Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maple Park Village during CMS and state inspections, most recent first.
Two residents with dementia and significant mental health histories were subjected to physical abuse by a CNA. In one case, a blind resident was found by an LPN with the CNA kneeling by the bed, both hands over the resident’s mouth and nose, telling him to be quiet; the resident was later documented with facial swelling, a skin tear, bruising, and complaints of headache and neck pain, and reported that the man tried to kill him. In the other case, a trauma-survivor resident, care-planned to receive female caregivers when possible, received personal care from the same male CNA, who later described using a military-style arm maneuver to break her grip, during which he struck her chin. This resident was documented with loose front teeth, extensive bruising under the chin, on both cheeks, hands, and neck in various stages of healing, and required dental evaluation for mobile teeth and a lost bridge. Staff interviews described the CNA as frequently stressed, frustrated, and performing unsafe care, with some residents reportedly afraid of him.
The facility failed to follow ordered medication hold parameters and failed to notify the physician of abnormal blood glucose readings. A resident with CHF received Entresto even when systolic BP was below the ordered hold threshold, and another resident with DM had blood glucose readings above the ordered notification limit without documented physician notification. The DON and Medical Records staff confirmed the Entresto should have been held, and there was no documentation that the physician was notified of the elevated glucose readings.
Medications lacked appropriate supporting diagnoses and, for one resident, a stop date. A resident with a history of herpes viral infection was started on valacyclovir for painful blisters, but the order used an aftercare diagnosis and did not include when the med would stop. Two other residents had multiple orders, including amlodipine, aspirin, atorvastatin, meropenem, famotidine, amantadine, and Humira, entered with incorrect or short-term aftercare diagnoses; RN and the DON acknowledged the diagnosis and stop-date issues.
Staff failed to properly use PPE and perform hand hygiene during isolation care, catheter care, and wound care. A CNA entered an isolation room with an untied gown and another entered without required eye protection; a CNA also donned gloves without hand hygiene during catheter care, and an LPN continued wound care without changing gloves or cleaning hands after removing contaminated items.
A resident with a J-tube was not administered the correct rate of enteral feeding due to a malfunctioning pump set at a default rate of 400 ml/hr instead of the ordered 45 ml/hr. Despite staff attempts to correct the issue, the resident experienced complications, including emesis and decreased oxygen saturation, leading to hospitalization.
The facility failed to conduct quarterly care plan meetings for two residents, resulting in outdated care plans. One resident with chronic conditions missed two meetings, while another with hydronephrosis and heart issues missed a scheduled meeting. The facility's policy mandates quarterly reviews, which were not followed.
The facility failed to follow physician's orders for medication administration for two residents, leading to a deficiency in care. One resident received metoprolol succinate despite having a systolic blood pressure (SBP) and heart rate (HR) below the ordered hold parameters. Another resident was given the same medication when their SBP was below the specified threshold. The Director of Nursing confirmed these instances, and the facility lacked a policy on adhering to physician's orders.
The facility failed to properly label and store medications and food. Unlabeled food items were found in a medication room refrigerator, and loose tablets were discovered in a medication cart without their original containers. The DON confirmed that food should be labeled, and the facility's policy requires medications to be stored in their original containers.
A cook in the facility was observed preparing pureed tuna casserole in an unsanitary manner by licking the food off her finger and then handling the food processor without washing her hands. The cook admitted to the inappropriate action during an interview. The facility's food handling policy requires adherence to state and local sanitation standards.
A facility failed to properly administer and document a narcotic pain patch for a resident with chronic pain conditions. The patch was administered early and not rotated as required, and there was a lack of proper documentation and destruction of the patch. Additionally, the facility did not maintain accurate narcotic count sheets, with missing signatures for on-coming and off-going nurses across multiple units.
Failure to Protect Two Cognitively Impaired Residents From Physical Abuse by a CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by a CNA, affecting two residents with cognitive impairments and significant medical histories. One resident, who was legally blind and had dementia with mood disturbance, major depressive disorder, and pain, was involved in an incident during incontinence care. According to staff interviews, a CNA became involved in a combative situation with this resident while providing care. An LPN, responding after hearing the resident yelling in a muffled way, entered the room without knocking and observed the CNA with his left knee bent on the bed, both hands over the resident’s mouth and nose, and telling the resident to “shut the hell up” while raising his hands up and down over the resident’s face. Another CNA reported that when she and the LPN entered, the resident appeared visibly shaken, frightened, and was shaking, and later stated that the man had held his hand over his mouth and tried to kill him. Subsequent documentation for this resident included a nursing progress note indicating a head-to-toe assessment that identified a bruise and a 0.5 cm skin tear on the left outer arm, swelling near the left eyebrow, and redness near the right side of the mouth, along with complaints of headache and neck pain. A social service note documented that the resident did not sleep well that night. The resident later reported in an interview that some man had attacked him and that he thought he was going to die. The resident’s care plans documented legal blindness and hearing loss, with interventions to obtain his attention prior to speaking and to maintain his physical safety, but the incident occurred during personal care despite these identified needs. The second resident involved had dementia, psychotic disorders with delusions and hallucinations, generalized anxiety disorder, osteoarthritis, major depressive disorder, and a documented history of trauma and prior abuse. Her care plan identified her as a survivor of abuse at risk for re-traumatization, with triggers including the sight of a male resident, and directed staff to ensure emotional and physical safety, including providing female caregivers during personal care when possible and explaining care before and during provision. Despite this, she was receiving personal care from a male CNA. During the facility’s investigation into the first resident’s abuse allegation, it was discovered that this same CNA reported using a “tactic move” learned from military experience—a circular arm motion—to break the resident’s grip when she had hold of his wrists, during which he struck the left side of her chin. Clinical records and staff statements for the second resident documented multiple physical findings temporally associated with the CNA’s care. Nursing notes recorded three loose front teeth on the left side, later confirmed by a dentist who found mobility of teeth and a lost bridge, with referral to an oral surgeon for extractions. Bruising under the chin and on both cheeks, in various stages of healing, was identified and measured, with additional bruises noted on both anterior hands and under the neck. Staff statements indicated that another staff member reported the CNA was responsible for the resident’s missing teeth, describing that the resident did something to him and he moved his arms in a way that caused her teeth to fall out. Other staff reported that the CNA admitted he might have caused the bruising by crossing his arms in front of his chest, possibly hitting her chin with his elbow while trying to avoid being hit, and that he referred to having to “declaw the cat,” which he explained as clipping the resident’s nails. Multiple staff also reported that this CNA was frequently stressed, frustrated, fatigued, and showed signs of burnout, and that some residents were afraid of him, linking him to unusual bruises and unsafe, rushed transfers.
Failure to Follow Medication Hold Parameters and Notify Physician of Abnormal Blood Glucose
Penalty
Summary
The facility failed to ensure a medication was held according to ordered parameters for a resident with chronic diastolic heart failure, hypertensive heart disease, and chronic kidney disease with heart failure. The physician ordered Entresto 49-51 mg twice daily with instructions to hold the medication if systolic blood pressure was less than 120. Review of the MAR showed the medication was administered multiple times when the resident’s systolic blood pressure was below 120, including 13 administrations in one month and 5 administrations in the following period. Medical Records staff and the DON both indicated the medication should have been held according to the physician’s order. The facility also failed to notify the physician of abnormal blood glucose readings for a resident with type 2 diabetes, hypertension, and mixed hyperlipidemia. The care plan identified the resident as being at risk for adverse effects of hyperglycemia and hypoglycemia and directed staff to document abnormal findings and notify the physician. A physician’s order required notification if blood glucose was greater than 350 or below 60. The MAR/TAR showed blood glucose readings of 400 and 360, and there were no progress notes or observation documentation showing the physician was notified as ordered.
Medications Lacked Supporting Diagnoses and a Stop Date
Penalty
Summary
The facility failed to ensure physician-ordered medications had appropriate supporting diagnoses and, for one resident, a stop date. For Resident 11, the record showed a history of herpes viral infection that had resolved, yet a 7/7/25 physician note described painful blisters on the bilateral thighs and vaginal area and initiated valacyclovir 500 mg daily without documenting when the medication would stop or providing supporting documentation for the duration of use. The physician order listed valacyclovir for the diagnosis of encounter for other specified aftercare, which the DON stated was not an appropriate diagnosis and the medication was missing a stop date. For Resident 5, physician orders for amlodipine, aspirin, atorvastatin, and meropenem all listed encounter for other specified aftercare as the diagnosis. For Resident 13, physician orders for amlodipine, aspirin, atorvastatin, famotidine, and amantadine also used encounter for other specified aftercare, and a Humira order listed extrapyramidal and movement disorders as the diagnosis. RN 10 stated encounter for specific aftercare was a short-term diagnosis used when the correct diagnosis could not be found at the time of order entry and that staff were responsible for changing it to the correct supporting diagnosis; RN 10 also stated that if a medication did not include a stop date, the nurse would contact the physician for clarification. The Infection Preventionist stated the diagnoses for meropenem and Humira were not correct, and the DON stated the facility did not have a policy regarding medications with supporting diagnoses or stop dates.
Infection Control PPE and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure staff wore Personal Protective Equipment properly, wore the appropriate PPE when entering an isolation room, performed hand hygiene, and changed gloves during care for 3 of 7 residents reviewed for infection control. For Resident 57, who had diagnoses including hypertension, type 2 diabetes mellitus without complications, and cough, a physician’s order dated 9/10/25 indicated isolation for an active infection transmitted by physical contact or airborne or droplet transmission, and the care plan identified isolation related to infectious disease/cough. During observation, one CNA donned a gown, mask, and gloves outside the room but did not tie the gown at the neck before entering the droplet/contact isolation room, and another CNA entered the room without wearing the eye protection required by the posted precautions. Both staff members acknowledged the PPE issues during interview. For Resident 34, during observed catheter care, a CNA filled a wash basin, placed it on the bedside table with clean linen, put on a protective gown, and then put on gloves without performing hand hygiene after touching items in the resident’s environment. For Resident 5, during observed wound care, an LPN and RN donned PPE, removed the old dressing, cleaned the wound, and continued care without changing gloves or performing hand hygiene after discarding the dressing and 4 by 4. The LPN then opened sterile supplies and Santyl, applied the ointment and dressing, and only removed gloves and washed hands after completing the procedure. The Infection Preventionist stated hand hygiene was to be performed after touching items in the resident’s environment, gowns were to be tied at the neck, and hand hygiene was to be completed before donning gloves and after removing gloves.
Failure to Administer Enteral Feeding at Correct Rate
Penalty
Summary
The facility failed to ensure that a resident with continuous feeding through a Jejunostomy tube (J-tube) received the ordered amount of nutrient formula at the correct rate. Resident B, who had multiple medical conditions including multiple sclerosis, quadriplegia, and coronary artery disease, was supposed to receive Osmolyte 1.5 at 45 milliliters per hour via J-tube. However, the feeding pump was found to be set at a default rate of 400 milliliters per hour, which was not in accordance with the physician's order. The issue was compounded by a malfunctioning feeding pump that had been disconnected from a power source, making it impossible to access the pump's history. Despite attempts to rectify the situation, the pump continued to show a rate of 400 ml/hr, which was the factory reset. The night shift nurse had replaced the old pump with a new one and set the flow rate correctly, but the default rate of infusion was still 400 ml/hr. This discrepancy was not identified until after the resident experienced complications. On the morning of the incident, the resident was found with yellow emesis on her face and gown, and the feeding pump was beeping. The resident's condition deteriorated, leading to decreased oxygen saturation and eventual hospitalization. The facility's documentation and interviews with staff revealed that the feeding pump had been running at an incorrect rate, contributing to the resident's distress and subsequent medical emergency.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings at least quarterly for two residents, leading to a deficiency in maintaining updated care plans. Resident 5, who has chronic obstructive pulmonary disease with acute exacerbation, chronic systolic heart failure, and hypertension, had their last care plan meeting in March 2024. The Social Service Director confirmed that Resident 5 missed two care plan meetings that should have occurred in May and early August. Similarly, Resident 59, diagnosed with hydronephrosis, chronic atrial fibrillation, and acute chronic diastolic heart failure, had their last care plan meeting in June 2024. The Social Service Director acknowledged that Resident 59 was due for a care plan meeting in September 2024, which had not been scheduled. The facility's policy requires interdisciplinary comprehensive person-centered care plans to be developed and implemented, with reviews conducted quarterly, but this was not adhered to for these residents.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's ordered hold parameters for medication administration for two residents, leading to a deficiency in quality of care. Resident 36, diagnosed with essential hypertension, type 2 diabetes, and hyperlipidemia, had a physician's order to hold metoprolol succinate if the systolic blood pressure (SBP) was less than 110 or heart rate (HR) was less than 60. Despite this, the medication was administered on multiple occasions when the resident's SBP and HR were below the specified thresholds, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed the administration of the medication during these times. Similarly, Resident 55, with diagnoses including essential hypertension, type 2 diabetes, and edema, had a physician's order to hold metoprolol succinate for an SBP less than 120 or HR less than 55. The MAR showed that the medication was given on several dates when the SBP was below the ordered parameter. The DON acknowledged the administration of the medication outside the prescribed parameters. The facility did not provide a policy on following physician's orders, contributing to the deficiency.
Improper Labeling and Storage of Medications and Food
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as well as the appropriate use of medication room refrigerators. During an observation, it was found that the 200-hall medication room refrigerator contained two unlabeled cans of Canada Dry and a grocery sack with an unlabeled to-go container of food. The Registered Nurse (RN) present was unsure of the ownership of these items, and the Director of Nursing (DON) confirmed that food in the refrigerator should be labeled. This indicates a failure to adhere to the facility's policy on labeling personal food items brought into the facility. Additionally, in the Moving Forward South medication cart, 20 white oval tablets marked 4H2 (cetirizine) and one round white tablet were found loose in the bottom drawer without a corresponding bottle. RN 5 suggested that something might have spilled, and the DON noted that the cart had been cleaned that morning. The facility's policy requires medications and biologicals to be stored in their original containers, which was not followed in this instance. These observations highlight lapses in the facility's adherence to its policies on medication storage and labeling.
Unsanitary Food Preparation Practices
Penalty
Summary
The facility failed to ensure that staff prepared pureed food in a sanitary manner. During an observation, a cook was seen preparing pureed tuna casserole for lunch. While preparing the dish, the cook licked the pureed tuna casserole off her finger and then attempted to handle the food processor bowl without washing her hands. During an interview, the cook acknowledged that she should not have licked the food off her finger and should have washed her hands instead. The facility's current policy on food handling, dated November 2015, mandates that all food preparation and serving areas be maintained in accordance with state and local sanitation standards. This policy was provided by the Director of Nursing during the survey.
Deficiencies in Narcotic Patch Administration and Documentation
Penalty
Summary
The facility failed to ensure proper administration and documentation of a narcotic pain patch for a resident, identified as Resident B. The resident, who suffers from fibromyalgia, chronic pain, and polyneuropathy, was observed with a Fentanyl patch on her right upper arm, dated a day earlier than the scheduled change. The physician's order required the patch to be changed every 72 hours at 4:00 p.m. and to rotate sites. However, the patch was administered early by RN 1 at 2:12 p.m. on 7/21/24, without a documented reason for the early administration. Additionally, the patch was not rotated as required, as it was placed on the same site on multiple occasions. The facility also failed to ensure proper documentation and destruction of narcotic patches. RN 1 could not recall if the patch was placed on the resident or if it had fallen off, nor could he provide a reason for pulling the medication early. The Executive Director confirmed that RN 1 did not have a witness for the destruction of the old patch. Furthermore, the facility's policy required two nurses to be present for the destruction of medications and to sign off on the form, which was not adhered to in this case. Additionally, the facility did not maintain accurate narcotic count sheets for several medication carts. The review of the narcotic count sheets revealed missing signatures for both on-coming and off-going nurses across multiple units. The facility's policy required these signatures to verify the count of controlled substances at the beginning and end of each shift, which was not consistently followed. This lack of adherence to policy and procedure contributed to the deficiencies identified in the report.
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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.
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Nursing homes near Westfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellbrooke Of Westfield | 1 mi | ★★★★★ | 2 | 0 |
| Bridgewater Healthcare Center | 3.6 mi | ★★★★★ | 8 | 0 |
| Harbour Manor Health & Living Community | 5.1 mi | ★★★★★ | 11 | 0 |
| Copper Trace Health & Living Community | 5.4 mi | ★★★★★ | 9 | 0 |
| Majestic Care Of Carmel | 5.4 mi | ★★★★★ | 0 | 0 |
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