revealed that emergency trach supplies were not being kept at Resident #174's bedside and readily available for use. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to ensure that three residents (R4, R62, and R175) out of a sample of 36 were treated with dignity and respect. Specifically, R4 was not permitted to go out on a pass without an escort even though the resident was their own responsible party. R62's Do Not Resuscitate (DNR) wristband was not removed at the time of admission and could be observed by residents and visitors. R175 was denied the ability to leave the facility due to a past positive drug test and was not informed that he/she could refuse to submit to a drug screening. In addition, facility staff entered R175's room without knocking or announcing themselves. These failures resulted in actual and potential impacts on residents' dignity, autonomy, and rights.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure a resident's rooms was clean and in good repair creating a homelike environment for one resident (Resident (R)83) of 175 residents in the facility. Failure to provide a homelike environment has the potential to affect the resident's quality of life.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure a written transfer notice that contained all required information and the bed hold notice was provided for one of four residents (Resident (R)174) and/or their resident representatives (RR) reviewed for hospital transfer out of 36 sample residents. This failure had the potential to result in the resident and their RR to not have the knowledge of where and why a resident was transferred, the bed hold policy and/or how to appeal the transfer, if desired.

Inspectors wroteBased on, record review, interviews, policy review, the facility failed to provide training for three nurses (Licensed Practical Nurse (LPN)1, LPN2 and Registered Nurse (RN)3) to have the knowledge and competency to care for three of three residents (Resident (R)6, R174 and R199) with a tracheostomy. This failed practice had the potential to cause harm to the residents that had a tracheostomy.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 119) out of five residents did not receive an unnecessary medication during medication pass.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure that one resident (Resident (R) 142) out of five residents observed during medication administration received medication in a manner to prevent possible cross contamination in a sample of 36 residents.

Inspectors wroteBased on interview, and record review, and review of pertinent documentation it was determined that the facility failed to fully investigate and implement measures to address an allegation that a visitor provided illegal, unapproved substance to a resident with history of substance abuse; which the resident ingested and reported it to the facility. This deficient practice was identified for 1 of 4 resident reviewed (Resident #1). The evident is as followed: A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but not limited to; opioid dependence, anxiety disorder, muscle wasting and atrophy. [...]

Inspectors wroteBased on observations, interviews, and review of facility policy, it was determined that the facility failed to ensure residents were treated with dignity and respect by failing to remove the weekly menus posted from resident's rooms who had a physician's order (PO) for NPO (nothing per orem (mouth)). This deficient practice was identified for 3 of 3 residents (Resident #40, #88, and #141) reviewed that had a PO for NPO. The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on the interview and review of facility records, it was determined that the facility failed to consistently serve the residents a nourishing snack when there were more than 15 hours between dinner and breakfast mealtimes. This deficient practice was identified for 4 of 5 residents (Residents #29, #61, #132, and #144) who attended during the resident council meeting and was evidenced by the following: On 10/11/24 at 10:00 AM, the surveyor conducted a group meeting with 5 alert and oriented residents selected by the facility to attend the group meeting. Four of the five residents stated they did not receive bedtime snacks. On 10/10/24 at 11:19 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the kitchen provided the five units in different floors with bedtime snacks. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: During the initial tour of the kitchen, the surveyor, together with the facility's Dietary Manager (DM) on 10/9/2024 at 10:15 AM, the surveyor observed the following: Upon entering the room where the dish machine was located, the surveyor observed 2 dietary staff inside cleaning the dishes that were used during breakfast. The surveyor asked the DM to turn on the dishwasher machine. When the DM turned on the dishwasher, the surveyor observed a significant amount of water splashing towards the drying rack where there were trays placed. [...]

Inspectors wroteBased on observation, interview, record review and policy review it was determined the facility failed to document PO (by mouth) intake of a resident who is NPO (nothing by mouth). This deficient practice was observed for 1 of 9 residents reviewed for Nutrition, Resident #40, and was evidenced by the following: On 10/10/24 at 10:50 AM, the surveyor observed Resident #40 with eyes closed in bed and their ongoing Tube Feeding (TF) (a way of providing nutrition directly into the gastrointestinal tract through an enteral access device that is placed with its tip in the stomach or small intestine) machine. A review of Resident #40's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), and Muscle Weakness. [...]

Inspectors wroteBased on observation, interview, record review, and review of other documentation, it was determined that the facility failed to: a.) consistently follow a physician's order (PO) for the application of a hand splint to the left arm, b.) consistently document accountability for the placement of heel booties, and c.) follow the residents individualized comprehensive care plan (ICCP). The deficient practice was identified for 3 of 3 residents (Resident #51, #45 and #96) reviewed for positioning and mobility. This deficient practice was evidenced by the following: 1. On 10/9/24 at 11:05 AM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. On 10/10/24 at 12:30 PM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. The surveyor reviewed Resident #51 electronic Medical Record (eMR). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure nutritional evaluation for a resident on a 3-day calorie count were addressed in a timely fashion. This deficient practice was identified for 1 of 8 residents reviewed for Nutrition (Resident #20), and was evidenced by the following: On 10/10/24 at 10:07 AM, the surveyor observed Resident #20 awake in their room. During the surveyor's interview, Resident #20 stated, the food was horrible and were lacking flavor. The resident further added they have not seen the Registered Dietitian (RD) to address these concerns and believed they may have lost weight. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a resident's routine pain level assessment was being completed and documented according to the facility's policy and standard of practice. This deficient practice was identified for 1 of 2 residents (Resident #16) reviewed for pain management. This deficient practice was evidenced by the following: On 10/9/24 at 9:45 AM, the surveyor observed Resident #16 awake in bed. The resident reported they had pain to their wound on the back. The resident further stated that they request to take pain medication frequently. On 10/9/24 at 12:17 PM, the surveyor reviewed Resident #16's electronic medical record and revealed the following information: [...]

Inspectors wroteBased on observation, interview, record review, it was determined that the facility failed to monitor and document any potential side effects (SE) for a resident who was psychotropic medication as per Physician's Order (PO). This deficient practice was identified for 1 of 5 residents (Resident #94) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 10/9/24 at 11:28 AM, the surveyor observed Resident #94 in bed with eyes closed. On 10/10/24 at 11:38 AM, the surveyor reviewed the electronic medical record of Resident #94, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately complete the resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 33 residents (Resident #45) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 10/9/24 at 10:05 AM, the surveyor observed Resident #45 seated in their wheelchair in the dining room. The resident was unable to respond to the surveyor's questions. On 10/16/24 at 9:45 AM, the surveyor reviewed the electronic Medical Record of Resident #45, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring a.) that the Infection Preventionist Nurse (IPN) was aware and involved in the facility's surveillance and monitoring of facility's water management according to standards of clinical practice, facility policy, and IPN's job description to prevent Legionella and other opportunistic waterborne pathogens to grow and spread, this deficient practice has a potential to affect the 172 residents in the facility and b.) that the linens were handled in accordance to standards in order to maintain hygienically clean laundry and prevent the spread of infection for one (1) of five (5) units, (4th-floor unit). This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure certified nurse aide (CNA) credentials were verified upon hire. This deficient practice was identified for 4 (four) of 5 (five) newly hired staff reviewed, (CNA #1, CNA #2, CNA #3 and CNA #4) and was evidenced by the following: On 6/07/23 at 01:48 PM, the surveyor reviewed the facility provided employee files of five randomly selected newly hired employees. The review included the following: CNA #1 with a date of hire (doh) of 3/21/23 had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. [...]

Inspectors wroteNJ#00163298 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate, a.) timely report, (Resident#372 and #117) and b.) a hematoma of unknown origin on 4/07/23 of Resident#95. This deficient practice was identified for three (3) of seven (7) residents reviewed for abuse and was evidenced by the following: 1. A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 4/10/23 at 9:00 PM, with an event date of 4/07/23 at 11:56 PM. The incident was reported as an allegation of resident-to-resident abuse. The event was described as follows: While Resident #372 was transferring from bed to wheelchair, Resident #117 allegedly pulled Resident #372's wheelchair from underneath him/her. This resulted in Resident #372's fall with no injury. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for three (3) of 34 residents, (Resident #40, #103, and #162) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to a.) implement interventions, clarify a physician's order to consistently monitor behaviors and document an incident in the medical record to prevent resident to resident altercations for one (1) of seven (7) residents reviewed for abuse (Resident #24); b.) ensure a resident with severe cognitive impairment, who was at risk for elopement and had a known history of wandering was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building for one (1) of one (1) resident reviewed for elopement (Resident #162); and c.) conduct an investigation and determine causal factors of a fall incident that resulted in a hematoma for one (1) of nine (9) residents, (Resident #95) reviewed for incident and accident. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) dispensed and administered controlled substance (narcotic) medication were accurately accounted for (Unsampled Resident #170, #122, and #19), b.) discontinued medication was removed from active inventory (Resident #80), which were identified separately in 2 (two) of 3 (three) medication carts, and c.) failed to maintain a system of record keeping that ensured an accurate inventory and reconciliation of controlled dangerous substance (narcotics medications), with high potential for abuse and are tracked with detail observed during medication storage inspection. The deficient practice was evidenced by the following: [...]

Inspectors wrote2. On 5/26/23 at 7:35 AM, the surveyor asked the RDCC about Resident# 137's incident/accident reports, and the RDCC stated that she will get back to the surveyor. The surveyor reviewed Resident #137's medical record. Resident #137's AR reflected that the resident was admitted to the facility had diagnoses which included but were not limited to malignant neoplasm of kidney (also called kidney cancer or renal cell adenocarcinoma), schizophrenia (a serious mental disorder in which people interpret reality abnormally), alcohol abuse, and cocaine abuse. The resident's most recent qMDS with an ARD 4/25/2023 reflected that the resident had a BIMS score of 15 out of 15 which indicated the resident's cognition was intact. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to act upon rehab referral of nursing in accordance with standards of clinical practice for one (1) of two (2) residents, (Resident#103) reviewed for a limited range of motion (ROM). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) follow the Nurse Practitioner's (NP's) order for a stat (an abbreviation of statim means immediately) order of xray and b) notify the physician or nurse practitioner of the results that fall outside the clinical reference ranges (abnormal results) in accordance with standards of clinical practice to ensure the facility identify and provide needed care and services in accordance to resident's goals for care of one (1) of 34 residents reviewed, (Resident #95). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, the facility failed to a) ensure the indwelling urinary catheter (tube that is inserted for continuous drainage of the bladder) drainage tubing was stored in a manner to prevent Urinary Tract Infection (UTI) and b) develop and implement a care plan (CP) that included interventions that addressed catheter care based on current professional standards of practice to prevent UTI for 1 (one) of 2 (two) residents reviewed for urinary catheter care or UTI (Resident #164). The deficient practice was evidenced by the following: Reference: The Healthcare Infection Control Practices Advisory Committee guidance titled GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 with an updated date of June 6, 2019, includes the following: III. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to: a.) ensure physician orders for oxygen were implemented, and b.) maintain sustainability by following their plan of correction from the last recertification survey for the same deficient practice, and c.) perform appropriate hand hygiene during tracheostomy (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe) care observation consistent with professional standard of practice and Centers for Disease Control & Prevention (CDC) guidelines. This deficient practice was identified for 1 (one) of 2 (two) residents reviewed for respiratory care (Resident #111). The evidence was as follows: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a resident's preference for nectar thickened water was honored (Resident #157). This deficient practice was identified for 1 (one) of 1 (one) resident reviewed for choices and was evidenced by the following: On 5/23/23 at 12:52 PM, the surveyor interviewed Resident #157. The resident stated that he/she asked and did not receive a nectar thickened water, I have requested multiple times and they keep giving me nectar thickened milk and nectar thickened apple juice. I have requested from the [Certified Nursing Assistant] CNA. I called my CNA, and she told me they don't have nectar thickened water in the building. The surveyor reviewed the medical record for Resident #157. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer a resident the pneumonia vaccination. This deficient practice was identified for 2 (two) of 5 (five) residents, (Resident #95 and #143), reviewed for vaccination status and was evidenced by the following: Centers for Disease Control & Prevention (CDC) recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: (last reviewed 02/13/23). 1. On 5/22/2023 at 11:00 AM, the surveyor observed Resident #95 walking around the third floor hallway. The surveyor reviewed Resident #95's medical record. The resident's admission Record (AR; or face sheet; [...]

Inspectors wroteBased on interviews, it was determined that the facility failed to provide Saturday mail delivery services to residents. This deficient practice was identified for 5 (five) of 5 (five) residents interviewed during the resident council group meeting (Residents #9, #60, #61, #73 and #83) and was evidenced by the following: On 5/26/23 at 10:21 AM, during a resident council group meeting with Residents #9, #60, #61, #73 and #83, the surveyor asked the residents if they received mail on Saturdays. Resident #61 stated that they do not receive mail on Saturdays and that they have to wait until Monday to receive the mail from the Social Services Director (SSD). The other four residents were in agreement that mail was not delivered to them on Saturdays. [...]