Optima Care Fountains

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 2/12/26 at 10:30 AM, in the presence of the Food Services Director (FSD) and the Kitchen Supervisor (KS), the surveyor observed the following: In the south kitchen food preparation area, the surveyor observed that 1 of 2 of the fire suppression poles and sprinkler heads were soiled with a grease-like substance and dust like particles. In the food preparation area, the surveyor observed 3 of 10 burners on the cook top, which were soiled with a thick black grease-like substance, which was easily lifted with the tip of the surveyor's pen. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure call lights were within residents' reach and easily accessible for 4 of 33 residents reviewed (#15, #19, #57 and #234) and was evidenced by the following. This deficient practice was evidenced by the following: 1. On 2/12/26 at 10:29 AM, the surveyor observed Resident #57, in a bed that was low to the floor and against the wall. The call light was inaccessible to the resident as it extended between the wall and the bed, resting on the floor under the bed. On 2/12/26 at 12:10 PM, the surveyor returned to the resident's room. The call bell remained inaccessible in the same location as the previous observation. The surveyor confirmed the call light's placement with the Certified Nursing Assistant (CNA) #1. She stated the call light should be accessible to the resident. [...]

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to ensure that residents who maintained a Personal Needs Account (PNA) received a written notification that their account approached the limit that could jeopardize a resident's eligibility for Medicaid. This deficient practice was identified for 7 of 212 residents (Resident #4, #62, # 97, #183, #214, # 274, and #280) who maintained a PNA at the facility and was evidenced by: On 2/12/2026 at 11:08 AM, during entrance conference with the License Nursing Home Administrator (LNHA), the surveyor requested a list of the PNA balances. A review of the Fund Balances Report (FBR) from 2/11/2026 revealed a list of 212 active resident names with a total balance of $139,435.20. There were seven (7) residents listed with PNA funds that range from $1990.48 to $7956.76. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide resident confidentiality for 2 residents (#57, #225) of 33 reviewed for confidentiality and privacy and was evidenced by the following.1. On 2/12/26 at 10:16 AM, the surveyor observed Resident #57 in a low bed with eyes closed. The surveyor observed a handwritten sign taped to the front of the resident's clothes closet. The sign included care instructions for staff. A review of the electronic medical record revealed the following information. A review of the 11/19/25 quarterly Minimum Data Set (MDS) assessment tool indicated the resident had no cognitive deficits as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident had diagnoses including but not limited to dementia with behavioral disturbance and mood disorder. [...]

Inspectors wroteBased on observation, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents. This deficient practice was identified on 4 of 7 nursing units and was evidenced by the following:1. On 2/12/2026 beginning at 10:00 AM, the surveyor toured the first and second floors of Unit 11. The following environmental concerns were observed: -The first-floor day room/dining room had 2 chairs with torn vinyl on the seats. The wall-mounted air-conditioning unit had a broken face panel exposing the underlying coils. -The first-floor shower room's baseboard heating element was rusted and had chipped paint. The windowsill was damaged, and the window was not closed completely with a towel placed between the sill and the bottom of the window. [...]

Inspectors wroteBased on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete background checks for 3 out 97 employees (Employee #1, #2, #3). This deficient was identified for newly hired employees reviewed since last survey from 10/17/2024 and was evidenced as follows:A review of the employee personnel files revealed the following:For Employee #1, a dietary staff (cook) with a start date of 6/16/25, there was no evidence of a background check prior to the start of employment. For Employee #2, a Certified Nursing Assistant (CNA) with a start date of 4/1/25, there was no evidence of a background check prior to the start of employment. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 1 of 1 resident (Resident #25) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 (one) of 36 residents (Resident #15), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 2/12/26 at 11:00 AM, the surveyor observed Resident #15 asleep in bed. On 2/13/26 at 11:28 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #15, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #15 was admitted with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a residents who were unable to carry out activities of daily living (ADL) were provided care consistent with their needs and preferences for 2 of 3 residents (Resident #234 and #252) reviewed for ADL care. This deficient practice was evidenced by the following: 1. On 2/12/26 at 11:11 AM, the surveyor observed Resident #252 lying in their bed. Resident #252 was alert, verbally responsive, and Spanish speaking. The surveyor observed the resident's fingernails on both hands were long. The surveyor in Spanish asked the resident about their nail care. Resident #252 stated that their nails had not been trimmed, and they liked their nails kept short. On 2/12/26 at 2:28 PM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #252. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure appropriate dispensing and administration of a medication for 1 of 13 residents observed during medication administration. The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the device used to identify call device notifications were functioning properly for 1 of 7 units. This deficient practice was evidenced by the following: On [DATE] at 11:00 AM, the surveyor observed the call light was on outside the resident's room [ROOM NUMBER], but there was no audible sound. The surveyor observed unit 12's call light system machine in unit 12's nursing station had no audible sounds, and no button lights were on. On the same day, the surveyor observed another call light was on outside of another room in unit 12, but there was still no audible sound, and no lights were on in the nurses' station call light system machine. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure handrails were secure and intact on 2 of 7 resident units. This deficient practice was evidenced by the following:1. On 2/13/2026 at 10:19 AM, the surveyor toured unit 8, 2nd floor and observed the following: -a handrail located across from emergency exit door, near the pay phone, next to room [ROOM NUMBER], was coming loose away from the wall. On 2/13/2026 10:24 AM, the surveyor interviewed the Certified Nursing Aide (CNA) on the unit, who stated if something was broken, she would report it to the nurse, who would then notify maintenance. She stated she was unaware of the loose handrail. On 2/13/2026 at 10:32 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1, for unit 8. [...]

Inspectors wroteC#NJ183884Based on interviews, medical record review and pertinent facility documents reviewed on 7/18/2025 and 7/21/2025, it was determined that facility staff failed develop and implement an oxygen Care Plan (CP) with appropriate interventions for a resident (Resident #2) receiving oxygen. This deficient practice was identified for 1 of 3 residents reviewed for CP and was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows:According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to Parkinson's, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Atrial Flutter. [...]

Inspectors wroteComplaint #NJ183644Based on interviews, medical record review and pertinent facility documents reviewed on 7/18/2025 and 7/21/2025, it was determined that facility staff facility failed to maintain a complete and accurate medical record (MR) for 1 (Resident # 3) of 11 sampled residents. This deficient practice is evident by the following:According to the facility admission Record (AR), Resident #3 was admitted to the facility with the following diagnoses which included but not limited to: Atrial Fibrillation, Anogenital Warts, Hypertension, Diabetes Mellitus, and Nontraumatic Intracerebral Hemorrhage. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/17/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 14/15, which indicated that the resident's cognitive function was intact. [...]

Inspectors wroteComplaint #: NJ00181722, NJ00181697 Based on observation, interview, record review and review of other pertinent facility documents on 1/16/2025, 1/17/2025 and 1/22/2025, it was determined that the facility failed to provide adequate supervision to ensure a safe environment for a cognitively impaired, exit seeking resident. The facility failed to ensure exit doors were secured to prevent the resident's exit from the unit. This resulted in Resident #2 eloping from the nursing unit on 12/13/2024. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for elopement. The facility failed to ensure a safe environment for Resident #2, posed a serious and immediate risk to the health, safety and wellbeing of the resident.

Inspectors wroteComplaint #: NJ00182050 Based on interviews, review of medical records, and other pertinent facility documentation on 1/16/2025 and 1/17/2025, it was determined that the facility failed to: a.) administer medications as prescribed within the appropriate medication administration timeframe and b.) notify the physician when a medication was not available for administration. The facility also failed to follow its policy titled Medication Administration Policy. This deficient practice was identified for 2 of 3 residents reviewed for medication administration documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Parkinson's Disease, Unspecified Dementia, and Unspecified Depression. [...]

Inspectors wroteComplaint #: NJ00182050 Based on interviews, medical record review, and review of other pertinent facility documents on 1/16/2025 and 1/17/2025 it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents. This deficient practice was identified for 3 of 3 residents reviewed for ADL documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Parkinson's Disease, Unspecified Dementia, and Unspecified Depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of one (1) residents (Resident #157) reviewed for pain management received pain management related to pressure ulcer treatments. Resident #157 exhibited signs and symptoms of pain during their dressing change and staff failed to stop the treatment. The resident was not pre-medicated for pain which caused Resident #157 to suffer unnecessary pain. Findings Include: Review of Resident #157's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed Resident #157 was admitted to the facility with diagnoses which included but not limited to stroke; impaired thought process, and anxiety. Review of Resident #157's Care Plan, located under the Care Plan tab of the EMR and dated 06/29/23, revealed the resident had potential for pain related to their disease process. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain proper food holding temperatures. This had the potential to affect 273 of 273 residents who ate food from the kitchen. This failure had the potential to cause food borne illness in the facility.

Inspectors wroteBased on interview and record review, the facility failed to inform three of three residents and/or their responsible parties (Resident (R) 380, R112, and R265) reviewed for arbitration agreements out of a total sample of 45 of their right to rescind the arbitration agreement within 30 calendar days and their right to not be required to enter into a binding arbitration agreement as a condition of admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure their arbitration agreement informed three of three residents and/or their responsible parties (Resident (R) 380, R112, and R265) reviewed for arbitration agreements out of a total sample of 45 of their right to the selection of a neutral arbitrator agreed upon by both parties. The agreement also failed to inform the residents and/or their representatives of their right to select a venue for arbitration that was convenient to both parties.

Inspectors wroteBased on interview, observation, and facility policy review, the facility failed to provide information on how to file an anonymous grievance for seven of seven residents (Residents (R) 23, R44, R117, R140, R152, R177, and R200) reviewed for the grievance process out of a total sample of 45. The failure had the potential to affect residents' ability to safely report concerns without fear of retaliation.

Inspectors wroteBased on interviews, record review, review of facility reported incidents (FRI), and review of facility policy, the facility failed to protect the residents' right to be free from physical abuse by other residents for five (Resident (R) 262, R426, R424, R66, and R128) of eight residents reviewed for abuse out of a total sample of 45 residents. R262 scratched R76 on the face with a broken comb; R426 pulled R424's hair; and R140 struck R142, R66, and R128 with his hand. The facility's failure to protect residents from abuse placed resident at continued risk of harm.

Inspectors wroteBased on interview, record review, review of facility reported incidents (FRI), and review of facility policy, the facility failed to ensure allegations of resident-to-resident abuse involving four of eight residents (Resident (R) 262, R76, R426, and R424) reviewed for abuse out of a total sample of 45 were reported to the state agency (SA) within two hours of knowledge of the alleged incidents. This failure had the possibility of negatively impacting all 277 residents currently residing in the facility.

Inspectors wroteBased on interview, record review, review of facility reported incidents (FRI), and review of facility policy, the facility failed to ensure allegations of resident-to-resident abuse involving four of eight residents (Resident (R) 262, R76, R426, and R424) reviewed for abuse out of a total sample of 45 were thoroughly investigated. The failure to thoroughly investigate allegations of abuse had the potential to cause other residents to be at risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide written information regarding the facility's bed-hold policy for six of nine residents (Resident (R) 75, R111, R127, R209, R90, and R186) reviewed for hospitalization out of a total sample of 45. The failure had the potential to cause confusion for residents planning on returning to the facility.

Inspectors wroteBased on observations, interviews, record review, and test tray sample, the facility failed to provide food that was palatable, flavorful and at proper temperature for nine of nine residents (Resident (R) 111, R162, R117, R23, R44, R140, R152, R177, and R200) reviewed for food palatability. This failure had the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to maintain documentation and demonstrated evidence of its' ongoing Quality Assessment and Performance Improvement (QAPI) program. This failure had the potential to negatively affect 277 of 277 residents who resided at the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to obtain feedback, use data, and take action to conduct systematic investigations and analyses of underlying causes or contributing factors of problems affecting facility-wide processes. Specifically, the facility failed to use feedback and data from resident council meetings to address food palatability concerns. This failure had the potential to affect the nutritional status of 273 of 273 residents who ate food from the kitchen.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure one of 45 (Resident (R) 26) sampled residents observed while dining were treated with dignity. Specifically, staff failed to sit while feeding R265. This failure had the potential to cause residents to feel undignified.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure personal privacy during care for two of 47 (Resident (R) 75 and R110) residents observed. This had the potential to cause embarrassment or shame for the residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one public bathrooms (Unit 12 public bathroom) observed for concerns was free of insects and was maintained in a sanitary manner. This had the potential to cause the spread of infection by disease-causing organisms.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure interventions to aid in the healing of pressure ulcers were implemented as per the plan of care for one of five residents (Resident (R) 157) reviewed for pressure ulcers out of a total sample of 45. This failure had the potential to contribute to delayed healing of the resident's pressure ulcer.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that two residents (Resident (R) 110 and R76) from a sample of 45 residents had a way of making sure that medications were secured. This failure has the potential to expose residents to hazards of unsecure medications.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) when providing direct care to two of 13 residents (Resident (R) 110 and R157) on Enhanced Barrier Precautions (EBP) out of a total sample of 48. This failure could promote the spread of multi-drug-resistant organisms throughout the facility.

Inspectors wroteComplaint #: NJ000163659 and NJ000164821 Based on interviews, and record review, as well as review of pertinent facility documentation on 10/17/23, it was determined that the facility failed to consistently implement their policy on Charting and Documentation for 2 of 4 residents (Resident #1 and #2) reviewed for documentation. This deficient practice is evidenced by the following: 1. According to the admission RECORD (AR), Resident #1 was admitted to the facility on [DATE], with a diagnosis that included but was not limited to: Multiple Sclerosis. The Minimum Data Set (MDS) an assessment tool dated 7/15/23, Resident #1's cognition was intact and required total assistance from staff with Activities of Daily Living (ADLs). The Care Plan (CP) revised 8/16/23, indicated that Resident #1 had the potential for skin breakdown secondary to impaired mobility and incontinence. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident's primary physician reviewed, signed and dated the monthly physician orders (PO) to ensure that the resident's current medical regimen was appropriate. This deficient practice was observed for 17 of 35 residents. Resident #202, #239, #29, #30, #53, #137, #157, #245, #257, #165, #236, #58, #148, #152, #146, #127, and #111 were reviewed and found that for several months physicians did not sign resident's monthly POs. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above which revealed that the resident's primary physician had not physically signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure proper use of personal protective equipment (PPE) for staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control. This deficient practice was evidenced by the following: 1. On 11/14/22 at 11:21 AM, the surveyor observed the unit 2 Licensed Practical Nurse, Unit Manager (LPN UM) wearing an N 95 mask (a respirator mask) with both of the yellow straps cut and tied behind her ears. The LPN UM stated that she was fit tested to wear this N 95 mask but that it felt too tight to wear so she cut the straps and tied them so the straps go behind her ears. 2. On 11/14/22 at 11:29 AM, the surveyor observed a unit 2 Housekeeper (HK) wearing an N 95 mask on top of a surgical mask. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 2 of 10 sampled residents, Resident #94 and #204. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that residents were weighed monthly in accordance with physician's orders and facility policy. This deficient practice was identified for 2 of 11 residents, Residents #154 and #127 reviewed for nutrition. The deficient practice was evidenced by the following: 1. On 11/14/22 at 12:18 PM, the surveyor observed Resident #154 lying in bed on a pressure relieving mattress. Resident #154 responded to conversation in English and Spanish (main language). Resident #154 appeared comfortable, awake and alert. The surveyor reviewed the resident's hybrid paper and electronic medical record (EMR). The surveyor reviewed the admission Record (A one-page summary of important information about a resident) belonging to Resident #154. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain respiratory equipment in a sanitary manner for a resident who was receiving continuous oxygen (O2) and utilizing a BiPap machine (helps push air into your lungs). The deficient practice was identified for 1 of 2 residents (Resident #202) reviewed for respiratory care. This deficient practice was evidenced by the following: On 11/14/22 at 11:35 AM, the surveyor observed Resident #202 laying on bed with O2 in use via a nasal cannula (n/c) set at 2 liters per minute (LPM) attached to the humidified O2 concentrator (a medical device used for delivering O2). The surveyor observed the oxygen tubing was touching the floor. The nurse assigned to Resident #202 was brought inside the room and during the interview, the nurse stated that the oxygen tubing must not be touching the floor. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNA) on an annual basis. This deficient practice occurred with 5 of 5 CNAs whose personnel records were reviewed and was evidenced by the following: 1. According to data provided by the facility, CNA #1 was hired at the facility on 11/8/16. When reviewed, there were no current annual performance evaluations available in CNA #1's personnel file. When interviewed by the surveyor on 11/23/22 at 1:30 p.m., the Director of Nurses (DON) stated that CNA #1 was due for having her performance reviewed. The DON could not explain why there had been no annual performance evaluations conducted with CNA #1. 2. According to data provided by the facility, CNA #2 was hired at the facility on 11/7/05. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to label multidose medication containers with the open date. This was found in 1 of 9 medication carts inspected. The deficient practice was evidenced by the following: On 11/16/22 at 11:45 AM the surveyor inspected the Unit 11 medication cart in the presence of the Registered Nurse (RN) who was assigned to the cart. The following multidose medication containers were open and not dated with the open date: Latanoprost ophthalmic solution 2.5 ml multidose bottle Risperdal oral solution 10 ml multidose vial 1 mg/1 ml. Haldol 10 ml multidose vial 5 mg/1 ml. The RN stated the medications should have been dated when they were opened. The RN discarded the medications. On 11/16/22 at 11:30 AM the surveyor reviewed the facility's policy and procedure which was titled Medication Storage with a review date of 7/24/22. [...]