Spring Grove Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) 3 of 7 linen carts in 2 of 3 nursing units (North and [NAME] units), b.) 4 of 7 resident rooms (Rooms 10, 17, 18, and 20), and c.) 1 of 2 central baths (South unit) observed during environmental tour. This deficient practice was evidenced by the following: 1. On 3/24/26 at 11:20 AM, Surveyor #1 (S #1) observed during [NAME] unit tour two linen carts parked in between room [ROOM NUMBER] with posted sign for respiratory isolation and room [ROOM NUMBER] with posted sign for contact precaution. S #1 observed 1of 2 linen carts cover was ripped and there were clean linen supplies inside the ripped linen cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity during the medication (med) administration observation. This deficient practice was identified in 1 of 4 residents (Resident #43) observed during the med pass observation. This deficient practice was evidenced by the following: On 3/26/26 at 8:42 AM, the surveyor observed the Registered Nurse (med RN) assigned to Resident #43 prepare medications (meds) for administration to the resident. The surveyor observed the medRN enter the resident's room with the meds. The medRN stated that the resident was not in bed but was receiving care and being assisted in the lavatory. The surveyor observed the medRN enter the lavatory and administer meds to Resident #43 while they were seated on the toilet. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor target behavior for the use of psychotropic medications (meds) specifically an antianxiety and antidepressant meds and ensure an antianxiety medication was ordered for an appropriate diagnosis or indication for 1 of 5 residents (Resident #1), reviewed for unnecessary meds. This deficient practice was evidenced by the following: On 3/24/26 at 11:33 AM, the surveyor observed Resident #1 seated in their bed while on nebulizer treatment. A review of Resident #1's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool to facilitate the plan of care, to accurately reflect the residents' status as of the Assessment Reference Date (ARD) for 2 of 23 residents reviewed (Residents #1 and #4). The deficient practice was evidenced by the following: 1. On 3/24/26 at 11:33 AM, Surveyor #1 (S #1) observed Resident #1 seated in their bed while on nebulizer treatment. A review of Resident #1's admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), muscle weakness, difficulty walking, and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to correctly document administration of medications (meds) during the medication (med) administration observation. This deficient practice was identified for 2 of 4 residents observed during the med pass observation (Resident #43 and Resident #69). 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, and record review, it was determined that the facility failed to ensure that a resident with a Stage 3 pressure ulcer received care and services consistent with professional standards of practice, by failing to, a.) document the required daily wound care treatment on the electronic Treatment Administration Record (eTAR), and b.) to follow up on the wound care consultant's recommended change in treatment. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for pressure ulcer treatment and wound care documentation, and 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, and record review, it was determined that the facility failed to, a) ensure that an active physician order was in place for the management, care, and monitoring of a nephrostomy tube upon a resident's return from the hospital for 1 of 2 residents (Resident #10), and b) ensure that the comprehensive care plan accurately reflected the current status of a resident's indwelling urinary catheter following discontinuation of the device for 1 of 2 residents (Resident #57), reviewed for urinary catheter or UTI (Urinary Tract Infection), and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 3/25/26 at 10:35 AM, Surveyor #1 (S #1) observed Resident #10 lying in bed. Enhanced Barrier Precautions (EBP) signage was posted at the door. [...]

Inspectors wroteREPEAT DEFICIENCYBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) maintain the necessary respiratory care and services of residents in accordance with professional standards of practice and b.) follow physician orders, for 2 of 5 residents, (Resident #3 and Resident #139) reviewed for respiratory care. 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 and record review, it was determined that facility failed to provide pharmaceutical services in accordance with professional standards of nursing practice by failing to, a.) monitor and document pain levels and b.) administer the correct medication for pain according to the physician's orders. This deficient practice was identified for 1 of 23 residents (Residents #58) reviewed for medication administration. This deficiency 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, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted prior to the start of the current shift for 2 of 5 days during the annual re-certification survey. This deficient practice was evidenced by the following:On 3/24/26 at 8:55 AM, upon entry to the facility, the survey team observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main entrance. The NHRCSR posted was dated 3/23/26 (incorrect date) with a census of 100, for the (7:00 AM to 3:00 PM) day shift. There was no NHRCSR posted for 3/24/26. On 3/24/26 at 12:30 PM, the License Nursing Home Administrator (LNHA) provided NHRCSR dated 3/24/26, which revealed a census of 100; 2 Registered Nurses (RN); [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the implementation and accurate documentation of behavioral health monitoring for 2 of 5 residents reviewed, (Residents #4 and #9), reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 3/24/26 at 11:00 AM, Surveyor #1 (S #1) observed Resident #4 seated in his wheelchair (w/c) in the hallway outside their room. The resident responded to yes and no questions but did not engage in further conversation and was noted to be confused at baseline. On 3/25/26 at 10:39 AM, a second observation revealed the resident seated calmly in their w/c looking out the window in the hallway. No behavioral concerns were noted during this observation. S #1 reviewed the medical record for Resident #4. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure availability of a medication (med) for 1 of 4 residents (Resident #21) observed during the facility's med pass observation. The 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 and record review, it was determined that the facility failed to act upon Consultant Pharmacist (CP) recommendations for 3 of 23 residents (Resident #1, Resident #6 and Resident #58), from 2 of 3 nursing units, whose medication regimen were reviewed. This deficient practice was evidenced by the following: 1. On 3/24/26 at 11:33 AM, Surveyor #1 (S #1) observed Resident #1 seated in their bed while on nebulizer treatment. A review of Resident #1's admission Record or face sheet (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), muscle weakness, difficulty walking, and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store and label medication (med) per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 3 med carts and 1 of 2 med storage rooms observed in the facility. 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteComplaint: 2613838 Based on interviews, record reviews, and review of facility documentation it was determined that the facility failed to a.) keep resident medical information confidential and b.) follow their Resident Rights policy. The deficient practice was identified for one of 3 residents reviewed for medical records (Resident #4). This deficient practice was evidenced by the following:According to the, admission Record, Resident #4 was admitted to the facility with diagnoses including but not limited to: muscle wasting and atrophy (loss of muscle mass and strength); type 2 diabetes (chronic condition where the body cannot keep blood sugar at a normal level); need for assistance with personal care; and chronic lymphocytic leukemia (cancer of the blood and bone marrow). [...]

Inspectors wroteComplaint# NJ 174618 Based on interview, review of closed medical records, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate care was provided with no delay in treatment for a resident who sustained an injury during rehabilitation therapy on 2/23/24, complained of pain and was not assessed by a Registered Nurse until 2/25/24 (two days later), and the physician ordered an x-ray which indicated a non-displaced fracture of the medial malleolus (ankle fracture). This deficient practice was identified for 1 of 3 closed medical records reviewed (Resident #101), and 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, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 6 of 37 residents reviewed for accommodation of needs (Resident #70, #15, #1, #48, #13, and #86), and was evidenced by the following: a. On 10/22/24 at 10:43 AM, the surveyor observed Resident #70 in bed, with his/her eyes closed. Resident #70 did not respond to the surveyor's greeting. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was not within the Resident's reach. On 10/23/24 at 12:59 PM, the surveyor observed Resident #70 in bed with his/her eyes closed. Resident #70 did not respond to the surveyor. The surveyor observed the resident's call bell was not within the Resident's reach. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and/or the Notice of Medicare Non-coverage (NOMNC) for 3 of 3 residents (#82, #349, #348) reviewed for facility change notifications regarding insurance termination. The evidence is as follows. On 10/28/24 at 11:28 a.m., the facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and were required to have received Beneficiary Notices. The surveyor reviewed 3 of the residents listed (Resident #82, #349, #348) who were discharged from a Medicare Part A stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. [...]

Inspectors wroteComplaint # NJ 172317, NJ 172237; NJ 174618; NJ 175890 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 7 of 8 residents (Resident #82, #199, #48, #13, #86, #24, and #14) observed for incontinence care on 2 of 4 units (North Unit and [NAME] Unit). This deficient practice was evidenced by the following: On 10/24/24 at 7:35 AM, the surveyor completed an incontinence tour on the North Unit and observed the following: a. On 10/24/24 at 7:40 AM, the surveyor accompanied by Registered Nurse (RN #1) observed Resident #82 in bed. RN #1 exposed Resident #82's incontinence brief. At that time when RN #1 exposed the incontinence brief another incontinence brief was observed which was saturated with urine. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a.) discontinue a treatment order for a healed wound and b.) follow a physician's treatment order. The deficient practice was identified for 1 of 18 residents (Resident # 50) reviewed for physician orders and is 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 administer oxygen therapy according to the physician's order for 1 of 1 resident, (Resident #1) reviewed for respiratory care and services. This deficient practice was evidenced by the following: On 10/23/24 at 1:20 PM, the surveyor observed Resident #1 in his/her room seated in a geriatric chair. The resident did not respond to the surveyor. The surveyor observed an oxygen concentrator in the Resident's room, not in use. The surveyor observed a sign above the resident's bed which instructed to ensure oxygen was in use. At that time, the surveyor observed the Registered Nurse (RN) assigned to Resident #1's care entered the room and stated that the oxygen should have been on since the resident was supposed to be on continuous oxygen. [...]

Inspectors wroteBased on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to identify psychoactive medication irregularity, twice in four months, during the monthly MRR (Medication Record Review) of the CP (Consultant Pharmacist) for one (1) of five (5) residents reviewed for unnecessary medication, Resident #30. This deficient practice was evidenced by the following: On 10/23/24 at 11:20 AM, the surveyor observed the Resident's door of the room was closed. The surveyor knocked on the door and was opened by the Licensed Practical Nurse/Supervisor (LPN/S). The LPN/S offered his assistance, to the surveyor, and the surveyor politely declined. The LPN/S exited the room, while the surveyor entered the room. At that time, the surveyor observed Resident #30 was asleep, and was not roused by the surveyor's voice. [...]

Inspectors wroteC#NJ00168013 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one resident (Resident (R) 8) out of three residents investigated for falls, remained free from accident hazards. This had the potential to cause serious harm to a resident with Alzheimer's disease.

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to: a) ensure a safe, clean, comfortable, and homelike environment for 2 (two) of 7 (seven) residents, (Residents #69 and #143) and b) ensure that the residents Central Bath (use for shower by the residents) was safe, clean, and not used as a storage room for 2 (two) of 2 (two) Central Baths (CB) observed during environment tour. This deficient practice was evidenced by the following: 1. On 8/02/23 at 9:02 AM, the survey team entered the facility and there was a posted sign on the door upon entry that there was a COVID case in the facility. The Receptionist instructed the surveyors to use the kiosk (automated health screening for COVID-19 questions). [...]

Inspectors wrote2. On 8/02/23 at 11:06 AM, the surveyor asked the LNHA and the DON in the presence of the RDO the whereabouts of Resident #143 and the RDO informed the surveyor that the resident was discharged (d/c) on 01/27/22 to another facility. The surveyor asked for the closed record, grievances, incidents/accident reports, and reportable events since the last recertification and the facility management stated that they will get back to the surveyor. The surveyor reviewed the medical records of Resident #143 as follows: The admission Record (or face sheet; [...]

Inspectors wrote2. A review of the manufacturer's specifications for Flomax (tamsulosin), under section 1. Indication and Usage included an indication for the treatment of the signs and symptoms of benign prostatic hyperplasia (non-cancerous enlargements of the prostate glands which potentially slows or blocks the urine). The surveyor reviewed the medical record for Resident #293. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to ensure a) that a physician's wound care order was followed and clarified, b) provide wound care in accordance with the facility's policy and professional standards of clinical practice and Centers for Disease Control and Prevention (CDC) guidance for 1 (one ) of 2 (two) residents (Resident #27) reviewed for pressure ulcers. 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 state: [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure that the left thumb splint was consistently applied according to the physician's order. This deficient practice was identified for 1 (one) of 2 (two) residents reviewed for limited range of motion (ROM), Resident #57, and was evidenced by the following: During the initial tour on 8/02/23 at 10:36 AM, the surveyor observed Resident #57 in bed, with a left thumb dressing that appeared stained with yellow and brown discoloration. The resident had limited movement of the left thumb. There was not a date or initials on the gauze. On 8/03/23 at 10:31 AM, the surveyor observed the resident, in bed, with a left thumb dressing that was visibly stained with yellow and brown discoloration. The resident had limited movement of the left thumb. [...]

Inspectors wroteComplaint # NJ00151595 and NJ00159657 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored. The deficient practice was identified for one (1) of two (2) residents reviewed for dietary concerns (Resident #7) and was evidenced by the following. On 8/02/23 at 11:01 AM, the surveyor observed Resident #7 within their room and conversant. Resident #7 stated, they were supposed to be on a low carbohydrate and low salt diet because of their diabetes and kidney disease. The resident stated they had informed the dietician of their preferences but there were still no available choices for their needs. On 8/02/23 at 12:46 PM, Resident #7 informed the surveyor that he/she had fettuccine alfredo for lunch today and the food was not bat. [...]

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) used COVID test kits were not stored inside the Central Bath (where staff provides showers to residents) and b) sharp container was sealed and replaced with a new container when reached the full line (75% to 80% full) according to the standard of practice and facility policy. This deficient practice was evidenced by the following: On 8/02/23 at 9:02 AM, the survey team entered the facility and there was a posted sign on the door upon entry that there was a COVID case in the facility. The Receptionist instructed the surveyors to use the kiosk (automated health screening for COVID-19 questions). Later on, the Director of Nursing (DON) informed the surveyors that there was a COVID outbreak at the facility, with two residents remained in isolation. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a safe and sanitary environment in 1 (one) of 1 (one) laundry room in accordance with the facility procedures. This deficient practice was evidenced by the following: On 8/15/23 at 8:47 AM, the surveyor toured the laundry room in the presence of the Housekeeping Director (HD), District Manager (DM), and Laundry Staff (LS). The surveyor observed in the drying area and folding area of the laundry room an electric fan that was on the wall that was in use and vent#1 above the ceiling with an accumulation of white substance and dust wherein below were folded clean towels, linens, blankets, and house gowns. There was also a cable wire connected to a wall with an accumulation of dust. [...]

Inspectors wroteBased on interviews, 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 1 (one) of 20 residents, (Resident #7) reviewed, and was evidenced by the following: 1. On 8/14/23 at 10:11 AM, the surveyor reviewed Facility Task generated Resident Assessment sampled resident for MDS discrepancy that included Resident #7's MDS for admission on [DATE]. The surveyor reviewed Resident #7's medical records. The resident's admission Record (or face sheet; [...]