Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grove Park Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of substance abuse, who was receiving medication-assisted treatment and had intact cognition, reported ingesting a marijuana-infused brownie given by a visitor. The facility contacted the transportation company identified by the resident, but after the company denied knowledge of the individual, the facility ended its investigation without further follow-up, contrary to its own policy requiring thorough incident investigations.
The facility failed to treat residents with NPO orders with dignity by posting weekly menus in their rooms. Three residents with ongoing tube feeding and cognitive impairments were observed with menus, despite their dietary restrictions. The Recreation Director acknowledged placing menus without considering individual dietary needs, contrary to the facility's dignity policy.
The facility failed to provide bedtime snacks to residents, resulting in a gap of more than 15 hours between dinner and breakfast. Four residents reported not receiving snacks, and the Food Service Director confirmed the absence of a system to document snack distribution. The facility's policy required bedtime snacks, but there was no accountability or documentation to ensure compliance.
The facility failed to maintain proper kitchen sanitation practices, as observed by a surveyor. During a kitchen tour, the surveyor noted water splashing from the dishwasher onto meal trays placed on a drying rack. The trays were wet nesting and stacked together, which the Dietary Manager confirmed were used to serve residents' meals. The DM acknowledged that trays should not be stacked to ensure complete drying, and the LNHA confirmed the absence of a policy on tray drying.
A facility failed to accurately document the nutritional intake for a resident who was NPO, as the care plan incorrectly included goals for oral intake. The resident, with a history of dysphagia and gastrostomy, was receiving tube feeding, yet the RD's notes mistakenly aimed to maintain oral intake. The error was acknowledged by the RD, and facility leadership agreed that NPO residents should not have oral intake goals.
The facility failed to follow physician's orders and document the application of medical devices for three residents. A resident was observed without heel booties, another without a hand splint, and a third without heel booties, despite orders for their use. Staff interviews revealed a lack of awareness and documentation, and facility policies lacked guidance on documenting device application.
A resident with dysphagia, gastrostomy, and gastritis did not receive a timely nutritional evaluation after a 3-day calorie count, as required by the facility's policy. The RD, working remotely, delayed the assessment by 10 days, and missing meal percentage recordings were noted. The resident expressed dissatisfaction with food quality and had not seen the RD to address concerns.
A facility failed to document routine pain assessments for a resident with multiple diagnoses, including chronic osteomyelitis and pressure ulcers. Despite the resident's frequent requests for pain medication, there were no physician's orders for pain assessment or monitoring. An LPN confirmed that pain assessments were not completed every shift, contrary to the facility's policy requiring regular assessments for acute and chronic pain.
A facility failed to monitor and document side effects for a resident on psychotropic medication, as required by the Physician's Order. The resident, with severe cognitive impairment and on Olanzapine for symptoms like anxiety and depression, had no monitoring order in their eMAR. An LPN confirmed the absence of such an order, and the DON acknowledged this deficiency, which violated the facility's policy on psychoactive medication use.
A resident with severely impaired cognition was inaccurately assessed in the MDS, as it failed to reflect the administration of antipsychotic medication, despite evidence from medical records and staff confirmation. The MDS Coordinator acknowledged the error, and facility leadership recognized the inaccuracy.
Failure to Fully Investigate Alleged Provision of Illegal Substance to Resident
Penalty
Summary
The facility failed to fully investigate and implement measures to address an allegation that a visitor provided an illegal, unapproved substance to a resident with a history of substance abuse. The resident, who had diagnoses including opioid dependence and was receiving medication-assisted treatment for addiction, reported to the facility that a friend working for a transportation company gave them a marijuana-infused brownie. The resident's cognitive status was assessed as intact, and their care plan documented their substance abuse history and ongoing treatment. Upon learning of the incident, the facility contacted the transportation company, which denied having a driver by the name provided by the resident. After receiving this denial, the facility ended its investigation without further action. The facility's policy required prompt initiation and documentation of investigations into accidents or incidents, but the investigation was not pursued beyond the initial inquiry with the transportation company.
Failure to Remove Menus for NPO Residents
Penalty
Summary
The facility failed to ensure that residents with a physician's order for NPO (nothing by mouth) were treated with dignity and respect. This deficiency was identified for three residents who had ongoing tube feeding and were observed with the facility's weekly menu posted in their rooms. The presence of these menus was inappropriate given their NPO status, as it disregarded their dietary restrictions and could potentially affect their dignity and self-esteem. Resident #141, #40, and #88 were all observed with menus posted in their rooms despite having medical conditions such as dysphagia, gastrostomy, and cognitive impairments that necessitated NPO orders. The Recreation Director admitted that their department placed menus in every resident's room without considering individual dietary restrictions. The facility's policy on dignity emphasized treating residents with respect and sensitivity, particularly those with cognitive impairments, which was not adhered to in these instances.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to consistently provide nourishing snacks to residents when there was a gap of more than 15 hours between dinner and breakfast. This deficiency was identified during a group meeting with five alert and oriented residents, where four residents reported not receiving bedtime snacks. The Food Service Director (FSD) confirmed that while snacks were provided to the units, there was no accountability system in place to ensure that residents received their snacks, as there was no snack log or documentation available. The facility's policy on meal delivery times indicated a 15-hour gap between dinner and breakfast across all floors, which necessitated the provision of bedtime snacks. However, the Resident Council Meeting Minutes from previous months did not address the issue of food and bedtime snacks. During a meeting with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), both acknowledged the lack of documentation for bedtime snacks, which was contrary to the facility's policy that required providing bedtime snacks to residents.
Inadequate Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation practices, as observed during a surveyor's visit. During the initial tour of the kitchen, the surveyor, accompanied by the Dietary Manager (DM), observed two dietary staff cleaning dishes used during breakfast. When the DM turned on the dishwasher, a significant amount of water splashed towards the drying rack, where meal trays were placed. The DM acknowledged the water splash issue and indicated that the drying rack was used to dry meal trays. The surveyor noted that the trays were wet nesting and stacked together, which the DM confirmed were used to serve residents' meals. The DM admitted that the trays should not be stacked together to ensure they dry completely. The Licensed Nursing Home Administrator (LNHA) later confirmed that the facility lacked a policy and procedure regarding tray drying. The DM agreed that trays must not be stacked to allow for complete drying. This deficiency was discussed with the LNHA, Director of Nursing, Chief Nursing Officer, and the Regional Educator, but no further information was provided.
Inaccurate Documentation of Nutritional Intake for NPO Resident
Penalty
Summary
The facility failed to document the appropriate nutritional intake for a resident who was designated as NPO (nothing by mouth). This deficiency was identified during a survey when it was observed that the resident, who was receiving nutrition through a tube feeding machine, had a care plan that incorrectly included goals for oral intake. The resident had a medical history of dysphagia, gastrostomy, and muscle weakness, and was admitted with a physician's order for an NPO diet. Despite this, the Registered Dietitian's progress notes mistakenly included a goal to maintain oral meal and snack intake above 50%, which was not applicable to the resident's NPO status. The surveyor's review of the resident's medical records and interviews with facility staff confirmed the error in documentation. The Registered Dietitian acknowledged the mistake in the progress notes, stating that the resident did not take food or medication orally. The facility was unable to provide a policy regarding the accuracy of documentation, and during a meeting with the survey team, facility leadership agreed that residents with an NPO order should not have goals related to oral intake in their records.
Failure to Follow Physician's Orders and Document Device Application
Penalty
Summary
The facility failed to consistently follow physician's orders and document the application of medical devices for three residents, leading to deficiencies in care. Resident #51 was observed without heel booties on two separate occasions, despite having a physician's order for their use to prevent skin breakdown. The resident's electronic medical records did not reflect the order, and staff interviews revealed a lack of awareness and documentation regarding the application of the heel booties. Resident #45 was observed without a hand splint on two occasions, despite a physician's order for its use to manage hemiplegia and hemiparesis. Interviews with staff indicated that the splint was not applied as required, and there was a lack of documentation to confirm its use. The Director of Rehabilitation confirmed the order for the splint, and staff acknowledged the need for compliance with such orders. Resident #96 was also observed without heel booties, which were ordered for daily use while in bed. Staff interviews revealed that the heel booties were not consistently applied, and there was no documentation to confirm their use. The Director of Nursing acknowledged the oversight, and a review of facility policies showed a lack of guidance on documenting the application of such devices.
Delayed Nutritional Evaluation for Resident
Penalty
Summary
The facility failed to ensure a timely nutritional evaluation for a resident who was on a 3-day calorie count. This deficiency was identified for a resident with diagnoses including dysphagia, gastrostomy, and gastritis. The resident expressed dissatisfaction with the food quality and mentioned not having seen the Registered Dietitian (RD) to address these concerns, suspecting weight loss. The resident's cognition was intact, as indicated by a perfect score on the Brief Interview for Mental Status. A physician's order dated September 11, 2024, required a 3-day calorie count to observe meal and fluid intake, but the evaluation of this calorie count was delayed by 10 days after its completion. The RD, who works remotely, acknowledged the oversight in not completing the progress note within the expected timeframe of one to two days after the calorie count. The facility's policy required the dietitian to review daily caloric intake and assess the adequacy of caloric intake over the three-day period, initiating interventions if necessary. However, the RD's evaluation was not conducted in a timely manner, and the facility's leadership was aware of this delay. The surveyor noted missing meal percentage recordings for lunch and dinner on the last day of the calorie count, further contributing to the deficiency.
Failure to Document Routine Pain Assessments
Penalty
Summary
The facility failed to ensure routine pain level assessments were completed and documented for a resident, as per the facility's policy and standard of practice. This deficiency was identified during a survey when a resident, who was awake in bed, reported experiencing pain from a wound on their back and frequently requested pain medication. A review of the resident's electronic medical record revealed that the resident had been admitted with multiple diagnoses, including chronic osteomyelitis, open wound on the left lower leg, unstageable pressure ulcer in the sacral region, stage 3 pressure ulcer on the left heel, and paraplegia. The resident's cognitive status was assessed as intact, and they were on a pain medication regimen that included Morphine Sulfate ER, Oxycodone HCl, and Acetaminophen. Despite the resident's frequent requests for pain medication, there were no physician's orders to document pain assessment or monitoring. An interview with an LPN confirmed that the resident was alert, oriented, and able to verbalize pain, but pain assessments were not completed every shift. The facility's policy required pain assessments at least each shift for acute pain or significant changes in chronic pain levels, and at least weekly for stable chronic pain. The Licensed Nursing Home Administrator and Director of Nursing acknowledged the lack of pain assessment and monitoring during a discussion with the survey team.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor and document potential side effects for a resident on psychotropic medication as per the Physician's Order. This deficiency was identified during a survey when a resident was observed in bed with eyes closed, and a review of their electronic medical record revealed that there was no order to monitor for side effects of the psychotropic medication. The resident, who had severe cognitive impairment and was on antipsychotic medication, was admitted with diagnoses including dementia, anxiety, and mood disorder. Despite being on Olanzapine for target symptoms such as anxiety and depression, there was no documentation or monitoring for side effects as required by the facility's policy. The surveyor's interview with an LPN confirmed that the electronic Medication Administration Record did not include an order for monitoring or assessing the psychotropic medication's side effects. The Director of Nursing acknowledged the absence of such an order during a meeting with the survey team. The facility's policy on psychoactive medication use mandates that nursing staff monitor and report side effects and adverse consequences to the attending physician, which was not adhered to in this case.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment of the resident's status. The resident, who was observed to have severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 7 out of 15, was taking antipsychotic medication as per the physician's order and the electronic Medication Administration Record (eMAR). However, the MDS inaccurately reflected that the resident did not receive antipsychotic medication, despite evidence to the contrary. The surveyor's review of the resident's medical records and interviews with the Licensed Practical Nurse (LPN) and the MDS Coordinator/Registered Nurse (MDSC/RN) confirmed the error in the MDS coding. The MDSC/RN acknowledged that the psychotropic medication should have been coded as 'yes' in the MDS, aligning with the Resident Assessment Instrument (RAI) manual guidelines. The facility's leadership, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), also recognized the inaccuracy in the MDS assessment during discussions with the survey team.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,168 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near East Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Orange Park | 0.4 mi | — | 13 | 0 |
| Park Crescent Healthcare & Rehabilitation Center | 0.9 mi | — | 0 | 0 |
| Sinai Post-acute Nursing & Rehab Center | 1.4 mi | — | 1 | 0 |
| Brookhaven Health Care Center | 1.5 mi | — | 0 | 0 |
| Alaris Health At St Marys | 1.5 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Grove Park Healthcare And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.