Maple Glen Center

Inspectors wroteBased on observation, interviews, and a review of facility documentation, it was determined that the facility failed to ensure that a facility wide assessment was reviewed and updated to identify the required services and procedures necessary to protect the health, safety, and welfare of all residents to ensure adequate facility resources to provide resident care and services. These failures had the potential to affect all 122 residents who currently live in the facility during the time of the survey. This deficient practice was evidenced by the following:During the entrance conference on 8/26/25 at 9:45 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) documents to complete the survey process which included but were not limited to Facility Assessment (FA). [...]

Inspectors wroteBased on observations and interviews on 8/27/25 and 8/28/25 in the presence of the Senior Maintenance Director (SMD) and Maintenance Director (MD), it was determined that the facility failed to ensure that the resident call bell system was properly functioning in all areas. This deficient practice had the potential to affect all (122) residents and was evidenced by the following:Observations on 8/27/25 from 12:44 PM to 12:50 PM, revealed:The call bell system failed to activate for room [ROOM NUMBER] when tested by the MD. The light outside of the room did not turn on, and no audible or visual notification was given at the nurse's station. The call bell system failed to activate for room [ROOM NUMBER] when tested by the MD. The light outside of the room did not turn on, and no audible or visual notification was given at the nurse's station. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 2 of 4 nursing units (Units 2 and 3) observed during environment tour. This deficient practice was evidenced by: 1. On 8/27/25 at 11:35 AM, Surveyor #1 (S#1) with Licensed Practical Nurse #1 (LPN#1) went inside Resident room [ROOM NUMBER] (RR#208) and observed the following: The dresser top area with used coffee cup and plastic wrappers. The 1st drawer of the dresser near the window with peeled wood and there was a coffee cup that was mixed with resident's unfolded clothes. LPN#1 stated that the peeled wood needed a glue. The 2nd drawer of the dresser with small food plastic container (with dried food) that was mixed with unfolded clothes. [...]

Inspectors wroteREPEAT DEFICIENCYBased on interview and record review, it was determined that the facility failed to submit the Minimum Data Set (MDS) assessments in a timely manner for 2 of 27 residents reviewed (Resident # 74 and Resident #109). The deficient practice was evidenced by the following:On 8/29/25 at 10:16 AM, the surveyor reviewed the most recent MDS's, an assessment tool used to facilitate the management of care, for the timeliness of submission for three system-selected residents. Information in the electronic medical record and additional information provided by the facility revealed the following for two of the residents:1. Resident #74 had a discharge (d/c) MDS with an Assessment Reference Date (ARD) of 3/28/25. The MDS was completed but had not been submitted.2. Resident #109 had a d/c assessment with an ARD of 4/9/25. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to maintain professional standards of clinical practice by failing to a.) update a physician order for wanderguard with the correct expiration date for 1 of 1 resident, (Resident #12), reviewed for elopement and b.) ensure a medication was administered to a resident and not left at the bedside for 1 of 24 residents (Resident #13). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to: a) administer tube feeding per the physician's order (PO) and b) document the total volume according to PO and standards of clinical practice for 2 of 2 residents (Residents #2 and #9), reviewed for receiving nutrition via tube feeding, and was evidenced by the following:1. On 8/26/25 at 10:32 AM, Surveyor #1 (S#1) observed Resident #2's room was closed with an Enhanced Barrier Precautions (EBP) posted sign outside the door. Inside the resident's room, the resident's privacy curtain was pulled halfway, the resident's eyes were closed, tube feeding (TF, nutrition received through a flexible tube surgically inserted into the stomach) pump was on at 40 ml/hr (milliliter/hour), and Jevity 1.5 container was hung on the pole. [...]

Inspectors wroteBased on interview, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 27 residents (Resident #2), identified during Medication Regimen Review (MRR). This deficient practice was evidenced by the following:A review of the U.S. FDA (United States Food and Drug Administration) medication (med) guide for prevacid delayed release capsules., revised September 2012, reflected the instructions for use.should be taken before eating. Prevacid delayed release capsules through a nasogastric tube or larger, as prescribed by the doctor:.you can only use apple juice. 1. Open the capsule (cap) and empty the granules into a syringe. 2. Do not break or crush the granules. 3. Mix with 40 ml (milliliters) of apple juice. Do not use other liquids. 4. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure a Surety Bond was in place to provide coverage to protect resident personal needs account funds held by the facility. The deficient practice could affect all residents who had personal needs funds held by the facility and was evidence by the following:During the entrance conference on 8/26/25 at 9:45 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) documents to complete the survey process which included but were not limited to the facility's Surety Bond. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 of 3 residents (Residents #71 and #113), reviewed for beneficiary notification. The deficient practice was evidenced by the following:On 9/2/25 at 10:01 AM, the surveyor reviewed the beneficiary notification of three randomly selected residents from a facility provided list of residents who were discharged (d/c'd) from Medicare Part A services in the last six months which revealed the following: 1. Resident #71 had a last covered day from Medicare Part A services of 8/15/25 and remained a resident in the facility. There was no documentation that the resident received a SNF ABN.2. Resident #113 had a last covered day from Medicare Part A services of 8/18/25 and remained a resident in the facility. [...]

Inspectors wroteComplaint #: NJ00181779 Based on interviews, record review and review of pertinent facility documents, it was determined that the facility failed to protect the confidentiality and privacy of a resident (Resident #6)) during an investigation of an alleged sexual incident between the Resident and a staff member that is in accordance with the facility's written abuse prohibition policy. This deficient practice was identified for 1 of 6 residents and was evidenced as follows: According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses that include but not limited to: Abnormalities of Gait and Mobility, Radiculopathy, Lumbar Region, Benign Prostatic Hyperplasia, Chronic Pancreatitis, Adjustment Disorder with Mixed Anxiety and Depressed Mood, Personality Disorder, and Functional Intestinal Disorder. [...]

Inspectors wroteComplaint #: NJ00175767 Based on interviews, record review, and review of pertinent facility documents on 03/11/2025, it was determined that the facility failed to develop a baseline care plan with a focus [problem area] to address a special procedure, Pleurex Drainage (the process of removing excess fluids from spaces around the lungs) specific for a newly admitted resident (Resident #1) who had diagnosis of pleural effusion (a condition where excess fluids accumulates in spaces around the lungs). Resident #1 was not in the facility during the survey. This deficient practice was identified for 1 of 6 residents and was evidenced as follows: According to Resident #1's admission Record (AR), the resident was admitted to the facility with the following diagnoses that included but not limited to: [...]

Inspectors wroteComplaint #: NJ00175767 Based on interview and review of pertinent facility documents, it was determined on 03/11/2025 that the facility failed to ensure that a licensed nurse had the specific competency and skills set necessary to care for a resident's needs involving a Pleurex drainage (the process of removing excess fluids from spaces around the lungs) specific for Resident #1who had a diagnosis of pleural effusion (a condition where excess fluids accumulate in spaces surrounding the lungs). Resident #1 was not in the facility during the survey. This deficient practice was identified for 1 of 6 residents and was evidenced as follows: According to Resident #1's admission Record (AR), the resident was admitted to the facility with the following diagnoses that included but not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that medication orders that included parameters were not followed by the medication administering nurse. This was observed in 1 out of 3 nurses during medication administration. This 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 registered professional nurse is defined as diagnosing and treating human responses to actual or 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. 1. [...]

Inspectors wrote3. On 3/18/24 at 11:41 AM, the surveyor observed Resident #32 in the room with eyes closed. The resident was also observed with a tracheostomy in place (a medical device inserted into a surgically created opening in the trachea to facilitate breathing) in place. The surveyor also observed that Resident #32 was in the process of receiving their feed of Glucerna at a rate of 75 ml/hr via feeding pump. The surveyor reviewed Resident #32's hybrid medical records. The AR reflected that Resident #32 was admitted to the facility with medical diagnoses which included but not limited to Sepsis, Chronic Respiratory Failure, Dysphagia and Type II Diabetes Mellitus. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Minimum Data Set (MDS) timely for 1 of 27 residents reviewed, Resident #37 and was evidenced by the following: On 3/21/24 at 12:01 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is 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 up to 14 days of the assessment being completed. After transmitting of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. Resident #10 was observed to have an Entry MDS with an Assessment Reference Date (ARD) of 9/19/23 and was due to be completed no later than 9/26/23. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a.) implement the appropriate infection control precautions and personal protective equipment (PPE) for a resident actively treated for MRSA (Methicillin resistant Staphylococcus aureus), an MDRO (Multidrug Resistant Organism) for 1 of 2 resident (Resident # 47); b.) ensure proper use of personal protective equipment (PPE) for 1 of 4 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control; c.)perform hand hygiene appropriately for 4 of 11 staff; and d.) ensure that residents were offered and provided hand hygiene before and after meals. This deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services of a resident who was receiving oxygen and suctioning as needed according to the standard of practice. This deficient practice was identified for 1 of 1 resident (Resident #59) and evidenced by the following: On 11/3/21 at 10:58 AM, during initial pool, the surveyor observed Resident # 59 in bed awake with a tracheostomy (an opening surgically created through the neck into the trachea). The surveyor observed an oxygen concentrator next to the bed which was not in use. The oxygen tubing and humidification bottle was dated 10/4/21. There was a suction machine on top of the resident's bedside nightstand which had approximately 150 milliliters' (ML) of fluid in the suction canister. The tubing for the suction machine was dated 10/4/21. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in three (3) of five (5) medication carts and one (1) of three (3) medication refrigerators that were inspected. This deficient practice was evidenced by the following: On [DATE] at 10:25 AM, the surveyor inspected the Unit-3 low-side in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of Glucose test strips that were not dated and an unopened Levemir Insulin Pen that was stored in the medication cart. The surveyor interviewed LPN #1 who stated that an opened bottle of blood glucose test strips should have been dated and an unopened Levemir insulin pen should have been stored in the medication refrigerator. [...]

Inspectors wroteBased on observation, record review and review of pertinent documentation, it was determined that the facility failed to respond to a tap bell that was rung by a resident to call staff on two survey days. The tap bells were being used by residents in Station 4 after the electronic call light system had malfunctioned. This deficient practice was observed for 1 of 10 residents (Resident #148) in the admission Operation Unit (AOU) hallway and was evidenced by the following: On 11/03/21 at 11:45 AM, during the initial tour of the facility, the surveyor toured the AOU unit in which all residents were under droplet precautions and had the doors to their rooms closed. The surveyor observed Resident #148 towards the end of the hallway, far from the nurse's station, who had opened the door and was standing in the entry of his/her room. [...]