Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optima Care Fountains during CMS and state inspections, most recent first.
Facility staff did not develop or implement a care plan for a resident with an active order for oxygen therapy, despite the resident's complex medical history and cognitive impairment. Interviews with the RN and DON confirmed that a care plan should have been in place, and facility policy required oxygen administration to be included in person-centered care plans.
A resident with multiple chronic conditions and a history of stroke had incomplete documentation in their ADL records, with blank entries noted for several shifts. Interviews with the RN and DON confirmed that CNAs are responsible for documenting care provided, and facility policy requires all care to be recorded in the medical chart.
A resident with dementia and a history of elopement risk managed to exit a nursing unit through an unsecured door and was later found in the attic with an injury. Despite being identified as an elopement risk, the facility failed to secure exit doors and provide adequate supervision, posing a serious risk to the resident's safety. Staff interviews confirmed that the exit door was unsecured, and the facility's elopement policy was not effectively implemented.
The facility failed to administer medications as prescribed and did not notify the physician when medications were unavailable, affecting two residents. One resident with intact cognition did not receive medications within the appropriate timeframe, while another with moderate cognitive impairment did not receive HIV and diabetes medications due to unavailability. The facility's policies on medication administration and physician notification were not followed.
Facility staff failed to consistently document ADL care for three residents, as evidenced by missing entries in the DSR for various tasks such as bed bath, mobility, continence, and eating. Interviews with staff revealed that CNAs were responsible for documenting ADL care using a mobile app, but the facility lacked a policy on ADL documentation, and the ADON could not explain the blank spaces in the records.
A resident with a stage II pressure ulcer experienced unmanaged pain during a dressing change due to the facility's failure to administer pre-medication. Despite a care plan indicating the need for pain management, the resident did not receive scheduled or PRN Tylenol. The LPN continued the dressing change despite the resident's visible pain, and staff were unaware of the resident's pain issues.
The facility failed to maintain proper food holding temperatures, affecting all residents who consumed meals from the kitchen. During meal preparation, food items were removed from the oven at appropriate temperatures but were not monitored while on the steam table. The final tray from lunch showed significantly reduced temperatures, and previous complaints about low food temperatures had been discussed in meetings without resolution.
The facility did not inform residents and their representatives of their rights regarding arbitration agreements, including the right to rescind within 30 days and that signing was not a condition for admission. Interviews revealed that the arbitration clause was included in the admission packet, but residents were not clearly informed. One resident, with moderate cognitive impairment, did not recall signing the Arbitration Agreement.
The facility did not inform residents of their rights to select a neutral arbitrator and a convenient venue for arbitration, as revealed in their undated Admission Agreement. The Admission Director confirmed that the arbitration agreement was part of the admission packet, and a resident with moderate cognitive impairment did not recall signing it, indicating a lack of clear communication.
The facility failed to provide written bed-hold notices to six residents transferred to hospitals, despite having a policy requiring such notifications. This deficiency was confirmed through record reviews and interviews, revealing that residents and their representatives were not informed about the bed-hold policy, which allows for their return after hospitalization or therapeutic leave.
The facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program, affecting all 277 residents. Despite policy requirements to share QAPI activities and outcomes through meetings and newsletters, no meeting minutes or newsletters were observed. Interviews revealed that the facility did not keep meeting minutes, only agendas, indicating a lack of centralized documentation and transparency.
The facility failed to address food palatability concerns raised by residents during council meetings, with complaints about taste and temperature occurring in eight out of twelve meetings. A sample meal tray confirmed the food was cold and not palatable, potentially affecting the nutritional status of all 273 residents. The DON and other staff deferred responsibility and did not provide specific plans to address the issue.
The facility failed to inform residents about the process for filing anonymous grievances, as required by its policy. Although the policy allows for anonymous complaints via a Compliance Hotline and grievance boxes, no boxes were present, and residents were unaware of the hotline or the process. The DON and Administrator confirmed the lack of grievance boxes and that the process had not been reviewed with residents.
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents of resident-to-resident altercations. One resident with severe cognitive impairment scratched another resident, while another resident pulled a peer's hair due to agitation. Additionally, a resident with severe cognitive impairment struck multiple residents on separate occasions. These incidents highlight deficiencies in maintaining a safe environment and protecting residents from abuse.
The facility failed to report resident-to-resident abuse incidents to the state agency within the required two-hour timeframe. In one case, a resident with dementia scratched another resident's face, and in another, two residents were involved in a physical altercation. Both incidents were reported late, revealing a misunderstanding of reporting requirements among staff.
The facility failed to thoroughly investigate resident-to-resident altercations involving four residents, as required by their policy. In one case, a cognitively impaired resident scratched another's face, and in another, a resident pulled another's hair. Both incidents were ruled as misunderstandings, but the investigations lacked interviews with other potentially affected residents.
The facility failed to provide palatable and properly heated meals to residents, with reports of cold and tasteless food. Despite ongoing complaints documented in Resident Council Minutes and acknowledged by the RD, the FSD was unaware of these issues and did not attend council meetings. A test tray sample confirmed the food was below required temperatures, and no temperature logbook was maintained.
A resident with cognitive impairment and physical limitations was not treated with dignity during a meal when a CNA stood over them while feeding. The facility's policy requires staff to promote resident dignity, which was not initially followed until a supervisor intervened.
The facility failed to ensure privacy for two residents during care, leading to exposure of their private body parts. In both cases, CNAs left the residents' doors open, compromising their privacy. RN1 intervened by closing the door for one resident, but the CNAs were unaware of the privacy breach.
A facility failed to implement prescribed interventions for a resident with a pressure ulcer on her right heel. Despite the care plan requiring protective heel boots and heel offloading measures, the resident was observed multiple times without the boots, with her heels resting directly on the mattress. Staff confirmed the resident should have been wearing the protective boots, which were found stored in her closet.
The facility failed to ensure staff used appropriate PPE for two residents on Enhanced Barrier Precautions (EBP). One resident with an open leg wound and another with a stage II pressure ulcer received care from CNAs who did not wear gowns, despite EBP signage. The CNAs admitted to not using gowns due to shift changes and oversight, while the Infection Preventionist confirmed proper signage and education were in place.
A public bathroom in Unit 12 was found to have a roach infestation and was in disrepair, with crumbling plaster, peeling paint, and missing tiles. Despite bi-weekly pest control treatments, there was no documentation of roaches in the area. The Director of Housekeeping and Maintenance Director confirmed the need for repairs.
The facility failed to secure medications for two residents, leading to potential hazards. One resident's eye drops were left unattended on a medication cart, while another resident retained a cup of medications after refusing to take them. The LPN was unable to retrieve the medications, and the DON confirmed that medications should not be left unsecured.
Failure to Develop and Implement Oxygen Care Plan
Penalty
Summary
Facility staff failed to develop and implement a care plan (CP) for a resident who had a physician's order for oxygen therapy via nasal cannula at 2 liters per minute. The resident, who was admitted with multiple diagnoses including Parkinson's, COPD, diabetes mellitus, and atrial flutter, was assessed as moderately cognitively impaired with a BIMS score of 5/15. Despite the presence of an active order for oxygen therapy, a review of the resident's care plan did not show any evidence of an oxygen care plan being initiated or documented. Interviews with facility staff confirmed that a care plan should have been in place for any resident receiving oxygen, as it is considered a medication and requires monitoring of respiratory status. Both the RN and the DON acknowledged the absence of an oxygen care plan for this resident. Facility policies reviewed also required that oxygen administration be consistent with professional standards and incorporated into comprehensive, person-centered care plans, but this was not followed in the resident's case.
Incomplete Documentation of ADLs in Resident Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident, as evidenced by missing documentation in the Activities of Daily Living (ADL) records. The resident, who had multiple diagnoses including atrial fibrillation, hypertension, diabetes mellitus, and a history of nontraumatic intracerebral hemorrhage, was assessed to have intact cognitive function. The resident's care plan required monitoring and documentation of ADLs, with interventions to encourage self-care where possible. Upon review, the ADL records for the resident showed blank entries for all ADLs during specific shifts on several dates. Interviews with the RN and DON confirmed that Certified Nurse Aides (CNAs) are responsible for completing these records and that blank entries indicate tasks were not documented, even though care may have been provided. The facility's policy requires CNAs to document all care provided, including any refusals or unusual occurrences, in the resident's medical chart during their assigned shift.
Resident Elopement Due to Unsecured Exit Doors
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident who was at risk of elopement. The resident, who had a history of dementia with behavioral disturbances, was able to exit the nursing unit through an unsecured door and was later found in the attic. This incident occurred despite the resident being identified as an elopement risk and having a care plan in place that included interventions such as 15-minute checks and transfer to a locked unit. On the night of the incident, a nurse discovered the resident missing during rounds, prompting a Code Gray alert. Despite a thorough search of the facility and its perimeter, the resident was not found until the following morning when a nurse heard cries for help coming from the attic. The resident was found with a forehead injury and was sent to the emergency room for evaluation. The facility's failure to secure exit doors and provide adequate supervision posed a serious and immediate risk to the resident's health and safety. Interviews with staff revealed that the exit door leading to the stairway was unsecured, allowing residents to access the stairs freely. The Director of Maintenance confirmed that the attic door was unsecured at the time of the incident. The facility's elopement policy was not effectively implemented, as evidenced by the resident's ability to leave the unit and access the attic. The facility was unable to provide evidence that the unit door was secured, highlighting a significant lapse in ensuring a safe environment for residents at risk of elopement.
Removal Plan
- The facility implemented 24/7 monitoring of Unit 11's stairwell door from the first floor to ensure that Residents at risk of wandering and elopement will have the necessary supervision for preventing unsafe access to the stairwell door.
- The role of the BSPEC is to monitor the door. An Elopement Binder was put in place for high-risk Residents including photos of residents who are not allowed upstairs.
- Initiating in-services for all staff on the facility's policy on Elopement and Wandering.
Medication Administration and Notification Failures
Penalty
Summary
The facility failed to administer medications as prescribed and did not notify the physician when medications were unavailable, affecting two residents. For the first resident, who had intact cognition and was diagnosed with Parkinson's Disease, Dementia, and Depression, medications were not administered within the appropriate timeframe on multiple occasions in December 2024. The Medication Administration Record (MAR) indicated that medications were given outside the one-hour window before or after the scheduled time, and the Assistant Director of Nursing (ADON) confirmed that the standard practice was not followed. The ADON also noted that if a resident requested medication outside the timeframe, the nurse should have contacted the physician to adjust the administration time. The second resident, with moderate cognitive impairment and diagnosed with HIV, Diabetes, and Anxiety Disorder, did not receive their HIV and diabetes medications on several occasions because the medications were not available. The Licensed Practical Nurse (LPN) and ADON stated that the nurse should have contacted the pharmacy and the physician when medications were not delivered. However, there was no documentation in the resident's medical record indicating that the physician was notified about the unavailability of medications. The ADON confirmed that the medications were delivered, but the nurses failed to administer them or notify the physician. The facility's Medication Administration Policy, dated March 2023, requires timely and accurate administration of medications and mandates that the physician be informed when medications are unavailable. The facility's document on Medication Pass Observation also specifies that medications should be administered within one hour before or after the scheduled time. The failure to adhere to these policies resulted in the identified deficiencies.
Inconsistent ADL Documentation in LTC Facility
Penalty
Summary
The facility staff failed to consistently document the Activities of Daily Living (ADL) status and care provided to residents, as evidenced by the lack of documentation in the Documentation Survey Report (DSR) for three residents. Resident #1, who was admitted with diagnoses including Parkinson's Disease and Unspecified Dementia, had an intact cognition as per the Minimum Data Set (MDS). However, there were multiple instances in December 2024 where documentation was missing for various ADL tasks such as bed bath, bed mobility, bladder and bowel continence, dressing, personal hygiene, toilet use, GG mobility, GG self-care, locomotion, transferring, walking, and eating. Resident #4, with diagnoses including HIV and Diabetes, had impaired cognition and required assistance with ADLs. The review of their DSR and progress notes for December 2024 also revealed missing documentation for several ADL tasks, including bed bath, bed mobility, bladder continence, toilet use, locomotion, personal hygiene, bowel continence, dressing, GG mobility, GG self-care, transferring, walking, and eating. Similarly, Resident #5, who had diagnoses of Unspecified Dementia and Anemia, required assistance with ADLs. Their DSR and progress notes showed missing documentation for bladder and bowel continence, GG mobility, GG self-care, and eating on various dates in December 2024. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON), revealed that CNAs were responsible for documenting ADL care using a mobile app at the end of their shifts. The ADON acknowledged the responsibility of CNAs, nurses, supervisors, and Unit Managers to ensure complete ADL documentation. However, the facility could not provide a policy on ADL documentation, and the ADON could not explain the blank spaces in the DSRs.
Failure in Pain Management During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during pressure ulcer treatments. The resident, who was admitted with diagnoses including stroke, impaired thought process, and anxiety, exhibited signs of pain during a dressing change for a stage II pressure ulcer on the right heel. Despite having a care plan that included interventions for pain management, the resident was not pre-medicated for pain, resulting in unnecessary suffering. The resident's Medication Administration Record showed no evidence of receiving scheduled or as-needed Tylenol for pain relief from the beginning of October through mid-October. During an observation, the resident was seen grimacing and moaning in pain while an LPN performed a dressing change without administering pain medication beforehand. The LPN acknowledged the resident's pain but continued the procedure without stopping. Interviews with the facility's staff, including CNAs and the ADON, revealed a lack of awareness regarding the resident's pain during dressing changes. The facility was unable to provide additional information or policies on pain management and pressure ulcer care when requested by the survey team.
Failure to Maintain Proper Food Holding Temperatures
Penalty
Summary
The facility failed to maintain proper food holding temperatures, which had the potential to affect all 273 residents who consumed meals from the kitchen. During the noon meal preparation, food items such as seasoned chicken thighs, Italian green beans, and carrots were removed from the oven at appropriate temperatures but were not monitored for temperature maintenance while on the steam table. The food was placed on the steam table without a temperature logbook, and no temperatures were taken during the meal tray preparation and delivery process. Upon testing the final tray from lunch, the food temperatures had dropped significantly, with the chicken thighs at 117 degrees Fahrenheit, green beans at 114 degrees Fahrenheit, and carrots at 112 degrees Fahrenheit. The Registered Dietician noted that food complaints had been discussed in Morning Meetings/QA meetings, with specific mentions of low food temperatures on certain units. Despite these discussions, the facility did not have a system in place to ensure food temperatures were maintained, leading to the deficiency.
Failure to Inform Residents of Arbitration Rights
Penalty
Summary
The facility failed to inform residents and their responsible parties of their rights regarding arbitration agreements. Specifically, three residents and/or their representatives were not informed of their right to rescind the arbitration agreement within 30 calendar days and their right not to be required to enter into a binding arbitration agreement as a condition of admission. The facility's Admission Agreement and Arbitration Agreement lacked language that clearly communicated these rights. The facility's policy stated that binding arbitration was not a condition for admission or continued care, but this was not reflected in the agreements provided to residents. Interviews with facility staff revealed that the arbitration clause was included in the admission packet, and the Admissions Director explained it to families. However, the Admission Director indicated that signing the Admission Agreement also meant signing the Arbitration Agreement, which was not clearly communicated to residents. One resident, who was moderately cognitively impaired, did not recall signing an Arbitration Agreement, despite having signed the Admission Agreement. This indicates a lack of clear communication and understanding regarding the arbitration process and residents' rights.
Failure to Inform Residents of Arbitration Rights
Penalty
Summary
The facility failed to ensure that their arbitration agreement informed residents and/or their responsible parties of their right to select a neutral arbitrator and a convenient venue for arbitration. This deficiency was identified during a review of the facility's undated Admission Agreement, which stipulated that any disputes would be settled by binding arbitration conducted in Jersey City, New Jersey, without mentioning the residents' rights to choose the arbitrator or venue. The facility's policy stated that arbitration was not a condition for admission or continued care, yet the agreement was included in the admission packet, and signing it was part of the admission process. Interviews conducted with the Admission Director and a resident revealed further insights into the deficiency. The Admission Director confirmed that the arbitration agreement was part of the corporate admission packet and that the facility would select the arbitration location and arbitrator. A resident, identified as moderately cognitively impaired, stated she had signed the Admission Agreement but did not recall signing an Arbitration Agreement. This indicates a lack of clear communication and understanding regarding the arbitration process and the rights of the residents involved.
Failure to Provide Bed-Hold Notices
Penalty
Summary
The facility failed to provide written information regarding its bed-hold policy to six residents who were transferred to a hospital or placed on therapeutic leave. This deficiency was identified during a review of the facility's records and interviews with staff and residents. The facility's policy, revised in July 2023, mandates that residents or their representatives be informed in writing about the bed-hold policy, which allows residents to return to the facility after hospitalization or therapeutic leave. However, documentation for six residents did not include evidence of such notifications. Resident 75 was transferred to the hospital for a possible neurological event, and upon review, there was no documentation that the resident or their representative received a bed-hold notice. Similarly, Resident 111, who was transferred to the emergency room for abdominal pain, did not receive a bed-hold notice. Resident 127, transferred for evaluation of altered mental status, also lacked documentation of receiving a bed-hold notice. Interviews with the Director of Nursing confirmed that these notices were not provided. Additional cases included Resident 209, who was transferred for pneumonia, and Resident 90, who was transferred for a urinary tract infection and pneumonia. Both residents returned to the facility without having received a bed-hold notice. Resident 186, transferred for congestive heart failure, also did not receive a bed-hold notice. Interviews with residents and the facility's Regional Director further confirmed the absence of a bed-hold policy, despite the facility's written policy indicating otherwise.
Lack of QAPI Documentation and Transparency
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assessment and Performance Improvement (QAPI) program, which had the potential to negatively affect all 277 residents. The facility's policy indicated that QAPI activities and outcomes should be shared with staff, residents, and family members through meetings and newsletters, with minutes posted throughout the facility. However, during the survey, no QAPI meeting minutes or newsletters were observed in the designated areas of the facility. Interviews with the Director of Nursing (DON), Regional Nurse, and Assistant Director of Nursing (ADON3) revealed that the facility did not keep meeting minutes, only agendas. The DON stated that they might need to gather information from each department, indicating a lack of centralized documentation. This lack of documentation and transparency in the QAPI process was a significant deficiency, as it hindered the facility's ability to effectively communicate and implement quality improvement initiatives.
Failure to Address Food Palatability Concerns
Penalty
Summary
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 did not address food palatability concerns raised by residents during council meetings. Over the course of a year, residents consistently complained about the taste and temperature of the food during eight out of twelve meetings. A sample meal tray review confirmed that the food was cold and not palatable, which could potentially affect the nutritional status of all 273 residents who consumed meals from the kitchen. During an interview, the Director of Nursing (DON) and other staff members were questioned about the residents' concerns regarding food palatability. The DON indicated that food service was not their department and deferred responsibility to the Food Service Manager. The Assistant Director of Nursing (ADON3) acknowledged that complaints about food were ongoing but did not provide any specific plans or measures in place to address the issue. When asked about prioritizing opportunities for improvement and performance improvement projects, the group did not respond, indicating a lack of action or response to the grievances related to food palatability.
Failure to Inform Residents of Anonymous Grievance Process
Penalty
Summary
The facility failed to provide information on how to file an anonymous grievance for seven residents reviewed for the grievance process. The facility's policy, titled 'Resident and Family Grievances,' states that grievances can be filed anonymously using a Compliance Hotline or complaint/grievance boxes located throughout the facility. However, during an initial tour, no grievance boxes were observed, and residents were unaware of the ability to file anonymous complaints, the compliance hotline, or where to find the hotline number. During a group interview, the residents confirmed their lack of awareness regarding the anonymous grievance process. The Resident Council meeting minutes from October 2023 through August 2024 also showed no documentation that residents had been informed about making anonymous complaints. The Director of Nursing and the Administrator confirmed the absence of grievance boxes and acknowledged that the anonymous complaint process had not been reviewed with residents at group meetings.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents involving resident-to-resident altercations. One incident involved a resident with severe cognitive impairment who scratched another resident on the face with a broken comb after entering the latter's room multiple times. The cognitively intact resident asked the impaired resident to leave, which led to the aggressive behavior. The facility's response included separating the residents and initiating monitoring, but the initial failure to prevent the altercation highlights a deficiency in protecting residents from abuse. Another incident involved a resident with dementia and agitation symptoms who pulled another resident's hair in the day room. The altercation was triggered by the noise made by the second resident, who was confused and had a history of shouting episodes. Despite staff presence, the altercation occurred quickly, and the residents were separated immediately. The facility's inability to prevent the altercation before it happened indicates a lapse in ensuring resident safety and preventing abuse. A third incident involved a resident with severe cognitive impairment who struck multiple residents on separate occasions. The resident's aggressive behavior was unprovoked in some instances and triggered by misunderstandings in others. The facility's failure to prevent these repeated incidents of aggression and physical contact between residents demonstrates a deficiency in maintaining a safe environment and protecting residents from abuse.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse to the state agency within the required two-hour timeframe. This deficiency involved four residents out of a sample of 45. The facility's policy mandates that all alleged violations involving abuse or serious bodily injury be reported immediately, but not later than two hours after the allegation is made. However, in two separate incidents, the facility did not adhere to this policy. In the first incident, a resident with dementia and mood affective disorder became aggressive and scratched another resident's face, resulting in redness under the eye. The incident was reported to the state agency several hours later, beyond the two-hour requirement. In the second incident, two residents with dementia and bipolar disorder were involved in a physical altercation where one resident pulled the other's hair. Although no injuries were noted, the incident was not reported to the state agency until three days later. Interviews with facility staff revealed a misunderstanding of the reporting requirements, with the Risk Manager incorrectly believing that only major injuries and allegations of abuse needed to be reported within two hours. The Director of Nursing, however, considered resident-to-resident incidents as abuse and stated that they should be reported within the required timeframe.
Inadequate Investigation of Resident-to-Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving four residents, which could potentially place other residents at risk. The facility's policy requires immediate investigation of abuse allegations, including interviewing all involved persons and providing thorough documentation. However, in the incidents involving the residents, the investigations were not comprehensive, as other residents who might have been affected were not interviewed. In the first incident, a resident with severe cognitive impairment scratched another resident's face with a broken comb. The incident was reported, and both residents were separated for safety. The investigation concluded that the incident was a misunderstanding due to the resident's confusion, and abuse was ruled out. However, the investigation did not include interviews with other residents who might have witnessed or been affected by the incident. In the second incident, a resident pulled another resident's hair in response to shouting. The staff separated the residents, and no injuries were reported. The investigation concluded that the action was triggered by the noise, and abuse was ruled out. Similar to the first incident, the investigation did not include interviews with other residents who might have been present or affected, indicating a lack of thoroughness in the investigative process.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, flavorful, and at the proper temperature for nine residents reviewed for food palatability. Observations, interviews, and record reviews revealed that residents frequently received meals that were cold and tasteless. The facility's policy required hot food to be held at an acceptable temperature range prior to service, but this was not consistently followed. Residents, including those with cognitive impairments and specific dietary needs, reported dissatisfaction with the food quality, indicating that it was sometimes cold, overcooked, or lacking flavor. Interviews with residents and review of Resident Council Minutes from October 2023 to October 2024 highlighted ongoing complaints about food quality, including issues with temperature and taste. The Resident Council President and several residents confirmed that these concerns were frequently raised, yet the facility had not adequately addressed them. The Food Service Director (FSD) was unaware of these complaints, as they did not attend Resident Council meetings. During a test tray sample, food temperatures were found to be below the required levels, and the food was described as cold and not flavorful by both the surveyor and facility staff. The Registered Dietician (RD) acknowledged awareness of the food complaints and noted that these issues were discussed in Morning Meetings/QA meetings attended by department heads, including the FSD. Despite these discussions, the facility lacked a food temperature logbook for the steam table, and no temperatures were taken during meal preparation and delivery. The FSD admitted to not taking periodic temperatures on the steam table, which contributed to the deficiency in maintaining proper food temperatures.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity during a dining experience. Specifically, a Certified Nursing Assistant (CNA) was observed standing over a resident while feeding them, which is contrary to the facility's policy on promoting and maintaining resident dignity. The policy emphasizes treating each resident with respect and dignity, recognizing their individuality, and providing care in a manner that enhances their quality of life. The resident involved had been admitted with diagnoses including acute stroke with right-sided weakness and aphasia, and required partial to moderate assistance with eating. The resident was also noted to be severely impaired in cognitive skills for daily decision-making. During the observation, a Registered Nurse Supervisor intervened and instructed the CNA to sit while assisting the resident with feeding, indicating that the CNA was aware of the proper procedure but failed to adhere to it initially.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure personal privacy during care for two residents, identified as R75 and R110, which had the potential to cause embarrassment or shame. For R75, who was admitted with diagnoses including cerebral infarction due to embolism, chronic congestive heart failure, and Alzheimer's dementia, an incident occurred on 10/14/24. During this incident, CNA20 and QA/CNA3 were in R75's room with the door closed. However, CNA20 opened the door, exposing R75's private body parts to the hallway. CNA20 then called for UM1 to bring the resident's cream, using the resident's name. UM1 entered the room with the door open, provided the cream, and then left, closing the door afterward. Similarly, for R110, who was admitted with cerebrovascular disease and a personality disorder, an incident was observed on the same day. CNA20 and QA/CNA3 were in R110's room with the door closed, but CNA20 opened the door, leaving R110 exposed to the hallway. CNA20 left the room without closing the door and returned without closing it again, leaving R110 exposed while personal care was being provided. RN1, passing by, noticed the open door and immediately closed it. Both CNA20 and QA/CNA3 later confirmed they were unaware of leaving the doors open, compromising the residents' privacy.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement interventions for the healing of pressure ulcers as per the care plan for a resident with a pressure ulcer on her right heel. The resident, who was admitted with diagnoses including stroke, impaired thought process, and anxiety, was cognitively intact with a BIMS score of 14 out of 15. Her care plan included treatments as ordered, referral to a wound physician and dietician, and heel offloading measures. However, during multiple observations, the resident was found without protective heel boots, which were part of her prescribed interventions to aid in the healing of her pressure ulcer. On several occasions, the resident was observed lying in bed with her heels resting directly on the low air loss mattress without elevation, contrary to the care plan's requirements. A Licensed Practical Nurse confirmed that the resident should have had heel protectors on, but they were found stored in the resident's closet instead of being used. The Assistant Director of Nursing and the Minimum Data Set Coordinator also confirmed that the resident should have been wearing protective heel boots at all times, indicating a lapse in following the prescribed care plan for pressure ulcer management.
Failure to Use PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned the appropriate personal protective equipment (PPE) when providing direct care to residents on Enhanced Barrier Precautions (EBP). Specifically, two residents, identified as R110 and R157, were not provided care with the required PPE by the certified nursing assistants (CNAs). R110, who had an open wound on his left lower leg requiring a dressing, was observed receiving personal care from CNAs who did not wear gowns, despite the presence of EBP signage outside the resident's door. The CNAs admitted to not using protective gowns because it was the end of their shift and they were assisting the next shift. Similarly, R157, who had a stage II pressure ulcer on her right heel, was also not provided care with the required PPE. During a bed bath, CNAs were observed not wearing gowns, and one CNA held soiled linens against her uniform. The CNAs acknowledged their awareness of the EBP requirement but failed to comply, with one CNA stating she had not seen the EBP signage. The Infection Preventionist confirmed that proper signage and supplies were available and that the CNAs had been educated on EBP procedures.
Sanitation and Pest Control Deficiency in Public Bathroom
Penalty
Summary
The facility failed to maintain a sanitary and pest-free environment in one of its public bathrooms, specifically the Unit 12 public bathroom. During an inspection, a surveyor observed a roach running across the floor from under the sink to behind the toilet. The bathroom was also found to be in disrepair, with crumbling plaster and peeling paint on the walls, peeling paint on the heater unit, and missing tiles around the back of the toilet. These conditions were confirmed by a family member who reported seeing roaches on multiple occasions and described the bathroom's state of disrepair. The Director of Housekeeping stated that the facility's pest management company conducted bi-weekly treatments across the campus, and any pest issues were supposed to be documented at each nurses' station. However, a review of the pest control sheets for September 2024 showed no documentation of roaches on Unit 12. Both the Director of Housekeeping and the Maintenance Director acknowledged that there had been no reports of roaches in the bathroom and agreed that the bathroom required repairs.
Medication Security Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure the secure handling of medications for two residents, R110 and R76, which could potentially expose residents to hazards of unsecured medications. For R110, during a medication pass observation, the Unit Manager retrieved eye drops from the medication drawer and placed them on top of the medication cart before locking the cart and leaving the area to wash hands. This action left the medication unattended and unsecured, contrary to the facility's policy that requires medications to be kept secured in a locked area or under visible control at all times. For R76, an observation revealed a clear cup containing at least four different medications on the resident's overbed table. The resident had refused to take the medications earlier and did not return them to the LPN, who confirmed that she could not retrieve the medication cup from the resident. The LPN was unable to identify the medications in the cup. The Director of Nursing confirmed that medications should not be left with a resident or on top of the medication cart out of the nurse's line of sight, and if a resident does not take their medication, the nurse is responsible for removing it.
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 1,270 citations issued within 25 miles in the last 12 months — including the 16 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 Secaucus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optima Care Castle Hill | 1.6 mi | — | 2 | 1 |
| Manhattanview Ctr For Rehabilitation And Healthcar | 1.8 mi | — | 6 | 0 |
| Harbour View Senior Living Corp | 2.1 mi | — | 1 | 0 |
| Optima Care Harborview | 3 mi | — | 18 | 0 |
| Hoboken University Medical Center Tcu | 3.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.