Optima Care Harborview

Inspectors wroteComplaint #: 2787834, 2997846, 3022108 Based on interviews, medical record reviews, and review of other pertinent facility documentation, it was determined that the facility failed to develop a care plan (CP) for a resident who was on enhanced barrier precautions (EBP) (infection control measures using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms) (Resident #1). This deficient practice was identified for 1 of 5 residents reviewed for care plans. This deficient practice was evidenced by the following:Resident #1 was no longer at the facility. A closed record review was conducted. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to hemiplegia (one-sided paralysis), unspecified affecting nondominant side; [...]

Inspectors wroteComplaint #: 2787834, 2997846, 3022108Based on observations, interviews, record reviews, and review of pertinent facility documents it was determined that the facility failed to develop personalized care plans for 2 of 3 incontinent residents, based on the residents' preference for the use of two incontinence briefs (IB). This deficient practice was identified for 2 of 3 residents reviewed for incontinence care (Resident #2 and Resident #3). The deficient practice was evidenced by the following:Incontinence rounds (IRs) were conducted with Unit Manager (UM) #1 on the facility's fourth floor on 05/28/2026 at 10:55 AM. The Surveyor observed Resident #2 in their bed with Certified Nursing Assistant (CNA) #1 providing care. The resident was wearing a small IB which was damp with urine, inside an outer IB. UM #1 confirmed the presence of two IBs on Resident #2. [...]

Inspectors wroteBased on the interview and review of facility documentation, it was determined that the facility failed to; a.) ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plans, b.) update to include the New Jersey (NJ) Mandated law for staffing, c.) update to include the day to day operations with regard to the physical environment, and d.) ensure to include accurate and updated information in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 139 residents who currently live in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to; a.) consistently document enteral tube feeding (TF) flush administration to assure the total volume administered was in accordance with physician's orders (PO), b.) administer TF per PO, c.) clarify PO, and d.) properly store and date TF supplies to ensure appropriate care and services for a resident receiving enteral feedings . This deficient practice was identified for 3 of 5 residents (Residents #1, #15, and #43), reviewed for enteral tube feeding. This deficient practice was evidenced by the following: 1. On 1/8/26 at 10:54 AM, Surveyor #1 (S #1) entered Resident #1's room and observed that the resident was not in the room. S #1 observed a TF pump that was empty and on the dresser was a piston syringe in a container that was not dated. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent documents, it was determined that the facility failed to: a.) ensure appropriate hand hygiene was performed and use of personal protective equipment (PPE) and b.) ensure appropriate storage of clean linen supplies. The deficient practice occurred on 2 of 3 resident units (3rd and 5th floor), 1 of 3 clean linen rooms, 4 of 11 staff (1 Licensed Practical Nurse, 1 Housekeeper, and 2 Certified Nursing Aides), failed to follow appropriate infection control practices to prevent the spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following:According to CDC, Clinical Safety: [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for 4 of 4 common areas (2nd, 3rd, 4th, and 5th floors), 2 of 3 day rooms (3rd and 4th floor), and 1 Resident's room (room [ROOM NUMBER]). This deficient practice was evidenced by the following: 1. On 1/9/26 at 11:44 AM, Surveyor #1 (S #1), with Surveyor #2 (S #2), and in the presence of the Regional Quality Assurance Nurse (RQAN) toured the 3rd floor shower room and observed the following: -Upon entry, there was one floor tile missing. -The wall beneath the entrance door was broken and with hole. The surveyor asked the RQAN what the importance of ensuring the flooring was even and no missing tiles was. The RQAN acknowledged it was for safety of the residents who were using the shower room. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 5 of 5 Certified Nurse Aides (CNAs) reviewed for mandatory education (CNA #1, #2, #3, #4, and #5). This deficient practice was evidenced by the following:On 1/9/26 at 11:33 AM, the surveyor requested from the Staff Educator (SE) the mandatory annual education and any related attendance logs or documents that was done for five randomly selected CNAs based on their date of hire (doh). The surveyor asked the SE if QAPI was part of the educational in-services, and the SE stated yes, it was a mandatory. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to follow the provider's order and plan of care with regard to resident's laboratory need according to facility's policy and standard of clinical practice for 1 of 31 residents (Resident #43) reviewed. 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, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident with pressure ulcers (PU) received necessary treatment and services by failing to; a.) ensure accurate skin assessment, b.) appropriate and routine documentation of skin impairment progress, c.) follow the physician order with regard to wound doctor consult, and d. ) care plan reflected accurate skin condition and information for 1 of 2 residents reviewed for PU (Resident #1), consistent with professional standards of practice and facility's practice and policy. 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that residents that received oxygen (O2), CPAP (continuous positive airway pressure) and nebulizer treatments received the necessary respiratory care and services, according to the standard of clinical practice, specifically a.) the O2 tubing and sterile water bottle utilized for humidification of O2 was dated for 1 of 3 residents reviewed for respiratory care (Resident #17) and b.) that respiratory equipment were stored in accordance with infection control measures for 1 of 3 residents reviewed for respiratory care (Resident #17). [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to follow a physician's order for a fluid restriction for a resident that received hemodialysis for 1 of 1 resident reviewed for dialysis (Resident #14). This deficient practice was evidenced by the following:On 1/8/26 at 10:32 AM, the surveyor entered Resident #14's room, observed that the resident was not in the room, and the resident's breakfast tray was on the bedside table. The surveyor observed that the meal ticket did not have a fluid restriction listed and that it had listed 4 fl (fluid) oz (ounce) apple juice, 4 fl oz apple juice, and 4 fl oz hot tea (Decaf). The surveyor also observed an additional two 4 oz juices on the dresser and a 16-20ml bottle of soda on the bedside table. The Certified Nursing Assistant (CNA) stated that Resident #14 was at dialysis. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 3 of 6 days during the annual re-certification survey. This deficient practice was evidenced by the following:On 1/8/26 at 9:05 AM, upon entry to the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted on a wall next to the reception area. The NHRCSR reflected a date of 1/7/26, Day Shift, Shift Hours 7:00 AM - 3:00 PM, and a Current Resident Census (CRS) of 140. The Director of Nursing (DON) stated that the current census was 139. On 1/9/26 at 9:23 AM, the surveyor observed a NHRCSR and a Facility Staffing Sheet (FSS) posted in the facility lobby. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), with a parameter according to the physician's order to meet the needs of the resident. The deficient practice was identified for 1 of 28 residents reviewed (Resident #11). The deficient practice was evidenced by the following:On 1/8/26 at 10:18 AM, the surveyor observed Resident #11 laying in bed with their eyes closed. A review of Resident #11's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in 1 of 3 medication carts and one 1 of medication refrigerators inspected on 3 of 3 units. This deficient practice was evidenced by the following:On [DATE] at 10:47 AM, the surveyor began inspecting the medication (med) storage room located on the facility 3rd floor in the presence of the 3rd floor Unit Manager (UM3). The surveyor observed a package containing an opened vial of tuberculin, purified protein derivative, diluted. Aplisol. (PPD) (an injectable solution used for testing and diagnosing tuberculosis). The surveyor did not observe a date when the vial was opened marked on the vial or the box. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that all listed menu items were consistently provided at the meal during lunch meal rounds on 1 of 3 units (5th floor). The deficient practice was evidenced by the following:On 1/9/26 at 11:56 AM, the surveyor observed the 5th floor day room for lunch, there were four tables (1st table with 3 residents, 2nd table with 4 residents, 3rd table with 4 residents, and 4th table with 4 residents), 2 small tables (1 resident seated in a Geri chair and 1 small table with 1 resident), and with five staff assisting for lunch. At that time, the surveyor observed all residents received their lunch meals. [...]

Inspectors wroteComplaint #2613337Based on interview, and review of other facility documentation, it was determined that the facility failed to provide services in compliance with applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles for a resident who was denied admission to the facility to provide services. This deficient practice was identified for 1 of 20 resident referrals reviewed, Resident #154. This deficient practice was evidenced by the following:According to the Centers for Disease Control (CDC) guidelines dated 4/24/24, which revealed, the Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) for Candida Auris (C. Auris) are similar to those used for other multidrug-resistant organisms (MDROs). In most instances, facilities equipped to care for patients with other MDROs . [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that 1 of 3 residents (Resident #1) preference was honored by having a nurse removed from the resident's care team. This deficient practice was evidenced by the following:The surveyor reviewed Complaint #431358 submitted by Resident #1's family member. The complaint reflected that the facility allegedly continued to keep a nurse caring for the resident after the family member asked them not to on 4/11/25. The surveyor reviewed the electronic medical record (eMR) of Resident #1, and revealed the following: A review of the admission Record (an admission summary) reflected that the resident had diagnoses of but not limited to Alzheimer's Disease (progressive mental decline) and Dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the resident's representative of a significant change in the resident's skin condition for one of two residents (Resident (R) 224) reviewed for pressure sores out of a total sample of 37. The facility failed to provide documentation that R224's representative was notified of a pressure area on the resident's heel when she returned to the facility after a recent hospitalization.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to conduct a thorough investigation of an alleged incident of staff neglect for one resident (R375) of four residents reviewed for abuse out of a total sample of 37 after the family stated the resident told them staff dropped him during a transfer, and the resident was found to have a right femur fracture. This has the potential to affect all residents receiving care by staff who may put residents at risk for neglect during care.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I Assessment was completed accurately for two of three sampled residents (Resident (R) 108 and R79) reviewed for PASARRs out of a total sample of 45 residents. This had the potential to prevent or delay additional services to a resident that might qualify for a Level II PASARR.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide food that accommodated resident allergies for one of seven sampled residents (Resident (R) 81) reviewed for food concerns out of a total sample of 37. This failure had the potential to cause residents harm due to allergic reactions.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a Professional Standards of Practice by a.) not following a Physician's Order (PO) on application of hand rolls to maintain joint integrity for 1 of 4 residents reviewed with limited range of motion, Resident #71, b.) failed to label and date an Enteral feeding bottle for 1 of 2 residents reviewed for Enteral feeding, Resident # 58, c.) failed to assess a weight change for 1 of 5 residents reviewed for nutritional status which did not contribute to weight loss, Resident # 124 and, d.) Failed to have a valid physician's order and accurately document the administration of a controlled substance, Resident #61 and Resident #24. 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 interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 18 of 29 residents (Resident #3, #118, #130, #63, #87, #84, #32, #71, #11, #70, #147, #117, #22, #7, #127, #38, #54, #37) reviewed and occurred over several months. 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 the resident's primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents: 1. [...]

Inspectors wroteBased on observation interview and review of facility documentation, it was determined that the facility failed to maintain resident call bells that were accessible and within reach of all residents. This deficient practice occurred for 2 of 26 residents reviewed (Resident #130 and Resident #11). This deficient practice was evidenced by the following: 1. On 9/1/22 at 11:44 AM, two surveyors observed Resident #130 lying in bed. Resident #130 did not respond to surveyor questions. The resident's call bell (a bell used to summon staff) was observed on the floor behind the resident's bed. On 9/2/22 at 11:03 AM, two surveyors observed Resident #130 lying in bed. The surveyors observed the resident's call bell on the floor behind the resident's bed. The surveyors interviewed Resident #130 at this time. The surveyor asked Resident #130 how they call for staff to come help them. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to provide a homelike environment during meal service as evidenced by the following: On 9/6/22 at 11:59 AM, during the lunch meal service in the 5th floor dining room, the surveyor observed that all the meals in the dining room (DR) were served on meal trays and was left on the trays in front of the residents. Further observation revealed that the trays used to serve the resident's meals were observed to be warped. The surveyor also observed the Certified Nursing Assisntant (CNA's) who were providing assistance with set-up to the residents in the DR left the lid from the food plate on the table and placed all the empty packet of milk carton, straw papers and other trash in front of the resident. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 3 of 26 residents reviewed for resident assessment (Resident #3, Resident #11 and Resident #32). This deficient practice was evidenced by: On 9/6/22 at 12:45 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 1 of 3 residents reviewed, Resident #103 as evidenced by the following: On 9/01/22 at 10:20 AM, the surveyor observed Resident #103 lying in bed watching TV. The surveyor also observed a nebulizer machine on the nightstand, labeled with the resident's name. The resident stated, he/she receives nebulizer treatments three times a day. The surveyor reviewed Resident #103's hybrid medical record. The admission Record reflected that Resident #103 was admitted with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Emphysema, and Rhabdomyolysis. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to review and revise a care plan to reflect changes to a resident's nutritional care for 1 of 3 residents (Resident # 58) reviewed. The deficient practice was evidenced by the following: On 9/1/22 at 10:10 AM, the surveyor observed Resident #58 lying in the bed and observed Glucerna 1.5 tube feeding running at 50ml/hr. The resident was pleasant during the interview process. A review of the admission Record for Resident #58 revealed that he/she was initially admitted with diagnoses that included but not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a plan of care and failed to perform a smoking assessment to determine the level of supervision required for 1 of 3 residents reviewed for smoking, Resident # 22. The deficient practice was evidenced by the following: On 9/1/22 at 11:05 AM, the surveyor spoke with Resident # 22 in the resident's room while the resident sat in a chair. The resident stated they smoked at the facility three times a day, at 9 am, 1 pm, and 7 pm. The resident said the cigarettes were locked up in the recreation department as well as the lighters. The resident said the staff supervised the smokers, distributed the cigarettes, and lit the cigarettes for the residents. On 9/8/22 at 12:51 PM, the surveyor reviewed the residents hybrid medical record which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to perform post dialysis assessments for 1 of 1 residents reviewed for dialysis care and services, Resident # 127. The deficient practice was evidenced by the following: On 9/1/22 at 11:51 AM, the surveyor observed Resident # 127 laying in bed in the residents room. The resident didn't answer when spoken to. The resident was covered with a blanket. The Registered Nurse (RN) who was assigned to the resident confirmed that the resident went out for hemodialysis every Tuesday, Thursday, and Saturday. On 9/8/22 at 10:39 AM the surveyor reviewed the resident's record which revealed the following: An admission record with diagnoses that included Type 2 Diabetes, End Stage Renal Disease, Hypertensive Chronic Kidney Disease Stage 5, Dependence on Renal Dialysis. [...]

Inspectors wroteBased on observation, interview and review of medical records and other facility documentation, it was determined that the facility failed to a) accurately follow the facility documentation policy related to the inventory control wasting of opioids and benzodiazepam control substance classes of medications for 2 of 20 residents who were receiving controlled substance medications inspected on the 5th floor, Resident #61 and Resident #24, b) remove a discontinued control substance medication from stock, and c) keep an accurate physical inventory of back up narcotics stored in a CUBEX system (automated medication dispensing system). This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's needs. This deficient practice was identified for 1 of 29 residents, Resident #87, reviewed for hospice/end-of-life care. The deficient practice was evidenced by the following: On 9/6/22 at 10:56 AM, the surveyor observed Resident #87 in bed sleeping. On 9/7/22 at 11:53 AM, the Licensed Practical Nurse (LPN) informed the surveyor that Resident #87 was on hospice care. The LPN further stated that the hospice nurse came to the facility once or twice a week. The surveyor reviewed the resident's medical records which revealed the following: [...]