Optima Care Castle Hill

Inspectors wroteBased on interviews and review of pertinent facility documents on 01/12/26, it was determined that the facility failed to maintain a safe environment during supervision by staff of a severely cognitively impaired resident (Resident #1) who was a high risk for elopement, had poor safety awareness, and exit-seeking behaviors. On 12/30/25, Resident #1 was able to open the 6th floor [NAME] side alarmed exit door, went down ten flights of stairs and exited through the side door of the facility on to the street. At approximately 4:00 PM, Licensed Practical Nurse (LPN) #1 alerted the nurse management that the resident was nowhere to be found. The last sighting of the resident was approximately at 3:25 PM by LPN #1 when the resident was seen ambulating the hallway on the 6th floor towards the high side of the Unit near the exit door. [...]

Inspectors wroteBased on interviews and review of pertinent facility documents on [DATE] and [DATE], it was determined that the facility failed to thoroughly investigate by obtaining complete statements from involved staff on an incident of injury of unknown origin of a cognitively impaired resident, Resident #2, who was noted to have a fading discoloration on her left hand near thumb area and a fading [discolored] area on her left forehead. On [DATE], Resident #2 was noticed to have a fading discoloration on her left hand near thumb area, measuring 4.0x4.0 cm [centimeters] and a small fading area on her left forehead measuring less than 2.0x2.0 cm. There was no sign of swelling and the resident denied pain to the sites. Resident #2 who was cognitively impaired was unable to recall any fall, trauma or unusual event that led to discoloration. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure the proper rinse temperature was consistently maintained for the dish machine and dishware was appropriately dried to limit potential bacterial growth and the potential for food borne illness. The deficient practice was evidenced by the following: On 03/04/25 at 9:28 AM, the surveyor observed the dish machine in use cleaning the breakfast dishes. The surveyor observed, with staff, the final rinse temperature was 172 degrees Fahrenheit (F). Dietary Staff (DS #1) was also observed removing the plates from the dish machine with his bare hands and he proceeded to wipe the plates with a rag, and then placed them on a rack. The Food Service Director (FSD) was present and informed DS #1 to not wipe the dishes. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure all residents were treated in a dignified manner by failing to ensure a) residents who were dependent on staff for care were provided with incontinence care prior to being served meals, and b) residents eating meals in the same dining room were served meals at the same time. This deficient practice occurred for 3 of 3 residents reviewed for dignity (Resident #31 and #42 and #129) and was evidenced by the following: On 2/27/25 at 10:16 AM, the surveyor observed Resident #129 in bed and the resident was partly covered and the incontinence brief could be observed bulging from the back. The resident informed the surveyor they were last provided with incontinence care at 5:00 AM. [...]

Inspectors wroteComplaint # NJ 167926 Based on interview, record review and document review it was determined that the facility failed to report an allegations of abuse, and injury of unknown origin to the Department of Health (NJDOH) as required within two hours of the allegation being made. The deficient practice was evidenced for 2 of 4 resident reviewed for investigations (Resident #343 and #290) and was evidenced by the following: 1. On 2/28/25 at 12:05 PM, Surveyor #1 observed Resident #343, sitting in the room in a wheelchair. The surveyor observed the right side of the resident's face with large area of discoloration and a bump around their right eyebrow. On 3/4/25 at 12:29 PM, Surveyor #1 reviewed the medical record for Resident #343. [...]

Inspectors wroteComplaint # NJ 167926 Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to complete a thorough investigation to rule out abuse or neglect for a resident who sustained an injury of unknown origin, for an allegation of abuse, and ensure a resident was protected from potential abuse while an investigation was completed. This deficient practice occurred for 2 of 4 residents reviewed for abuse (Resident #290 and Resident #343) and was evidenced by the following: 1. On 2/28/25 at 12:05 PM, Surveyor #1 observed Resident #343 sitting in the wheelchair in their room. Surveyor #1 observed the right side of the resident's face with large area of discoloration, and a bump around their right eyebrow. On 03/04/25 at 12:29 PM, Surveyor #1 reviewed the Medical Record (MR) for Resident #343 which revealed the following: [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement a baseline individual comprehensive care plan (ICCP) to meet resident preferences and goals to address all medical and psychosocial needs within 48 hours of admission. This deficient practice was identified for 1 of 27 residents (Resident #131) reviewed for ICCP and was evidenced by the following: On 2/28/25 at 9:38 AM, the surveyor observed Resident #131 being escorted off the unit. When asked, the Licensed Practical Nurse Unit Manager (LPN UM) stated that the resident was anxious, and they wanted to provide the resident with activities. On 2/28/25 at 11:00 AM, the surveyor reviewed the admission Record (an admission summary) which reflected Resident #131 had diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint NJ # 169842 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate incontinence care and bathing for 2 of 2 residents (Resident #73 and #104) reviewed for activities of daily living. This deficient practice was evidenced by the following: On 02/27/25 at 9:57 AM, the surveyor observed Resident #73 in bed. A Certified Nursing Aide (CNA) was at the bedside providing care and an interview conducted with the CNA revealed that the resident skin was intact. Per the surveyor request the CNA checked the resident for incontinence care. The surveyor observed that Resident #73 was wearing two incontinent briefs. One of the brief was folded and placed inside the first brief and secured in place with the liner of the first brief. [...]

Inspectors wroteBased on observation, interview, record review and review of facility provided documents, it was determined that the facility failed to care for, and remove an intravenous (IV) line for 1 of 1 resident (Resident #38) reviewed for IV therapy. This deficient practice was evidenced by the following: On 2/27/25 at 10:11 AM, the surveyor observed Resident #38 in their room with an IV connection line inserted in the right hand between the thumb and first finger. Resident #38 stated that the IV had been inserted weeks ago for medication and had never been removed. On 2/28/25 at 9:56 AM, the surveyor observed Resident #38 in their room with the IV connection line still in place. On 3/04/25 at 9:00 AM, the Licensed Practical Nurse Unit Manager (LPN UM) stated the IV line was inserted because the resident had been receiving an IV antibiotic which had been stopped on 2/10/25. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to consistently perform and document functional maintenance for 1 of 2 residents (Resident #51) reviewed for restorative care. This deficient practice was evidenced by the following: On 2/27/25 at 10:17 AM, the surveyor observed Resident #51 in bed and their left wrist and hand were bent backwards. On 2/27/25 at 1:23 PM, the surveyor reviewed the electronic medical record. The admission Record revealed diagnoses which included need for assistance with personal care. A review of the quarterly MDS dated [DATE], documented a BIMS of 02 out of 15 indicating severely impaired cognition, and that Resident #51 had ended both Occupational and Physical Therapy on 9/3/24. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure controlled substances were properly disposed of and ensure adequate supervision was provided to a resident who had a history of falls. This deficient practice was identified for 1 of 1 resident (Resident #1) observed during the medication pass and 1 of 1 resident reviewed for accidents (Resident #110). The evidence is as follows: a) On 3/4/25 at 8:39 AM, the surveyor conducted a medication pass observation and observed the Licensed Practical Nurse (LPN) prepared medication for Resident #1. The LPN prepared the following medications: Klonopin (a Benzodiazepine scheduled IV controlled substance that has the potential for abuse) 0.5 milligram (mg)1 tablet (a medication used to treat anxiety); Eliquis (anticoagulant ) 2.5 mg 1 tab; [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to record and document the urinary output for residents with an indwelling urinary catheter per the Physician Order. This deficient practice was identified for 1 of 2 resident's reviewed for urinary catheter (Resident #122) and was evidenced by the following: On 3/4/25 at 9:48 AM, the surveyor observed Resident #122 resting in their bed. The resident's urinary drainage bag was in a blue colored bag (privacy bag) and secured to the bed frame on the right-hand side. On 3/4/25 at 10:38 AM, the surveyor reviewed the electronic medical record for Resident #122 which revealed the following: [...]

Inspectors wroteRepeat Deficiency Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician order and ensure oxygen equipment was stored properly. This deficient practice was identified for 1 of 1 resident (Resident #341) reviewed for respiratory care and 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, record review and document review, it was determined that the facility failed to ensure that staff monitored, assessed and documented the care of a hemodialysis access site. This deficient practice was identified for 2 of 2 residents reviewed (Resident #2 and Unsampled Resident #1), and for 2 of 2 staff observed for dialysis access site care, and was evidenced by the following: On 2/27/25 at 1:26 PM, the surveyor observed Resident #2 in bed, and observed that Resident #2 had an Arterioventricular (AV) Fistula to the left arm (a procedure that connects an artery to a vein in preparation for dialysis). The resident's dominant language was Spanish and the resident was unable to communicate with the surveyor. At that time, a review of Resident #2's medical record revealed the following: [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to ensure a resident who required assistance with Activities of Daily Living (ADLs) had all necessary items maintained within reach of the resident. This deficient practice was identified for 1 of 1 resident (Resident #129) reviewed for accommodation of needs and was evidenced by the following: On 3/5/25 at 9:15 AM the resident was not available in their room, and at that time the surveyor reviewed the electronic medical record which revealed: a Progress Notes dated 3/4/25 timed 11:50 PM: Interdisciplinary Team Note. Note Text: Resident found on the floor at around 10:15 PM. According to the resident, the staff failed to place the bedside table within the resident's reach. While attempted to reach for the phone the resident fell on the floor, complaining of pain in their back. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to complete and transmit the required Material Data Set (MDS) assessment for 1 of 1 system selected MDS assessments reviewed and was evidenced by the following: On 3/4/25 at 10:05 AM, the surveyor reviewed the medical record for Resident #83. The MDS record revealed that the Resident was discharged on 10/9/24 and the MDS record was identified as 132 days overdue. On 03/04/25 at 10:51 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (RN/MDS) regarding the MDS process when a resident was discharged . The RN/MDS stated the facility must complete a discharge MDS, and she stated it is usually completed immediately. The surveyor asked the RN/MDS to review Resident #83's MDS in the presence of the surveyor. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement an individual comprehensive care plan (ICCP) for a resident who received intravenous (IV) therapy and had an IV catheter. The deficient practice was identified for 1 of 1 resident (Resident #38) reviewed for IV therapy and was evidenced by the following: On 2/27/25 at 10:11 AM, the surveyor observed Resident #38 sitting in a wheelchair in their room. The surveyor observed the resident's right hand with a short IV line (a tube that administers fluid or medication into veins) between the thumb and first finger. Resident #38 stated that they had received medication through an IV weeks ago. On 2/28/25 at 9:56 AM, the surveyor again observed the short IV line inserted in Resident #38's right hand. [...]

Inspectors wroteBased on observation, record review, interview, and review of the facility policies, the facility failed to ensure staff followed enhanced barrier precautions (EBP) and standard nursing precautions while transferring one of six residents (Resident) 6 reviewed on EBP. Specifically, facility staff failed to don personal protective equipment (PPE) (gown and gloves) when transferring R6 from his/her bed to his wheelchair. Additionally, two Certified Nurse Aides (CNAs) and one Licensed Practical Nurse (LPN) did not follow hand washing protocol during the lunch meal services.

Inspectors wroteBased on observations, interviews and review of documentation, the facility failed to consistently maintain a functional Heating, Ventilation and Air Condition Unit (HVAC) in good repair on 1 of 3 nursing units ( 3rd floor) in order to maintain a comfortable environment for its residents, staff, and visitors . This deficient practice was evident by the following: On 08/29/24, at 10:30 am., the surveyor conducted a tour of an empty 3rd floor unit with the Administrator (ADM) and Maintenance Director (MD). According to the ADM, a decision was made to utilize the 3rd floor unit to accommodate isolation for 11 Coronavirus (COVID-19) positive residents and 9 residents presumed exposed. The 11 COVID positive residents and 9 presumed exposed were housed on this unit from 8/27/2024 to 8/28/2024. [...]

Inspectors wroteBased on observation, interview, review of the medical records and other facility documentation, it was determined that the attending physician failed to document a discharge summary which included a recapitulation (recap) of the resident's stay and a final summary of the resident's status for 3 of 3 closed record's reviewed for discharge to community, expiration, and discharge to the hospital (Resident #128, #129, and #130). This deficient practice was evidenced by the following: 1. On [DATE] at 11:40 AM, the surveyor reviewed the closed medical record for Resident #130. The closed record revealed that the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Further review of the medical record revealed that the Medical section of the discharge summary was not completed by the resident's physician but by the Minimum Data Set (MDS) Coordinator. 2. [...]

Inspectors wroteBased on observation, interview, and review of electronic medical records, it was determined that the facility failed to ensure that a fully Registered Dietitian sign/co-sign the nutrition assessment and nutrition re-assessments for 11 of 16 residents, Resident #286, #95, #59, #283, #284, #114, #287, #282, #93, #285 and #128. This deficient practice was evidence e by the following: (Rev. 207; Issued: 09-30-22; Effective: 09-30-22; Implementation: 10-01-22) §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: [...]

Inspectors wrote4. On 1/3/23 at 10:15 AM, prior to the initial tour of the COVID 19 positive residents' unit, the DON who was also the acting Infection Preventionist informed the surveyor that when touring the 6th floor, all staff and visitors must wear a face protection (face shield or goggles) and a N95 mask. On 1/3/23 at 10:34 AM, during the initial tour, the surveyor interviewed the 6th floor Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM stated to the surveyor that the unit had 2 residents who were placed on contact and droplet precautions due to being tested positive for COVID 19. The rooms were located at the end of the hallway, Rooms 601 B and 602 P. The two rooms were across from one another. On 1/3/23 at 10:43 AM, while the surveyor was standing in the hallway between the rooms [ROOM NUMBERS], the resident's doors were observed to be open. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to issue the required Medicare Beneficiary Protection Notification for 1 of 3 residents (Resident #119) reviewed. This deficient practice was evidenced by: On 1/5/23 at 10:00 AM, the facility's Social Service Director (SSD) and Social Worker provided the surveyor with a list of residents who were discharged from the facility within 6 months and should have received Beneficiary Notices. The surveyor reviewed one of the residents, Resident #119 listed who was discharged from a Medicare Part A coverage stay at the facility and was documented as having a discontinuation of their insurance payment. Review of facility medical records showed that Resident #119 was admitted to the facility on [DATE]. The last date documented for insurance coverage was from Medicare Part A service, 10/28/22. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to develop and implement a person-centered baseline care plan (CP) for facility residents within 48 hours of admission. This deficient practice was identified for 4 out of 28 residents reviewed, Resident #232, #83, #64 and #234 who had impaired communication, impaired vision and diagnosis of Diabetes Mellitus (DM). This deficient practice was evidenced as follows: 1. On 1/3/23 at 10:34 AM, during the initial tour, the 6th floor Licensed Practical Nurse/Unit Manager (LPN/UM6) informed the surveyor that one of the Spanish speaking residents on their unit was Resident #83. On 1/3/23 at 11:15 AM, the surveyor observed Resident #83 laying on the bed. The surveyor greeted the resident who responded in Spanish. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan (CP) for residents in the facility. This deficient practice was identified for 3 of 28 residents reviewed for comprehensive care plans (Resident #122 and #7) who had impaired communication related to a language barrier and (Resident #129) who had an advance directive and was evidenced by the following: 1. On [DATE] at 1:47 PM, the surveyor observed Resident #122 sitting in their wheelchair watching a Spanish T.V. show in the dayroom. The surveyor introduced herself to the resident who responded in Spanish. At around the same date and time, the surveyor interviewed the Licensed Practical Nurse/LPN and stated that Resident #122 speaks only Spanish. A review of Resident 122's medical record revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to review and revise a care plan (CP) to reflect changes to a resident's nutritional care for 2 of 28 residents (Resident #5 and #116) reviewed. The deficient practice was evidenced by the following: 1. On 1/3/23 at 10:30 AM, the surveyor observed Resident # 5 with eyes closed, laying on an air mattress. The resident was not able to be interviewed. A review of the admission Record for Resident #5 revealed that the resident was last admitted to the facility on [DATE] with diagnoses that included but were not limited to: Cerebrovascular disease, Vascular dementia, and Type 2 Diabetes without complications. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to administer, and appropriately document resident's physician ordered medications. This deficient practice was identified for 3 of 5 residents reviewed and observed during medication administration, Resident #34, #109 and Resident #11. 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 wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a communication device for a resident identified as having a language barrier. This deficient practice was identified for Resident #83, 1 of 4 residents reviewed for language and communication and was evidenced by the following: 1. On 1/3/23 at 10:34 AM, during the initial tour, the surveyor was informed by the Licensed Practical Nurse/Unit Manager (LPN/UM) that one of the Spanish speaking residents on their unit was Resident #83. On 1/3/23 at 11:15 AM, the surveyor observed Resident #83 laying on the bed. The surveyor introduced self to the resident who responded in Spanish. On 1/3/23 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the resident who stated that Resident #83 speaks only Spanish. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the oxygen (O2) therapy was administered to a resident in accordance with the current physician's orders (PO). This deficient practice was observed for 1 of 4 residents (Resident #56) reviewed for respiratory care. This deficient practice was evidenced by the following: On 1/3/23 at 1:26 PM, the surveyor observed Resident #56 laying in bed with O2 in use via a nasal cannula (NC) set at 2 liters per minute (LPM) attached to a humidified O2 concentrator (a medical device used for delivering O2). On 1/5/23 at 10:57 AM, the surveyor observed Resident #56 laying in bed with O2 in use via NC at 2 LPM attached to the humidified O2 concentrator. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide adequate indications and documentation supporting the rationale for blood sugar monitoring checks performed at 3 AM for a resident with a diagnosis of Diabetes Mellitus (DM). This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #27) and was evidenced by the following: On 1/4/23 at 2:00 PM, the surveyor observed Resident #27 seated in a wheelchair, eyes closed, with Oxygen in use via nasal cannula at 2 liters per minute attached to the humidified oxygen concentrator. A review of the resident's face sheet (an admission summary) reflected that Resident #27 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Type 2 DM, Acute Kidney Failure and Congestive Heart Failure. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain a medication rate error below 5%. The surveyor observed 4 nurses administer 28 doses of medication to 5 residents and there were 2 errors which resulted in a medication error rate of 7.14 %. The deficient practice was evidenced by the following: 1. On 1/5/22 at 8:14 AM, during the medication administration observation (medpass), the State Surveyor along with the Federal Surveyor observed the Licensed Practical Nurse (LPN) #1 preparing to administer medications to Resident #34 which included a Physician's order (PO) for Sennoside 8.6 mg 2 tablets twice daily for constipation. LPN#1 stated that the Sennoside 8.6 mg was unavailable. LPN#1 proceeded to administer Docusate Sodium 100 mg (1) soft gel (stool softener) in place of the Sennoside 8.6 mg. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. [...]