Arbor Glen Center

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program in 1 of 1 kitchen observed. The deficient practice was evidenced by the following: During the initial tour on 12/1/25 at 9:51 AM, the surveyor observed the dual conventional oven that had a stove and a grill on top. The Food Service Director (FSD) stated the stove and grill on top were being used to cook residents' food. The FSD stated the dual ovens in the bottom do not get used for cooking. The surveyor did not observe any signage that the dual ovens in the bottom were out of order or not to be used. The surveyor opened the dual ovens and observed inside four strips of glue board traps with dead roaches. The surveyor observed inside the first oven five dead roaches on one glue board, and seven dead roaches on another. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to follow its Grievance/Concern Policy by failing to a.) thoroughly investigate a grievance filed by unsampled resident, b.) followed through the concerns of 1 of 1 resident during resident council meeting, and c.) notify the residents of the comprehensive resolution with regard laundry concerns identified during resident council meeting for 5 of 5 residents (Residents #23, #31, #42, #61, and #65). This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 2 of 21 residents (Residents #20 and #39) call bells were within reach, able to use to accommodate residents' needs, and follow facility's call light policy. This deficient practice was evidenced by the following: 1. On 12/8/25 at 11:01 AM, Surveyor #1 (S #1) in the presence of the Registered Nurse/Unit Manager #1 (RN/UM #1) entered Resident #39's room and both observed the resident lying in a low bed with a cane by their side. S#1 observed the resident's call bell wrapped up in a loop and clipped to the wall where the system was attached to the wall. The call bell was not within reach of the resident. S #1 asked RN/UM #1 if the resident could reach the call bell, and she replied no they cannot. [...]

Inspectors wroteComplaint # 406936Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan for 1 of 24 residents (Resident #98) reviewed for comprehensive care plans. This deficient practice was evidenced by the following: 1. On 12/9/25 at 9:04 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #98. A review of the admission Record (an admission summary) revealed that Resident #98 had diagnoses that included, but were not limited to; chronic kidney disease, peripheral vascular disease (a condition where blood vessels outside of the heart and brain become narrowed or blocked), hypertension (high blood pressure), and difficulty walking. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to update and revise the comprehensive care plan of a resident. This deficient practice was identified for 2 of 24 residents reviewed, Resident #9 and Resident #33. The deficient practice 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteComplaint # 2682000Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to ensure that a resident received a physician's order for Librium in a timely manner or notify the physician that the ordered medicine was unavailable for additional orders for 1 of 24 sampled residents reviewed (Resident #63). This deficient practice was evidenced by: A review of Resident #63's admission Record 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 observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to complete post dialysis communication record assessments upon the resident's return from the dialysis center for 1 of one 1 resident, (Resident #6), reviewed for dialysis services, and consistent with professional standards of practice. 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 review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 3 of 5 days in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: On 12/1/25 at 10:55 AM, Surveyor #1 (S #1) interviewed Registered Nurse/Unit Manager #1 (RN/UM #1) in unit 1 nursing station, who informed S #1 that the unit's census was 16, with two Certified Nursing Aides (CNAs) for 7:00 AM-3:00 PM (7-3) shift. On 12/1/25 at 11:08 AM, S #1 interviewed RN/UM #2, who informed the surveyor that the unit's census was 26 in unit 4, with three CNAs for 7-3 shift. [...]

Inspectors wroteBased on observation, interview, review of the medical records, and other facility documentation, it was determined that the facility failed to; a.) provide adequate monitoring for the use of psychoactive medication for 1 of 5 residents (Resident #7), b.) review duplicate orders for the as needed (PRN) bowel regimen medications for 2 of 5 residents (Residents #7 and #35), and c.) review, clarify, and sequenced the PRN pain medications for 1 of 5 residents (Resident #7), reviewed for unnecessary medications. The deficient practice was evidenced by the following: 1. On 12/1/25 at 11:00 AM, Surveyor #1 (S #1) observed Resident #7 lying on bed, awake, and informed S #1 that they were at the facility for short term rehabilitation. S #1 reviewed the medical records for Resident #7. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 2 medication carts observed on 1 of 1 medication storage areas 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 wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to retain health files for staff that were no longer employed with the facility for the timeframe required, for 2 of 20 new employee files reviewed. This deficient practice was evidenced by the following: On 12/1/25 at 10:14 AM, during entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the medical files of the facility's 20 new hire employees since their last recertification survey. On 12/4/25 at 10:18 AM, the surveyor asked the LNHA for additional files for employees that were not given to the surveyor. The LNHA stated that the files were sent to storage if they were no longer employed with the facility and that she was calling to get the files. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for soiled linens and waste to decrease the possibility of spreading infection. The deficient practice was observed during tour on 1 of 4 units. This deficient practice was evidenced by the following: On 12/8/25 at 11:17 AM, the surveyor observed with a Registered Nurse Unit Manager (RN/UM) the soiled utility room of Unit #1. The RN/UM stated the designated room was the only soiled utility room on the unit. The room had signage which indicated storage room and was secured with a keypad lock. Upon entering the room, the surveyor accompanied by the RN/UM observed on the front, right side of the room, one covered yellow colored bin with signage indicating only soiled diapers please; [...]

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.) 2 of 2 dining areas, b.) 1 of 4 unit hallways, and c.) and 2 of 21 sampled residents (Residents #20 and #33) rooms. This deficient practice was evidenced by the following: 1. On 12/2/25 at 11:23 AM, Surveyors #1 (S #1) and Surveyor #2 (S #2) in the presence of the Registered Nurse/Unit Manager (RN/UM) observed the 2nd floor dining (also known as the activity room) area with 10 residents and one activity staff. The surveyors and the RN/UM observed the six heating system inside the grill with dried leaves, plastics, pieces of puzzles, papers, and grayish substances which the RN/UM confirmed that was accumulation of dust and should have been cleaned. [...]

Inspectors wroteComplaint # 406965Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure that the physician was notified in a timely manner of a resident's change in condition for 1 of 3 residents reviewed for transfer to the hospital (Resident #1). This deficient practice was evidenced by the following:On 11/10/25 at 9:30 AM, the surveyor reviewed Resident #1's closed medical record. A review of Resident #1's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint #: NJ00184015 Based on interviews, medical record reviews, and review of other pertinent facility documents on 03/06/2025, it was determined that the facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse between a Certified Nursing Assistant (CNA), Home Health Aide (HHA), and a resident (Resident #1). On 02/28/2025 at approximately 1:10 PM, Resident #1 verbalized that their skin was bruised due to rough handling by two staff members during transfer that morning. The accused CNA continued to care for residents with no additional supervision after 1:10 PM on 02/28/2025 and on 03/04/2025 before the facility's investigation was complete. Interviews with the Director of Nursing (DON) on 03/06/2025 and Clinical Lead for New Jersey (CLNJ) on 03/07/2025 revealed that the facility did not conduct a thorough investigation into the abuse allegation. [...]

Inspectors wroteBased on the interview and review of pertinent facility documentation, the facility failed to have the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) present for one (1) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 111 residents who currently live in the facility. The deficient practice was evidenced by the following: On 8/01/24 at 9:44 AM, the surveyor met with the LNHA and the DON during an Entrance Conference meeting. Both the LNHA and the DON confirmed that day census (total number of residents) of 111 with no bed hold. On 8/01/24 at 12:09 PM, the LNHA provided the last three-quarters of QAPI sign-in sheets and revealed the following: QAPI Attendance: 01/17/24=the Medical Director (MD), DON, and other Interdisciplinary Team (IDT) signed the QAPI Attendance sheet. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy for one of (1) of two (2) residents, (Resident #82), reviewed for hospitalizations. This deficient practice is evidenced by the following: On 8/01/24 at 10:39 AM, the surveyor observed Resident #82 lying on their bed while watching the television with an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine). There was an Enhanced Barrier Precaution (EBP) sign outside the door. The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #82. [...]

Inspectors wroteBased on observation, interview, and record review 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, in accordance with federal guidelines for three (3) of 24 residents, Residents #23, 109, and 167, reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. The surveyor reviewed the electronic health record (EHR) of Resident #109 which revealed the following: The admission Record (AR; a summary of important information about the resident) revealed that Resident #109 had diagnoses that included, but were not limited to, spinal stenosis (narrowing of the space around the spinal cord), osteoporosis (a condition which bones become weak and brittle), and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) act upon the recommendations of the Urologist for one (1) of two (2) residents (Resident #82) reviewed for the care of urinary catheter and b.) ensure a resident's medication administration time was adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) for one (1) of one (1) resident (Resident #12), reviewed for dialysis, according to facility's policies and standards of clinical practice. 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 wroteComplaint#: NJ#174298 Based on interviews, record review, and review of other pertinent facility-provided documentation, the facility failed to ensure a.) that the resident with injury of unknown origin received treatment and implemented an intervention according to comprehensive assessment and person-centered care plan in accordance with professional standards of practice, and facility's policy and procedure for one (1) of three (3) residents, Resident #165, reviewed for abuse. 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 wroteComplaint #NJ160835 Based on interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of clinical practice for a resident with pressure ulcers. This deficient practice was identified in one (1) of four (4) residents, Resident #168, reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following: On 8/05/24 at 12:19 PM, the surveyor reviewed the hybrid (paper and electronic) medical records for Resident #168. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, dementia, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to initiate an active care plan for smoking and complete the entire smoking assessment for one (1) of one (1) resident reviewed for smoking (Resident #24). This deficient practice was evidenced by the following: On 8/01/24 at 01:45 PM, the surveyor reviewed the facility provided list of smokers which reflected that Resident #24 was an independent smoker. On 8/05/24 at 10:25 AM, the surveyor reviewed Resident #24's electronic medical record and revealed: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) was comprehensively evaluated and care planned to receive appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of one (1) resident (Resident #91) reviewed for mood and behavior. This deficient practice was evidenced by the following: On 8/01/24 at 10:01 AM, the surveyor observed Resident #91 resting in bed. The resident was alert, and verbally responsive. Resident #91 stated they liked to stay in their room and watch television. The resident verbalized no concerns. [...]

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 the target behavior for the use of a psychotropic medication specifically a antipsychotic medication (used to manage psychosis, a mental disorder characterized by a disconnection from reality) by not having an order for behavior monitoring and indicating the target behavior on the resident's individualized care plan for one (1) of five (5) residents (Resident #36) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 8/06/24 at 9:44 AM, the surveyor observed Resident #36 seated upright in bed. On 8/06/24 at 01:06 PM, the surveyor reviewed Resident #36's hybrid (a combination of paper, scanned, and computer-generated records) medical record. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices for one (1) of two (3) staff (Housekeeper) and b.) follow transmission-based precautions (TBP) and enhanced barrier precautions (EBP) protocol to prevent the potential spread of infection for two (2) of two (2) residents (Residents #82 and #108) reviewed for infection control, in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: [...]

Inspectors wroteBased on observation, interview, record review, it was determined that the facility failed to maintain dignity during mealtime for a resident who needed assistance with eating. This deficient practice was observed for 1 of 25 residents reviewed, Resident #26 and was evidenced by the following: On 8/8/22 at 12:25 PM, the surveyor observed Resident #26 in bed, eating lunch when she called the Certified Nurse's Aide (CNA) for assistance. The CNA entered the resident's room placing paper trash (removed from protected articles on the tray) ex. Straw paper covering) on top of the resident's meal tray. The surveyor further observed that the CNA was standing over the resident while feeding. The surveyor interviewed the CNA on 8/9/22 at 12:30 PM, and specified that staff should be seated next to the resident while assisting them during feeding time. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident's call light was readily accessible for a resident who was dependent on staff for care. This deficient practice was identified for 2 of 25 residents reviewed for call bell/light (CBL), Resident #26 and #84, evidenced by the following: 1.) On 8/11/22 at 1:16 PM, the surveyor observed Resident #84's door closed. When the surveyor knocked on the door, the resident stated that she needed the nurse. The surveyor observed that the CBL was hanging toward the floor and out of reach for the resident. The surveyor asked the resident about the CBL. Resident #84 informed the surveyor that they didn't know that there was a CBL to use whenever they needed assistance. The surveyor handed the CBL to the resident. The surveyor observed Resident #84 press the CBL for assistance. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 1 of 25 residents reviewed for resident assessment (Resident #1). This deficient practice was evidenced by: On 8/17/22 at 1:30 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. Resident #1 was observed to have a Discharge MDS with an Assessment Reference Date (ARD) of 5/13/22 and was due to be transmitted no later than 6/10/22. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the appropriate management of an enteral feeding formula. This deficient practice was identified for 1 of 5 residents reviewed for tube feeding (Resident #25), and was evidenced by the following: On 8/9/22 at 1:38 PM, the surveyor observed Resident #25 in bed, in a room where the resident was connected to oxygen via tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) tube along with a feeding pump that was turned off at the time. On 8/15/22 at 11:07 AM, the surveyor observed Resident #25 in bed receiving tube feeding regulated by a pump. The surveyor noted that the feeding pump was set at 60 ml/hr with a total fed display of 1065 ml and 135 ml left to feed. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure a.) that a concentrator for a resident who was dependent on supplemental oxygen (O2) via a tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) had the proper settings, b.) that the O2 supply for a resident who was dependent on supplemental O2 via a tracheostomy was connected properly and c.) that a resident who was dependent on supplemental O2 via a tracheostomy had a valid physician's order for O2 in place. This deficient practice was identified for 1 of 2 residents reviewed with a tracheostomy (Resident #25), and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) accurately follow facility policy related to the wasting of contaminated medication, b.) ensure that physician ordered hold parameters were accurately followed, c.) accurately document the administration of an as needed (prn) controlled substance. This deficient practice was identified for 4 of 24 residents reviewed for medication management (Resident #164, #95, #25 and #161), and was evidenced by the following: 1. On [DATE] at 8:42 AM, the surveyor observed the Unit 1 Registered Nurse (RN) prepare medication for administration to Resident #164. During the medication preparation the RN dropped Losarten 100-12.5 mg (an antihypertensive medication) on the contaminated medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices identified during 3 of 22 residents observed for infection control breaches, Resident # 95, #25 and #61. This deficient practice was evidenced by the following: 1. On 8/11/22 at 9:05 AM, the surveyor observed the Unit 3 Licensed Practical Nurse (LPN3) prepare for the administration of medication to Resident #95. Prior to the administration of medication, LPN3 removed a device from her pocket, a Pulse Oximeter (Pulsox) (a noninvasive device placed on the fingertip which uses a light beam to estimate the oxygen saturation and pulse rate). The surveyor did not observe LPN3 sanitize the Pulsox prior to placing the device on the resident's finger. When LPN3 completed the Pulsox check, she placed the Pulsox back into her pocket. [...]