Above 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 Glen Center during CMS and state inspections, most recent first.
Facility Assessment Not Updated or Complete: The LNHA and DON stated the facility had a census of 122 residents, but the Facility Assessment provided to the surveyor was not updated and did not include staffing amounts related to the resident population, required staffing ratios, or a staffing contingency plan. The LNHA initially provided a 35-page assessment dated 8/7/23 to 8/6/24, then later stated the FA had not been updated; additional staffing reports and schedules still did not supply the missing information required by facility policy.
Call bell system failures were identified in multiple resident bathrooms and bathing areas when testing showed no audible, visual, or light notification at the nurse’s station for several room activations. The annunciator panel was found inactive with multiple fault conditions, one unit did not correctly identify room numbers, and one bed station was missing a call bell cord entirely.
Surveyors found multiple environmental deficiencies involving resident rooms, bathrooms, and a shower room. Observations included dirty and cluttered furniture, damaged dresser drawers, a fly in a room, a nonworking wall clock, a hole in a toilet room ceiling, peeling molding, a loose toilet, stained bathroom flooring, and a soiled, torn shower curtain. Staff interviews showed concerns were known or mentioned in some cases, but work orders were not documented for several of the issues.
Failure to Timely Transmit MDS Assessments: The facility failed to submit discharge MDS assessments to the State within the required timeframe for two residents. One discharge MDS was completed but not transmitted, and another was inactivated after completion and not submitted. The MDSC stated that one assessment may have been set to no for transmission by a previous MDSC, and she could not explain the other omission.
Wander Guard Order Not Updated and Medication Left at Bedside: A resident with severe cognitive impairment and exit-seeking behavior was observed wearing a wander guard, but the order in the EMR had an expired date and was not updated when the device was replaced. In a separate event, another resident’s seizure med, phenytoin, was observed in a cup at the bedside after the morning dose, even though the DON and an LPN stated meds were to be observed as taken and not left at the bedside.
Two residents with feeding tubes had tube feeding and flush documentation that did not match physician orders. One resident with cirrhosis, CVA, vascular dementia, and gastrostomy status was observed receiving Jevity 1.2 instead of the ordered Jevity 1.5, and staff confirmed the formula was incorrect while the eMAR also reflected inaccurate flush totals. Another resident with severe cognitive impairment, dysphagia, and gastrostomy status had Jevity 1.5 and water flush orders, but the eMAR showed shift totals that either exceeded or did not add up to the ordered 24-hour volume.
A CP failed to identify an irregularity during MRR for a resident receiving Prevacid delayed release capsules via g-tube while continuous TF was running. The resident had multiple diagnoses including cirrhosis, CVA, vascular dementia, gastrostomy status, and epilepsy, and the med was ordered daily for GERD and documented as given at 9 AM during active TF. Survey review showed the FDA guide directs Prevacid to be given before eating and, when administered through a tube, to follow specific instructions; the RN/UM confirmed the TF was ongoing, and the DON and Clinical Lead stated it should be given on an empty stomach.
The facility failed to ensure a Surety Bond was documented to protect resident personal needs account funds held by the facility. A surveyor requested the bond, but the facility’s bond report showed no bond on file. The LNHA later provided bond-related documents, while the BOM stated she was new, could not locate the bond, and had to have the Regional print it. The surveyor noted there was no documented evidence that the Surety Bond was in effect until surveyor inquiry.
Failure to Issue Required SNF ABN Notices: The facility did not provide the required SNF ABN for two residents who had remaining Medicare Part A skilled benefit days and continued to stay in the facility after their last covered day. The BOM stated she was unaware of the SNF ABN requirement and confirmed that no SNF ABN was issued to either resident.
A resident with intact cognition and psychosocial distress was interviewed about an alleged sexual incident in the presence of multiple staff and another resident, leading to feelings of humiliation and embarrassment. The investigation process did not maintain confidentiality or privacy as required by facility policy, resulting in emotional distress for the resident.
A resident admitted with pleural effusion, end stage renal disease, and other complex conditions had physician orders for Pleurex catheter drainage, but the baseline care plan developed within 48 hours of admission did not include a focus, goal, or interventions for this special procedure. The DON confirmed the omission, which was identified through record review and staff interview.
A facility failed to ensure that a nurse had documented competency for performing Pleurex drainage on a resident with pleural effusion and other complex conditions. Although education was reportedly provided, the facility could not produce records verifying that nurses were assessed and found competent in this procedure, leading to concerns about the adequacy of care and discrepancies in drainage documentation.
A registered nurse did not follow medication orders for a resident with heart disease and hypertension, relying on outdated vitals instead of retaking them before administering Zestril. The issue was reported to the facility's administration.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in their medical records. Errors included incorrect coding of bed rails as restraints, omission of tracheostomy care, and incorrect discharge status. These inaccuracies were identified through observations, interviews, and record reviews.
The facility failed to complete the MDS assessments on time for a resident, with delays confirmed by the MDS Coordinator and validated through submitted reports. This is a violation of federal mandates and NJAC 8:39 - 11.1.
Facility Assessment Not Updated or Complete
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that was reviewed and updated to identify the services, procedures, staffing, and resources needed to care for residents competently during day-to-day operations and emergencies. During the entrance conference, the LNHA and DON stated the facility census was 122 residents. The surveyor requested the Facility Assessment, and the LNHA first provided a 35-page assessment dated 8/7/23 to 8/6/24 that included resident population profile data and sufficiency analysis categories for overall staffing, staff training/competencies/skill sets, and services, but it did not include additional information for staffing or a staffing contingency plan. When the surveyor asked whether the assessment was the most up to date and complete, the LNHA said he would check and provide an updated version if needed. A later review of the assessment and additional documents provided by the facility still did not include information about staffing amounts related to the resident population, required staffing ratios, or a staffing contingency plan. The LNHA later stated that the facility assessment had not been updated. The facility policy required the assessment to be reviewed and updated annually and whenever substantial changes occurred, and it stated that the assessment must be used to determine staffing levels and inform contingency planning for events affecting patient care.
Call Bell System Failures in Resident Bathrooms and Bathing Areas
Penalty
Summary
The facility failed to ensure that the resident call bell system was properly functioning in resident bathrooms and bathing areas. During observations with the Senior Maintenance Director and Maintenance Director, call bell activations in multiple rooms did not produce the expected light, audible, or visual notification at the nurse’s station, and one room’s call bell did not activate the system at all when tested. The annunciator panel at the nurse’s station was found powered on but inactive, and when accessed it displayed fault conditions for several bathroom and bed station locations. Additional observations showed that the call bell system on Unit 3 did not provide audible notification for a shower room activation until the audio connection was found to be improperly attached. On Unit 2, the system did not correctly identify room activations by room number and instead displayed a device number. On the following day, activations for a bathroom station and a bed station again failed to produce audible notification, and the annunciator panel showed multiple fault conditions that had been active since prior dates. Further testing showed that some stations produced no audible or visual alerts, and one bed station was missing a call bell cord entirely.
Unsafe and Unmaintained Resident Environment
Penalty
Summary
The facility failed to maintain resident rooms, bathrooms, and shower areas in a safe, clean, comfortable, and homelike condition. During an environmental tour, surveyors observed in one resident room a used coffee cup and plastic wrappers on the dresser top, peeled and chipped wood on dresser drawers, a coffee cup mixed with unfolded clothes, a small plastic food container with dried food mixed with clothes, a fly in the room, a wall clock that was not moving, a hole in the toilet room ceiling, and peeling molding on the toilet floor. The LPN present stated the peeled wood needed glue, the clock needed a battery, and the ceiling hole and other concerns would be reported to maintenance. In another resident room, a resident stated the toilet was loose and the shower curtain was dirty with dark discoloration. Surveyors observed the toilet slightly wobbled with pressure and the bathroom floor had black-gray discoloration in front of the toilet and sink. The same concerns remained on a later observation. In the shower room, surveyors observed a shower curtain with dark brown to black discoloration toward the bottom and a torn corner with missing material. Staff interviewed during the survey stated they were unsure how long the bathroom floor discoloration had been present, that attempts had been made to clean it without success, and that the shower curtain condition had been known to maintenance for approximately a couple of weeks. A separate observation found a wall clock above a resident’s bed with the hands frozen at 3:31 and not moving. The resident confirmed the clock was not working, and the RN/UM was unable to state how long it had been broken. Review of the facility’s work order records showed no work order entered for the clock, and no work orders were found for the loose toilet, bathroom floor discoloration, or shower curtains. The facility policy provided during the survey stated that housekeeping and maintenance services were necessary to maintain a sanitary, orderly, and comfortable interior and to support the resident’s physical environment.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to submit MDS assessments to the State within 7 days of assessment for 2 of 27 residents reviewed. Resident #74 had a discharge MDS with an ARD of 3/28/25 that was completed but had not been submitted. Resident #109 had a discharge assessment with an ARD of 4/9/25 that had been inactivated after completion and was not submitted. During the survey, the MDS Coordinator stated that a discharge MDS should be submitted as completed as much as possible and that she follows the RAI manual. She later stated that the previous MDS Coordinator might have selected no instead of yes to transmit Resident #74’s discharge MDS, and she could not explain why Resident #109’s discharge MDS was not submitted. In the presence of the LNHA, DON, and CLoNJ, the MDS Coordinator stated that Resident #74’s discharge MDS was transmitted after surveyor inquiry, and that Resident #109’s discharge MDS had been inactivated in error and was planned to be activated and transmitted.
Wander Guard Order Not Updated and Medication Left at Bedside
Penalty
Summary
The facility failed to maintain professional standards of clinical practice by not updating a physician order for a wander guard with the correct expiration date for a resident with severe cognitive impairment and a history of exit-seeking behavior. The resident was observed ambulating in the hallway with the wander guard on the left ankle, and the unit clerk redirected the resident back to the room. The resident’s record showed diagnoses including vascular dementia, tracheostomy status, and osteoporosis, and the quarterly MDS indicated severely impaired cognitive skills for daily decision making and daily use of a wander/elopement alarm. The resident’s eMAR and eTAR showed wander guard orders for placement checks and function checks that had an expiration date that had passed, yet the orders continued to be signed as completed through later dates. The record further showed that the orders were not discontinued and replaced until after the expiration date had already passed. During interview, the LPN stated the expiration date should have been updated when the wander guard was replaced, and the RN/UM stated the same. The DON later stated the device had been changed before the expiration date because the strap was loose, but the order was not updated in the electronic record at that time. The facility also failed to ensure that a medication was administered and not left at the bedside for another resident. The resident was observed lying in bed with a clear medication cup on the bedside table containing two orange capsules, which the resident identified as seizure medication taken that morning. The resident stated the medication had been left at the side to take later and that the resident had forgotten to take it. The DON stated the nurse was to observe the resident take the medication and it should not be left at the bedside, and the LPN confirmed that residents were to be observed taking medications and that medications were not allowed to be left at the bedside. The medication was identified as phenytoin, and the medication administration record showed the dose was signed as administered later than the scheduled time.
Tube Feeding Not Given and Documented According to Orders
Penalty
Summary
The facility failed to administer tube feeding according to physician orders and failed to document the total volume according to the orders and standards of clinical practice for two residents receiving nutrition via feeding tube. One resident had diagnoses including cirrhosis of the liver, cerebrovascular disease, vascular dementia, gastrostomy status, and epilepsy, and had a BIMS score of 11 indicating moderately impaired cognition. The physician order required Jevity 1.5 at 40 ml/hr over 20 hours or until 800 ml was delivered, with 80 ml water flushes every 2 hours during continuous feeding times. During observation, the resident was found with tube feeding running at 40 ml/hr, but the formula hanging was Jevity 1.2 instead of the ordered Jevity 1.5. The RN/UM confirmed the formula was not according to the physician order and stated the resident should have been receiving Jevity 1.5. The RN/UM also stated the total volume fed was 591 ml with 209 ml remaining to complete the ordered 800 ml. Review of the electronic records showed the tube feeding and flush orders were transcribed and signed as administered, but the documented flush totals were incorrect because staff recorded 1600 ml per shift rather than the ordered 1600 ml per 24 hours, and the ordered 80 ml flush every 2 hours was not followed as written. A second resident had diagnoses including hereditary cerebrovascular disease, dementia, frontotemporal neurocognitive disorder, dysphagia, and gastrostomy status, with a BIMS score of 5 indicating severe cognitive impairment. The physician order required Jevity 1.5 at 65 ml/hr over 10 hours until 650 ml was delivered, with 200 ml water flushes every 2 hours and a total nutrient plus flush volume of 1650 ml per 24 hours. Observation and record review showed the eMAR documented 1650 ml on each shift for multiple days, which exceeded the ordered total volume, and on other days the documented shift totals did not add up to 1650 ml per 24 hours. Staff interviews confirmed the pump automatically flushed water, but the documentation remained inaccurate and did not match the physician order.
Consultant Pharmacist Failed to Identify Irregularity in Prevacid Administration During Tube Feeding
Penalty
Summary
The facility’s Consultant Pharmacist failed to identify an irregularity during the monthly medication regimen review for a resident receiving Prevacid delayed release capsules via gastrostomy tube while continuous tube feeding was running. The resident had diagnoses including cirrhosis of the liver, cerebrovascular disease, vascular dementia with mood disturbance, gastrostomy status, and epilepsy. The quarterly MDS reflected moderately impaired cognition and tube feeding. The physician’s order directed Prevacid 15 mg via g-tube once daily for GERD, and the medication was transcribed to the eMAR and signed as administered at 9:00 AM, which was during ongoing tube feeding at 40 mL/hr. Surveyor review of the FDA medication guide showed Prevacid delayed release capsules should be taken before eating and, when given through a nasogastric tube or larger, should be mixed with apple juice and administered in a manner that does not include other liquids or foods. The RN/UM confirmed the tube feeding was ongoing at the time the medication was scheduled, and the DON and Clinical Lead stated the medication should be given on an empty stomach. The Consultant Pharmacist acknowledged that Prevacid should be given on an empty stomach but did not recommend that for this resident because the resident was on tube feeding, and did not identify the irregularity during the medication regimen review.
Missing Documentation for Resident Funds Surety Bond
Penalty
Summary
The facility failed to ensure a Surety Bond was in place to protect resident personal needs account funds held by the facility. During the entrance conference, the surveyor requested the facility’s Surety Bond, and a facility-provided Surety Bond Report showed “no bond on file” for the insurance carrier. When asked about the report, the LNHA stated that the facility had a Surety Bond and would provide it. The LNHA later provided documents including a Power of Attorney dated 12/11/23 and a Verification Certificate for Indefinite Term Surety Bond stating that sufficient premium had been paid to satisfy the carrier’s requirements through 2/28/25. When the surveyor questioned the bond documentation, the LNHA stated corporate had sent the bond and that it was indefinite. The next day, the LNHA provided additional bond documents dated 8/27/25, and the BOM stated she was new, was working with the Regional Business Office Advisor, and had to have the Regional print the bond because she could not locate it. The BOM stated she did not know about the surety bond as of yet. The surveyor notified the LNHA, DON, and Clinical Lead of New Jersey that the facility did not have documented evidence that the Surety Bond was in effect from 2/28/25 until surveyor inquiry.
Failure to Issue Required SNF ABN Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 of 3 residents reviewed for beneficiary notification. Resident #71 had a last covered day from Medicare Part A services of 8/15/25 and remained in the facility, but there was no documentation that the resident received a SNF ABN. Resident #113 had a last covered day from Medicare Part A services of 8/18/25 and also remained in the facility, and there was no documentation that the resident received a SNF ABN. During interview, the Business Office Manager stated she was not aware of the SNF ABN and was not aware that it had to be provided to residents who had skilled benefit days remaining when being discharged from Part A services and continuing to reside at the facility. She confirmed that Residents #71 and #113 did not exhaust their skilled benefit days and remained at the facility, and acknowledged that a SNF ABN was not issued to either resident. The surveyor also reviewed a facility chart titled Valid Forms of Delivery and Required Follow Up, which stated that for SNF ABN, Medicare Part A only residents with days remaining and who will remain in the center at least one billable day should receive the notice prior to the last covered day and preferably with the NOMNC.
Failure to Protect Resident Privacy During Abuse Investigation
Penalty
Summary
The facility failed to protect the confidentiality and privacy of a resident during the investigation of an alleged sexual incident involving a staff member. The resident, who had intact cognition and a history of psychosocial distress related to the allegation, was interviewed in a conference room with multiple staff members and another resident present. The social worker conducted the interview in the presence of the accuser, a supervisor, a unit manager, and a business manager, despite the sensitive nature of the allegation. The resident expressed feeling humiliated, embarrassed, and disrespected due to the presence of unnecessary personnel and the public recounting of the alleged incident. The investigation process did not adhere to the facility's abuse prohibition policy, which requires maintaining confidentiality and protecting residents from mental abuse, including humiliation and degradation. The social worker was unable to articulate the facility's policy on confidentiality and privacy during the surveyor's interview. The resident reported ongoing emotional distress, including being subjected to jokes and derogatory comments from staff following the incident. Documentation showed that the resident was not physically harmed and denied any inappropriate interaction with the staff member. The investigation included interviews with the accused staff member and other residents, none of whom corroborated the allegation. However, the manner in which the investigation was conducted resulted in a breach of the resident's privacy and confidentiality, as required by facility policy and state regulations.
Failure to Include Pleurex Drainage in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's need for a special procedure, specifically Pleurex catheter drainage, despite physician orders indicating the necessity for this intervention due to a diagnosis of pleural effusion. The resident was admitted with multiple complex medical conditions, including pleural effusion, end stage renal disease, dependence on renal dialysis, and chronic atrial fibrillation. The resident required assistance with activities of daily living and had orders for both dialysis and Pleurex drainage on specific days. A review of the resident's baseline care plan showed that while several focus areas were addressed, such as assistance with ADLs, fall risk, skin breakdown, and renal function, there was no specific care plan focus, goal, or interventions created for the Pleurex catheter drainage procedure. The Director of Nursing confirmed during interview that the baseline care plan should have included the Pleurex catheter drainage as a special procedure upon admission, in accordance with facility policy and professional standards. The omission was identified through record review and staff interview, and was not corrected within the required timeframe.
Lack of Documented Nurse Competency for Pleurex Drainage Procedure
Penalty
Summary
The facility failed to ensure that a licensed nurse had the specific competency and skill set necessary to care for a resident with a Pleurex drainage system, as required for a resident diagnosed with pleural effusion, end stage renal disease, dependence on renal dialysis, and chronic atrial fibrillation. The resident required staff assistance for activities of daily living and had physician orders for Pleurex drainage twice weekly. Documentation showed that the drainage was performed by different nurses, with significant discrepancies in the recorded output volumes within the same day. The resident's family expressed concerns about the adequacy of care and the accuracy of the drainage procedure, leading to the resident being taken home against medical advice. Interviews with nursing staff and the staff educator revealed that while education on Pleurex drainage was provided via video and bedside demonstration, the facility was unable to produce documentation verifying that nurses had completed competency assessments specific to the Pleurex drainage procedure. The staff educator and Director of Nursing both acknowledged that competency sign-offs were expected but could not provide records to confirm that the involved nurses were assessed and deemed competent for this specific clinical skill. No additional documentation was provided to demonstrate that the required competencies were met.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The deficiency involved a registered nurse (RN) who did not follow medication orders that included specific parameters for administering Zestril to a resident. The RN prepared the medication based on vitals taken earlier in the shift, which were documented on a piece of paper. The State Surveyor requested the RN to retake the vitals before administering the medication, revealing different readings. The RN initially relied on outdated vitals, which could have led to improper medication administration. The resident involved had a history of heart disease, congestive heart failure, essential hypertension, and ventricular tachycardia. The resident's care plan required monitoring and reporting of vital signs to ensure blood pressure remained within baseline parameters. The facility's policy also mandated obtaining necessary vital signs before medication administration. The deficiency was reported to the Licensed Nursing Home Administrator and Director of Nursing, who did not provide additional information at the time.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies in their medical records. For Resident #33, the MDS indicated the use of bed rails as restraints, which was contradicted by observations and staff interviews that confirmed the bed rails were used as enablers for repositioning. Similarly, Resident #95's MDS also incorrectly coded the use of bed rails as restraints, despite the resident being observed without bed rails and being independent in bed mobility. Both errors were acknowledged by the MDS Coordinator as data entry mistakes. Resident #32's MDS inaccurately reflected the absence of tracheostomy care, despite the resident having a tracheostomy and receiving daily care as documented in the medical records. This discrepancy was identified during a review of the resident's treatment administration records and was later confirmed as an error by the Director of Nursing (DON). Additionally, Resident #133's discharge MDS incorrectly documented the discharge status as being to an acute hospital, while the resident was actually discharged home with family. This error was also acknowledged by the MDS Coordinator as a typographical mistake. These coding inaccuracies were identified through a combination of observations, interviews, and record reviews conducted by the surveyors. The facility's policy on MDS completion was found to be in place, but the errors indicate lapses in adherence to the policy. The DON and Licensed Nursing Home Administrator (LNHA) acknowledged the errors and indicated that corrections would be made, but no further comments were provided during the survey team's meeting.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments in a timely manner for one resident. Specifically, the Entry MDS for a resident with an Assessment Reference Date (ARD) of 9/19/23 was due by 9/26/23 but was not completed until 9/28/23. Additionally, the Admission MDS for the same resident with an ARD of 9/21/23 was due by 10/4/23 but was not completed until 10/6/23. These delays were confirmed by the facility's MDS Coordinator and validated through the submitted MDS reports. The issue was identified during a review of the facility's assessment tasks and was discussed with the facility's Licensed Nursing Home Administrator and Director of Nursing. The MDS Coordinator responsible for completing the assessments could not initially provide an explanation for the delays. The facility's MDS Coordinator later confirmed the late completion of the MDS assessments through a Validation Report. This failure to complete the MDS assessments on time is a violation of the federal mandate and the New Jersey Administrative Code (NJAC 8:39 - 11.1).
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 1,539 citations issued within 25 miles in the last 12 months — including the 21 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 Fairlawn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careone At Ridgewood Avenue | 1.6 mi | ★★★★★ | 0 | 0 |
| Family Of Caring Healthcare At Ridgewood | 2 mi | ★★★★★ | 0 | 0 |
| Bergen New Bridge Medical Center | 2.2 mi | ★★★★★ | 1 | 0 |
| New Jersey Veterans Memorial Home At Paramus | 2.3 mi | ★★★★★ | 2 | 0 |
| Complete Care At Fair Lawn Edge | 2.3 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maple Glen 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 July 2026) and official state health department websites.