Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optima Care Castle Hill during CMS and state inspections, most recent first.
A severely cognitively impaired, independently ambulatory resident with a history of wandering, exit‑seeking behavior, recent craniotomy for subdural hematoma, and a care plan including a wander guard and helmet eloped from a unit. The resident was last seen by an RN in a wheelchair at the nurse station and later by an LPN ambulating toward an alarmed exit door and sitting on a nearby couch. Shortly afterward, the LPN could not locate the resident and began a search. Around the same time, a social worker heard the exit door alarm, deactivated it, briefly checked only partway down the stairwell, and did not see anyone. When the social worker and LPN later went down the full stairwell, they found the ground‑floor exit door partially open to the street and no residents outside. The facility’s investigation and the resident’s reenactment showed the resident had opened the 6th‑floor alarmed door, descended the stairs, and exited to the street, later being found by police and taken to an ED, leading surveyors to cite a deficiency for failure to provide a safe environment and adequate supervision to prevent accidents.
A resident with severe cognitive impairment and a history of fragile skin was found with fading discoloration on her hand and forehead. The facility's investigation into the injury of unknown origin was incomplete, as it did not include a statement from the CNA assigned to the resident at the time. Despite attempts, the CNA could not be reached, and the facility did not obtain all required staff statements as per policy.
A facility failed to ensure staff followed enhanced barrier precautions and hand hygiene protocols. A CNA did not wear PPE while transferring a resident with end-stage renal disease, and staff did not use alcohol-based hand rub between handling dirty meal trays and providing care. Interviews confirmed the expectation for PPE use and hand hygiene to prevent infection spread.
The facility failed to maintain a functional HVAC system on the 3rd floor, which was used to house COVID-19 positive and exposed residents. The floor had been closed for over a year, and the air conditioning units were not operational when residents were transferred there. Temperatures ranged from 76 to 79 degrees Fahrenheit, and residents reported discomfort due to non-functioning air conditioning units, despite the provision of fans.
Elopement of Severely Cognitively Impaired Resident Through Alarmed Stairwell Exit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for a severely cognitively impaired resident who was at high risk for elopement and exhibited exit‑seeking behaviors. The resident had a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive impairment, poor judgment, poor safety awareness, and an inability to recognize environmental hazards. The resident’s care plan identified a potential for wandering related to behavior and history of wandering, a risk for elopement due to exit‑seeking behavior with an intervention for a wander guard on the left ankle, and special needs for a protective head helmet due to a cranioplasty wound following a traumatic subdural hematoma and craniotomy. The resident was able to ambulate independently and had been admitted after a significant fall that resulted in brain surgery. On the day of the incident, the resident was last seen by an RN at approximately 3:15 PM seated in a wheelchair in the back of the nurse’s station on the 6th floor. Around 3:25 PM, an LPN beginning the 3–11 shift observed the resident no longer in the wheelchair but slowly ambulating in the hallway toward the high side of the unit near the alarmed exit door and then sitting on a couch along that hallway. After reviewing the 24‑hour report, at about 3:35 PM the LPN went to look for the resident and found that the resident was no longer on the couch. The LPN began a room‑to‑room search of the 6th floor and informed the DON that the resident could not be found. A CNA arriving for the 3–11 shift at about 3:30 PM also reported looking for the resident and not seeing them. During this same time frame, the social worker, whose office is across from the alarmed exit door on the 6th floor, returned to the floor and heard a door alarm sounding from the high side exit door. The social worker deactivated the alarm, looked down the stairwell, but only went down two to three flights and did not see anyone, then returned to the floor to inform nursing staff. The social worker and the LPN subsequently went down the stairwell to the bottom and noted that the exit door on the ground floor, which leads directly to a local street, was partially open; they checked outside and did not see any facility residents. The facility’s internal investigation and the resident’s later reenactment indicated it was probable that the resident had opened the 6th floor alarmed exit door, descended ten flights of stairs, and exited through the side egress door to the street. The resident was reported missing to police at approximately 4:17 PM and was later found by local police in a neighboring town and transported to a hospital emergency department for evaluation and overnight stay. The facility’s failure to ensure adequate supervision and to prevent this resident’s access to and use of the alarmed stairwell exit resulted in an elopement that constituted an immediate jeopardy situation beginning at the time the resident was last seen near the exit door.
Removal Plan
- Initiated an immediate room-to-room and in-house thorough search and initiated a foot and car search near the building perimeter
- Paged Code Gray to the entire building to alert all staff
- Informed local police about the missing person and provided the resident’s profile and description
- Notified the resident’s family and physician
- Alerted hospitals of the missing person
- Brought the resident to the emergency department for evaluation and the resident stayed overnight
- Completed a full head count of all residents in the building and confirmed all residents were accounted for
- Reassessed all residents at risk of elopement and re-evaluated care plans; determined interventions were appropriate and in place
- Upon the resident’s return, placed the resident on 1:1 supervision
- Upon the resident’s return, reassessed elopement risk and re-evaluated the resident’s care plan; deemed appropriate and in place
- Re-educated all staff on the facility’s Elopement and Wandering policy and continued ongoing re-education
- Implemented monitoring of the 6th floor East and [NAME] stairwell doors to ensure residents at risk have necessary supervision to prevent unsafe access to stairwell doors
- Placed a STOP sign barrier on both the East and [NAME] doors as an additional deterrent
- Requested a work order from the door security vendor for installation of an additional magnetic lock
Failure to Obtain Complete Staff Statements in Injury Investigation
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a cognitively impaired resident who was found with fading discoloration on her left hand near the thumb and a small fading area on her left forehead. The resident, who had a history of dementia, falls, and fragile skin, was unable to recall any fall, trauma, or unusual event that could have caused the discoloration. The incident was first noticed by the resident's daughter during a visit, and the physician was informed, resulting in an x-ray order for the resident's left hand. The facility's documentation indicated that the resident was alert but confused, with a severely impaired cognition as evidenced by a BIMS score of 3 out of 15, and required staff assistance for activities of daily living. The investigation conducted by the facility included reviewing the resident's care plan, which noted interventions for skin integrity due to her fragile skin and use of protective devices such as padded siderails and arm sleeves. The facility's summary of investigation stated that statements were obtained from direct caregivers within 48 hours of the discovery of the discoloration, and no unusual occurrences were reported. However, the investigation did not include a statement from the certified nursing assistant (CNA) who was specifically assigned to the resident during the shift when the discoloration was discovered. Attempts to contact the agency that employed the CNA were unsuccessful, and the CNA did not return to work at the facility. The Director of Nursing and the Licensed Nursing Home Administrator acknowledged that the CNA's statement was important but was not obtained. Facility policy requires immediate and thorough investigation of possible abuse, neglect, or injury of unknown origin, including identifying and interviewing all involved persons and providing complete documentation. Despite this, the facility did not obtain a complete set of statements from all staff involved, particularly the CNA assigned to the resident at the time of the incident. This incomplete investigation constituted a failure to follow facility policy and regulatory requirements for investigating injuries of unknown origin in residents, especially those who are cognitively impaired and unable to provide their own account of events.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure staff adhered to enhanced barrier precautions (EBP) and standard nursing precautions during the care of a resident with end-stage renal disease. Specifically, a Certified Nurse Aide (CNA) did not don personal protective equipment (PPE), including a gown and gloves, while transferring the resident from bed to wheelchair, despite EBP signage being posted at the room entrance. This oversight was confirmed by the CNA during an interview, acknowledging the failure to follow proper donning procedures. Additionally, during meal services, two CNAs and one Licensed Practical Nurse (LPN) did not adhere to hand hygiene protocols. Observations revealed that these staff members did not use alcohol-based hand rub (ABHR) between handling dirty meal trays and providing care to different residents. Interviews with the involved staff and the facility's Infection Preventionist and Director of Nursing confirmed the expectation for staff to perform hand hygiene between resident interactions and tasks to prevent infection spread. The facility's policies on EBP and hand hygiene were reviewed, highlighting the requirement for PPE use during high-contact activities and proper hand hygiene to prevent infection transmission.
HVAC System Failure on 3rd Floor
Penalty
Summary
The facility failed to maintain a functional Heating, Ventilation, and Air Conditioning (HVAC) system on the 3rd floor, which was used to house 11 COVID-19 positive residents and 9 presumed exposed residents. The 3rd floor had been closed for over a year, and the air conditioning units were not operational when the decision was made to transfer residents there on 8/27/2024. The Maintenance Director (MD) was not conducting daily maintenance rounds on this floor, and the Environmental Temperature Log (ETL) showed temperatures ranging from 76 to 79 degrees Fahrenheit, which is within the normal range but did not specify locations for each reading. The Administrator confirmed that no temperatures were recorded after 5 PM on 8/27/2024 and 8/28/2024. Residents and their families reported discomfort due to the non-functioning air conditioning units. One resident confirmed that the room air conditioner was not working and that a fan was provided, but the room remained hot. Another resident's daughter also reported that the air conditioner was not working, although an electric fan was provided. The Administrator responded to complaints by deploying additional portable air conditioners and electric fans to residents' rooms and placing a commercial electric fan in the hallway.
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 1,630 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Union City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manhattanview Ctr For Rehabilitation And Healthcar | 0.4 mi | ★★★★★ | 6 | 0 |
| Optima Care Fountains | 1.6 mi | ★★★★★ | 12 | 0 |
| Harbour View Senior Living Corp | 1.8 mi | ★★★★★ | 22 | 0 |
| Hoboken University Medical Center Tcu | 1.9 mi | ★★★★★ | 0 | 0 |
| Optima Care Harborview | 2 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Optima Care Castle Hill.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.