Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Harborview during CMS and state inspections, most recent first.
A resident with hemiplegia, severe cognitive impairment, a feeding tube, and surgical wounds was ordered EBP for a PEG tube, but the care plan did not include the EBP need or related interventions. The DON confirmed the omission and stated that the care plan is meant to communicate interventions for resident safety, protection, and care.
Incomplete Care Planning for Double Incontinence Brief Use: Two residents were observed wearing two incontinence briefs, and staff confirmed the residents had requested this practice. One resident had diagnoses including amputation, DM2, and repeated falls; the other had rhabdomyolysis, DM2, sepsis, and UTI and was incontinent of bowel and bladder, chairfast, and severely limited in walking. Staff stated the nurse was not informed before the briefs were applied, and the residents’ care plans were updated after the surveyor’s observations.
Facility-wide assessment was incomplete because it did not include the staffing contingency plan, NJ mandated CNA staffing ratios, updated resident profile information, or required physical environment details. The LNHA acknowledged the facility used acuity-based staffing, later confirmed the census-based NJ staffing ratios should have been included, and the staffing report showed CNA shortages on multiple day shifts. The assessment also left physical plant and equipment sections blank, and the LNHA stated the facility was unaware of the updated CMS guidance for the FA.
A facility failed to follow TF orders, document flushes and total volumes accurately, clarify conflicting enteral orders, and store/date TF supplies properly for residents with feeding tubes. Surveyors observed undated syringe supplies, incorrect or inconsistent TF and water flush documentation, conflicting order entries, and a pump set at a rate that did not match the ordered regimen; staff acknowledged the discrepancies and said the orders should have been followed or clarified.
Hand hygiene, PPE use, and clean linen storage were not properly maintained. A CNA donned gloves without cleaning hands and later wore gloves in the hallway, another CNA was observed with gloves in the hallway after resident care, an LPN washed hands for only a brief period under running water, and a housekeeper removed gloves and touched an exit keypad without hand hygiene. In addition, multiple linen carts had stained, ripped, or holed covers, and the clean linen room contained dust, stains, and linen supplies left open to air.
Surveyors found multiple environmental cleanliness and maintenance issues, including a shower room with missing and broken tiles, dripping water, stained shower chairs, discolored ceiling tiles, and uncovered sprinkler/ceiling openings. A resident room had a plastic pipe on the floor and a blinking light, while a day room had stained table coverings, improperly covered water pitchers, a broken floor tile, uncovered garbage receptacles, window debris, and dust/discoloration on the floor. Broken moldings and dirty air vents were also observed in other common areas, and staff interviews confirmed concerns about cleaning practices and lack of deep-cleaning logs.
Facility staff failed to document mandatory QAPI training for five CNAs. Review of annual education records, in-service logs, and the staff education calendar did not show QAPI training for the selected CNAs, and two CNAs interviewed could not recall receiving it. The SE said QAPI was mandatory, but the DON stated staff may not have had a clear understanding of what QAPI was.
A resident with a known Candida auris (C. auris) diagnosis, who had previously stayed at the facility and lived nearby, was denied readmission after referral from a hospital. The referral system recorded the denial reason as "Medical," which the Regional Admission Director later clarified meant C. auris, despite CDC and state guidance stating that most facilities can care for C. auris-positive individuals and should not deny admission based solely on that diagnosis. Interviews with the IP/ADON, LNHA, and Regional Nurse confirmed that the facility already cared for residents on enhanced barrier precautions (EBP) and contact precautions, had appropriate protocols and supplies, and recognized that C. auris is managed with contact precautions. Bed availability records showed multiple open beds, including private rooms, at the time of the referral, yet the resident was directed instead to a sister facility with a dedicated C. auris unit, resulting in a denial of admission that conflicted with regulatory guidance and the facility’s own infection control policies.
A resident with seizures, cerebral palsy, aphasia, severe cognitive impairment, and tube feeding had an APN order to check Vimpat, Keppra, and Topamax levels, with the same plan documented in the neurology note. The lab order was not carried out as ordered, no requisition was found at the time of review, and the chart lacked documentation explaining the delay or any refusal. The DON stated the expectation was to follow the order and document if the resident refused, while the Regional Nurse said staff believed the resident refused but there was no documentation in the record.
A resident with impaired cognition and multiple skin impairments had inaccurate skin assessment entries, missing routine wound progress documentation, and no documented wound doctor consult in the record. The care plan did not identify the wound locations, and staff interviews confirmed that wound measurements and consult documentation were expected but were not present in the resident’s hybrid chart.
Respiratory equipment for a resident with COPD and OSA was not handled as required. The resident was observed receiving O2 via NC with undated tubing and an undated humidification water bottle, and the nebulizer tubing and CPAP mask were not consistently stored in a plastic bag when not in use. Staff confirmed that O2 tubing, the water bottle, and respiratory equipment should be dated and stored to follow infection control practices, and the resident’s care plan was not updated to match the current O2 order.
A resident with ESRD on HD had a physician-ordered 1000 mL FR split between nursing and dietary, but meal tickets and room observations showed beverages provided without the FR being reflected on the meal ticket or meal pattern. The resident’s dietary fluids totaled more than the ordered allowance, and staff interviews showed the FSD did not see the resident flagged for FR in the computer while the RD confirmed the printed meal tickets exceeded the ordered dietary amount.
The facility failed to ensure the NHRCSR accurately posted licensed nurse staffing, CNA staffing, and resident census at the beginning of the shift on multiple days. Surveyors found mismatches between the posted NHRCSR, the Facility Staffing Sheet, and census records, and interviews showed the SC or Supervisor was responsible for posting, but postings could be late or missed when the SC was unavailable or busy. The facility policy did not address posting staffing or census information or the accuracy of the posting.
A resident with hypotension, hemiplegia, hemiparesis, and chronic atrial fibrillation had a Midodrine order to hold if systolic BP was over 110. The eMAR showed the med documented as given when BP readings were above the hold parameter, and staff interviews confirmed that the check mark meant administered and that the order should not have been followed that way.
Medication storage and labeling deficiencies were identified in a med storage room and a med cart. An opened PPD vial was found without a date when opened, a vial of insulin lispro in a Humalog-labeled bag had inconsistent open/expiration labeling and was expired, and the controlled substance lock box in the cart could be opened without a key and would not latch closed. Staff stated the PPD should have been dated, the expired insulin should have been removed, and the lock box should have remained locked.
A facility failed to ensure that all menu items listed on diet slips were consistently served during lunch meal rounds on one unit. One resident received the main meal and beverages but did not get the listed jello, and another resident received the meal and beverages but did not get the listed rosy pears; CNAs stated they did not know why the items were missing. The Regional Nurse stated staff had been in-serviced that the meal served should match the tickets.
A resident with severe cognitive impairment and behavioral issues continued to receive care from an LPN after the family requested the nurse's removal from the care team. Despite the family's request, facility records showed the LPN continued to provide care, and leadership could not provide documentation or explanation for not honoring the preference, contrary to the facility's resident rights policy.
A facility failed to notify a resident's family about a new unstageable pressure sore on the resident's left heel after readmission. Despite the facility's policy, there was no documentation of notification, and the family member was unaware of the condition. The MDS/Care Plan Coordinator recalled discussing the issue, but it was not documented in the meeting notes.
A resident who required assistance for transfers was found to have a right femur fracture after complaining of leg pain following a transfer. The facility's investigation into the incident was incomplete, as it did not include interviews with all staff involved in the resident's transfers on the day of the incident. Only the two CNAs who assisted with the transfer before the resident's appointment were interviewed, leaving gaps in the investigation process.
The facility failed to accurately complete PASARR Level I Assessments for two residents, potentially delaying necessary services. One resident's assessment incorrectly indicated no mental illness despite diagnoses of major depressive disorder and anxiety, while another resident's assessment was incomplete, missing responses related to mental illness despite a history of psychiatric hospitalization.
A resident with a known fish allergy was served fish for lunch despite the allergy being noted on their meal ticket and care plan. The resident consumed some of the fish and requested hospital care after experiencing facial redness. Staff interviews revealed that the meal ticket system identified the allergy correctly, but the meal was plated incorrectly, and there was no policy to ensure meal accuracy.
Failure to Include EBP for PEG Tube in Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident who was on enhanced barrier precautions related to a PEG tube. Resident #1 was admitted with diagnoses including hemiplegia affecting the nondominant side, need for gastrostomy care, and need for assistance with personal care. The resident’s MDS dated 04/10/2026 showed a BIMS score of 6 out of 15, indicating severe cognitive impairment, and also documented a feeding tube present on admission and surgical wounds. The Order Summary Report showed an order for enhanced barrier precautions related to the resident’s PEG tube, with an order date of 04/03/2026. Review of the resident’s care plans did not show a focus or interventions addressing the need for enhanced barrier precautions. During interview, the DON stated that the purpose of the care plan was to communicate appropriate interventions for resident safety, protection, and care, confirmed that the resident was on EBP because of the PEG tube, and acknowledged that the need for EBP was not included in the care plan.
Incomplete Care Planning for Double Incontinence Brief Use
Penalty
Summary
The facility failed to develop personalized care plans for 2 of 3 incontinent residents based on their preference for using two incontinence briefs. During incontinence rounds on the fourth floor, one resident was observed in bed with a small incontinence brief that was damp with urine inside an outer brief, and another resident was observed in bed wearing two incontinence briefs. Unit managers confirmed both residents were wearing two briefs at the time of the observations. One resident’s record showed diagnoses including aftercare following surgical amputation, acquired absence of the left leg below the knee, type 2 diabetes mellitus, need for assistance with personal care, and repeated falls. The care plan included a focus on risk for skin impairment and fragile skin, with interventions to provide incontinent care as needed and keep the skin clean and dry. It also included a focus on the resident’s preference for double diapers for comfort and dignity, with interventions to educate the resident on increased moisture retention, risk for skin breakdown, and discomfort, and to continue assessing the preference and discussing risks and benefits. The other resident’s record showed diagnoses including rhabdomyolysis, type 2 diabetes mellitus, sepsis, and urinary tract infection. The admission/readmission evaluation documented bowel and bladder incontinence, use of incontinence briefs, chairfast status, and severe limitation in walking. The care plan included a focus on potential skin impairment related to fragile skin, a focus on decreased ADL skills, and a focus on preference for double diaper use, with interventions to assess and document preferences, discuss risks and benefits, educate regarding skin breakdown, infection, and discomfort, and encourage use of one appropriately sized brief whenever possible. Staff interviews confirmed that the residents requested two briefs, that nurses were not informed before the briefs were applied, and that the use of two briefs had been added to the care plans after the surveyor’s incontinence rounds.
Facility Assessment Missing Staffing, Resident Profile, and Physical Environment Information
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that included the resources necessary to care for residents competently during day-to-day operations and emergencies. During the entrance conference, the surveyor requested the Facility Assessment from the LNHA, and the facility census was identified as 139 residents. Review of the Facility Wide Staffing and Resource Assessment showed an assessment/update date of 7/29/25 and QAPI review on the same date, but it did not include information about a staffing contingency plan. The staffing plan stated the facility did not use a census-based approach to staffing and instead used resident acuity to guide staffing. The assessment also did not include the NJ mandated minimum staffing law for census, even though the LNHA later stated the facility followed the NJ staffing ratios of 1:8 on 7-3, 1:10 on 3-11, and 1:14 on 11-7. Review of the Nurse Staffing Report for the two weeks before survey showed CNA staffing deficiencies on 8 of 14 day shifts. In interview, the LNHA acknowledged that the census-based approach was part of the NJ mandated staffing requirement and should have been included in the Facility Assessment. He also stated he was unaware of the CMS memo effective 8/8/24 regarding the Facility Assessment. Further review showed Part 3: Resident Profile, Special Treatments and Conditions-Per Category was listed as April-June 2023, which did not match the 7/29/25 team review date. The Physical Environment and Building/Plant Needs section was also incomplete, with blank entries for physical equipment such as bath benches, showers, bathrooms, safety features, and the process for ensuring adequate supply, maintenance, and replacement. The LNHA later stated that the facility updated the assessment after the surveyor’s inquiry and identified physical plant issues, linen cart cover replacement, and staffing contingency language, but the originally provided assessment did not contain that information.
Tube Feeding Orders, Documentation, and Supply Storage Not Followed
Penalty
Summary
The facility failed to consistently document and administer enteral tube feeding flushes and formula in accordance with physician orders, failed to clarify conflicting tube feeding orders, and failed to properly store and date tube feeding supplies for residents receiving enteral feedings. These issues were identified for three residents with feeding tubes: one resident with diagnoses including cerebral infarction, gastrostomy, and hepatic encephalopathy; one resident with hypoxic ischemic encephalopathy, anoxic brain damage, tracheostomy, gastrostomy, and dysphagia; and one resident with dysphagia, seizures, cerebral palsy, and bed confinement status. For one resident, surveyors observed a TF pump that was empty and a piston syringe in a container on the dresser that was not dated. The resident’s record showed a feeding tube and moderately impaired cognitive skills for daily decision making. Staff told surveyors that the syringe and bottle were usually changed daily and dated, but when shown the undated item, the LPN/UM stated it should not be that way. The DON also stated the syringe and bottle should be contained in a dated bag for infection control, yet another undated syringe and bottle was again observed on the dresser and discarded. For a second resident, the record showed orders for Vital 1.5 via PEG at 50 ml/hr with a total volume of 1000 ml/24 hours and water flushes of 200 ml every 6 hours. Review of the eMAR showed multiple days where the documented total volume of formula and flushes did not match the ordered amounts, including flush totals that exceeded the ordered daily volume. The RN/UM confirmed the flush documentation was incorrect and stated nurses were not reading the orders correctly. The facility’s tube feeding policy stated tube feedings were to be given as ordered and the pump set up with the proper volume, rate, and auto flush. For a third resident, surveyors found conflicting tube feeding orders in the record, including two different daily total volumes for the same enteral feeding order and a water flush order that was plotted without milliliter amounts. The resident was observed with the TF machine off and no formula hung, and when the DON checked the pump, the displayed number was identified as the rate per hour rather than the total volume infused. The LPN confirmed the pump was set at a rate different from the order and stated the orders should have been followed and clarified. The facility’s policy required tube feedings to be given per physician order and the pump to be set up with the proper volume and rate.
Hand Hygiene, PPE, and Clean Linen Storage Failures
Penalty
Summary
The facility failed to ensure appropriate hand hygiene and PPE use during resident care and staff movement in resident care areas. On the 5th floor, a CNA entered a resident room wearing a double surgical mask, donned gloves without performing hand hygiene, and then checked the resident’s incontinence brief. The CNA later acknowledged that hand hygiene should have been performed before putting on gloves. In another observation on the same unit, a CNA was seen walking in the hallway with gloves on while carrying a plastic bag and stated that she had performed incontinence care for a resident but should not have been using gloves in the hallway. A nurse was also observed performing handwashing inside a resident room for nine seconds under running water before putting on a new pair of gloves. When questioned, the nurse stated that handwashing should be at least 30 seconds and acknowledged that she was washing her hands under the stream of running water while trying to finish. On the 3rd floor, a housekeeper was observed walking in the hallway with gloves on, removing the gloves, touching the exit door pin pad, and leaving the unit without performing hand hygiene. The DON was notified of the observation, and the housekeeper’s actions were confirmed in the moment. The facility also failed to maintain appropriate storage and cleanliness of clean linen supplies. Linen carts on the 3rd and 5th floors were observed with stained, ripped, and holed cart covers while clean linens remained inside. One clean linen cart had plastic wrapper debris in the cart cover pocket. In the 5th floor clean linen room, the floor near the door had blackish buildup and dust, shelves had brown dried stains that were described as possibly coffee drippings, and clean linen supplies were not all stored inside bags and were open to air. Staff and leadership acknowledged that the linen cart covers were dirty, that coffee should not have been in the clean linen room, and that the room should have been cleaned.
Unsafe and Unsanitary Conditions in Common Areas, Shower Room, and Resident Room
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment in multiple common areas, day rooms, and one resident room. During a tour of the 3rd floor shower room, surveyors observed a missing floor tile, a broken wall beneath the entrance door, a door bottom metal part scraping the floor, a sink faucet continuously dripping, dust and blackish accumulation on the floor, five ceiling tiles with blackish and brownish discoloration, two shower cubicles with one broken floor tile in the second cubicle, three shower chairs stained brownish and yellowish, and sprinkler head and ceiling tile conditions that were open, uncovered, or loose. The Director of Maintenance was notified of these findings and identified some items as maintenance issues and the shower chairs as housekeeping responsibility. In room [ROOM NUMBER], surveyors observed a plastic pipe on the toilet room floor next to the toilet seat and a blinking light over the sink. The DON later observed the same conditions and stated the pipe should not have been there. In the 5th floor day room, surveyors and the DON observed a table covered with a towel that had brownish staining, two water pitchers dated 1/12/26 covered with saran wrap instead of appropriate covers, one broken floor tile, uncovered garbage receptacles, paper and plastic on the side of the middle window, and floor tiles with scattered brownish discoloration and dust accumulation. The DON removed the paper and plastic from the window area and stated it should not be there. Additional observations included broken moldings on both sides of the 4th floor day room entrance and dirty air circulation vents on the 2nd floor hallway and above the 5th floor nurses' station, both with black, grayish, and dust-like accumulation. Staff interviews reflected that shower room cleanliness was the responsibility of housekeeping, that there were no logs for deep cleaning of shower rooms, that the linen room did not appear to have been deep cleaned, and that staff should not be drinking coffee inside the clean linen room. The facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment with a clean, sanitary, and orderly setting.
Missing Mandatory QAPI Training Documentation
Penalty
Summary
Facility staff failed to ensure mandatory training on the Quality Assurance and Performance Improvement (QAPI) program was provided to all staff, as required. Based on review of staff education records for five randomly selected CNAs, the individual mandatory in-service sheets did not show any QAPI topic for CNA #1, CNA #2, CNA #3, CNA #4, or CNA #5. The Staff Educator stated that QAPI was a mandatory in-service, but the reviewed records did not document that these five CNAs received it. The surveyor also reviewed the facility’s staff development in-service program sign-in logs and the Mandatory/Competency Annual Calendar 2025. The sign-in logs dated 12/9/25 showed topics such as Trauma Informed Care, QAPI process, and restraints, but the logs did not reflect QAPI training for CNA #1, CNA #3, CNA #4, or CNA #5, and CNA #2 appeared only on a page labeled Trauma Informed Care. The annual calendar did not list QAPI or QAPI process, and the facility binder reviewed with the Staff Educator and DON did not contain additional documents showing QAPI education. When interviewed, two CNAs could not recall receiving QAPI in-service, and the DON stated that staff may not have had a clear understanding of what QAPI was.
Improper Denial of Admission for C. auris-Positive Resident
Penalty
Summary
The deficiency involves the facility’s failure to comply with Federal, State, and local laws, regulations, and accepted professional standards by denying admission to a referred resident based solely on a diagnosis of Candida auris (C. auris). CDC guidance dated 4/24/24 states that transmission-based precautions (TBP) and enhanced barrier precautions (EBP) for C. auris are similar to those used for other multidrug-resistant organisms and that most facilities equipped to care for MDROs can also care for patients with C. auris. New Jersey Department of Health guidance dated 3/24/23 further specifies that most healthcare facilities can provide adequate care for C. auris-positive individuals and therefore should not deny admission based upon a C. auris diagnosis. Despite these directives, the facility’s referral list showed that one referred resident was denied admission, with the reason documented as “Medical,” which the Regional Admission Director later clarified was due to C. auris. The resident in question had a prior admission at the facility, had been referred again from a nearby hospital, and lived in the vicinity of the facility. The Regional Admission Director explained that referrals are reviewed by an outside clinical team and the in-house admissions team, including the LNHA, and that the denial reason “Medical” in this case meant the resident had C. auris. He stated the facility did not have a dedicated C. auris unit and cited infection control and lack of isolation as the basis for the denial. However, the Infection Preventionist/Assistant DON reported that the facility admits residents on EBP and contact precautions, that staff are knowledgeable in caring for residents on these precautions, and that the facility had policies for EBP and contact precautions. The facility’s own EBP policy indicated that a private room is not required, and its infection prevention and control program policy recognized contact precautions as one of the established transmission-based precautions. Further review showed that on the date relevant to the referral, the facility had numerous available beds, including multiple private rooms on several floors. The LNHA described the admission process as involving review of referrals by an outside clinical team and the in-house admissions team, with final decisions made on a case-by-case basis, typically denying residents deemed not appropriate such as those on ventilators. When questioned, the LNHA and Regional Nurse acknowledged that the facility had residents on EBP and contact precautions, that staff could meet the needs of such residents, and that C. auris is managed with contact precautions. The Regional Nurse also stated that another affiliated facility had a dedicated C. auris isolation unit and that the resident was directed there, while acknowledging that at the time “we did not really accept C. auris,” despite having EBP and contact precaution protocols in place. When asked why the resident was denied admission under these circumstances, the LNHA, DON, and Regional Nurse did not provide a response, establishing that the denial was inconsistent with CDC and NJ DOH guidance and the facility’s own policies.
Delayed and undocumented seizure medication lab monitoring
Penalty
Summary
The facility failed to follow a provider’s order and plan of care for a resident’s laboratory monitoring. Resident #43 was admitted with diagnoses including dysphagia, seizures, cerebral palsy, bed confinement status, aphasia, and severe cognitive impairment. The resident was receiving tube feeding, and the most recent quarterly MDS indicated severely impaired cognition for daily decision making. A physician/APN order dated 10/9/25 directed that Vimpat, Keppra, and Topamax levels be checked, and the APN’s neurology follow-up note also documented a plan to check those levels in the morning. Review of the laboratory records showed no requisition for the ordered labs on 10/9/25, and the medical record contained no documented explanation for why the order and plan were not carried out at that time. When the DON was questioned, she stated that the expectation was to follow the physician or APN order and that there should have been documentation if the resident refused or if the labs were not done. The DON later provided lab results showing that the Vimpat and Keppra levels were obtained on 10/31/25 and the Topamax level on 12/2/25, well after the original order. The Regional Nurse stated that staff believed the resident refused, but the record did not contain documentation of refusal.
Inaccurate skin assessments and missing wound documentation
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and prevention for one resident with multiple skin impairments. The resident was admitted with diagnoses including cerebral infarction, gastrostomy, and hepatic encephalopathy, and the most recent MDS reflected moderately impaired cognitive skills for daily decision making. The care plan included a focus area for a break in skin integrity due to wounds, but it did not identify the wound locations. The resident’s record also included treatment orders for Silver Sulfadiazine cream to the right buttock and earlier treatment with Vitamins A & D ointment to the sacrum. Survey review found that the skin assessment documentation was inaccurate. The electronic skin assessment order required staff to document whether there were no skin impairments, a previous skin impairment, or a newly identified skin impairment, with additional progress note documentation required if a new impairment was identified. Nurses documented no skin impairment on several dates even though a right buttock open area had been observed and documented in a progress note as measuring approximately 1 cm by 1 cm. The record also showed earlier documentation of a Stage 2 pressure ulcer on the left buttock from the hospital transfer form and a Stage 1 pressure ulcer on the sacrum on readmission assessment, but the facility’s progress notes did not consistently identify the skin impairment noted on the skin assessment dates. The facility also did not maintain routine wound documentation in the resident’s hybrid record and did not follow the physician order for a wound doctor consult. Staff interviews showed that wound rounds were expected weekly and that wound documentation should include measurements and wound description to show progress, but the resident’s wound doctor visit documentation was not uploaded in the record. The facility provided wound timelines that contained measurements not found in the resident’s medical record, and the care plan did not specify the wound locations. The facility’s policy stated that wound care provider rounds weekly and provides wound documentation that is uploaded in the resident’s electronic record.
Respiratory Equipment Not Dated or Properly Stored
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who was receiving O2, CPAP, and nebulizer treatments. On observation, the resident was lying in bed receiving O2 via nasal cannula at 4 lpm through a concentrator, but the O2 tubing and the water bottle used for humidification were not dated. The resident was also observed with nebulizer tubing and a CPAP mask laid out on the dresser rather than stored in a plastic bag. The resident stated they had recently been hospitalized for pneumonia and flu and had been intubated, and also stated they had not used the nebulizer since before going to the hospital because it made them jittery. The resident’s record showed diagnoses including COPD, obstructive sleep apnea, and hypertension, and the most recent MDS indicated the resident was cognitively intact with a BIMS score of 15 and received O2 therapy. The order summary included O2 via nasal cannula at 4 lpm every shift, while the care plan still reflected an older O2 intervention of 2 lpm and was not updated to match the current physician order. On a later observation, the O2 tubing was dated, but the water bottle was still not dated. The nebulizer tubing was stored in a plastic bag, but the CPAP mask was not stored in a plastic bag and was found in the dresser drawer. Staff interviews confirmed the expected process for respiratory equipment. An LPN stated that O2 tubing and the water bottle should be labeled and dated, and that nebulizer tubing and the CPAP mask should be dated and stored in a plastic bag when not in use to prevent exposure to bacteria. The LPN/UM stated that respiratory equipment should be placed in a plastic bag when not in use and that the water bottle should also be dated. The surveyor showed staff the observations, and the LPN/UM stated the equipment should not have been like that because of possible infections. The facility’s oxygen and nebulizer policies required dated tubing and infection control handling, while the BIPAP/CPAP policy did not contain information on storing the CPAP mask.
Fluid Restriction Not Followed for Resident on Hemodialysis
Penalty
Summary
The facility failed to follow a physician-ordered fluid restriction for a resident receiving hemodialysis. The resident had diagnoses including end stage renal disease, dependence on renal dialysis, and hypertension, and the most recent MDS reflected that the resident was cognitively intact and received HD. The care plan and physician order both reflected a 1000 mL fluid restriction with the daily amount divided between nursing and dietary, and the dietician note documented that the resident was aware of and understood the 1000 mL restriction. On observation, the resident was away at dialysis when the surveyor entered the room, and the breakfast tray and meal ticket were present. The meal ticket did not indicate a fluid restriction and listed 4 fl oz apple juice, 4 fl oz apple juice, and 4 fl oz hot tea (Decaf). Additional fluids were also observed in the room, including two 4 oz juices on the dresser and a 16-20 ml bottle of soda on the bedside table. The resident stated that dialysis occurred three times weekly and that the resident left the facility early in the morning and returned later in the morning. Record review showed that the meal tickets for breakfast, lunch, and dinner listed multiple beverages totaling 1302.4 mL of dietary fluids in a 24-hour period, which exceeded the ordered total of 1000 mL for dietary and nursing combined. The meal pattern did not identify the resident as being on a fluid restriction. Interviews with dietary and nursing staff showed that the FSD stated the resident was not flagged in the computer as being on a fluid restriction, while the RD confirmed that the dietary portion should have been 720 mL and that the printed meal tickets showed more than the ordered amount. The report also noted that the updated order entered on 1/8/26 was created after breakfast meal tickets had already been printed and distributed.
Inaccurate Daily Staffing and Census Posting
Penalty
Summary
The facility failed to ensure that the daily Nursing Home Resident Care Staffing Report (NHRCSR) accurately reflected licensed nurse staffing, CNA staffing, and resident census at the beginning of the shift on 3 of 6 days reviewed during the annual recertification survey. On 1/8/26, the surveyor observed a posted NHRCSR showing a census of 140, while the DON stated the current census was 139. On 1/9/26, the posted NHRCSR listed 19 CNAs, but the Facility Staffing Sheet showed 18 CNAs and identified one CNA as called out. On 1/12/26, the posted NHRCSR showed a census of 145 and 18 CNAs, while the facility’s records for 1/10/26 showed a census of 143 on the NHRCSR and a Midnight Daily Census Report reflecting 144 residents. During interviews, the Regional Nurse stated that the Staffing Coordinator or the Supervisor were responsible for posting accurate staffing and census information. The Staffing Coordinator stated the report should be posted daily at the beginning of the shift so visitors could see it, but also stated that if they were not in the building, the ADON or Supervisor would physically post it. The Staffing Coordinator further stated that the Supervisor could become busy with an emergency and not update the report, post it late, or forget to post it, and later acknowledged that on one day the staffing was posted late because they arrived around 11:00 AM. The facility’s Staffing Policy and Procedure, dated 11/16/25, did not address posting staffing or census information or the accuracy of posting.
Medication Documented as Given Outside BP Parameter
Penalty
Summary
The facility failed to provide pharmaceutical services by ensuring accurate administration of Midodrine for one resident with hypotension. The resident had diagnoses including hemiplegia, hemiparesis, hypotension, and chronic atrial fibrillation, and the most recent MDS indicated severely impaired cognitive skills for daily decision making. The physician’s order on the eMAR directed Midodrine HCl 10 mg via PEG tube every 8 hours for hypotension, with the medication to be held if systolic BP was over 110. Review of the January 2026 eMAR showed that the medication was documented as administered when the resident’s BP was 114/74 and again when it was 118/64, both above the ordered hold parameter. During interviews, an LPN stated that if there was a hold order and the BP was outside the parameter, the medication would not be given, and both the LPN and the LPN/UM stated that a check mark on the eMAR meant the medication was given. The DON also confirmed that the order should have been followed and the medication should not have been given. The Regional Nurse later stated that nurses reported they had not given the Midodrine but signed it as given, and that a med error report had been completed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled appropriately in the medication storage room, one medication cart, and one medication refrigerator inspected on 3 of 3 units. In the 3rd floor medication storage room, the surveyor observed an opened vial of tuberculin purified protein derivative (PPD) diluted Aplisol with no date marked showing when it was opened. The 3rd floor UM stated the vial should have been dated when opened and that, because no date was present, it should be discarded. On the 4th floor B side medication cart, the surveyor observed a plastic bag labeled Humalog containing a vial of insulin lispro with handwritten open and expiration dates that did not match the printed storage directions. The RN stated the date should have been different and that the medication should have been disposed of if it was expired. The surveyor also observed the controlled substance lock box in the same cart could be opened without a key and would not latch or lock when closed; the RN stated it should always be locked. The manufacturer inserts reviewed by the surveyor stated that in-use PPD vials should be discarded after 30 days and that in-use Humalog vials must be used within 28 days or discarded.
Missing Menu Items During Lunch Meal Service
Penalty
Summary
The facility failed to ensure that all listed menu items were consistently provided during lunch meal rounds on one of three units, the 5th floor. During observation of the lunch meal, all residents received their meals, but Resident #7 was served breaded fish fillet, yellow rice, seasoned green beans, whole milk, diet ginger ale, and hot tea, while the 4 oz jello listed on the diet slip was missing. When asked about the missing jello, CNA #1 stated she was unsure why it was not provided and said she would notify the nurse; Resident #7 stated she wanted the jello. At another table, an unsampled resident was observed receiving filet of fish, yellow rice, seasoned green beans, apple juice, whole milk, hot tea, and peanut butter and jelly wheat sandwiches, but did not receive the 4 oz rosy pears listed on the diet slip. CNA #2 stated she did not know why everyone had dessert except that resident. The facility’s Diet Communication Policy and Procedure stated that dietary services maintains up-to-date diet cards, meal tickets, or electronic diet lists, and the Regional Nurse stated staff were in-serviced that the meal served should match the tickets.
Failure to Accommodate Resident's Preference for Care Team Assignment
Penalty
Summary
The facility failed to honor a resident's preference regarding their care team by not removing a specific nurse from the resident's care, despite a request from the resident's family member. The family member had asked on 4/11/25 for a particular LPN to be removed from the resident's care team, but records showed that the LPN continued to administer medications and perform assessments for the resident after this date. The resident in question had severe cognitive impairment, as indicated by a BIMS score of zero, and a history of behavioral problems, including refusing care and aggression toward staff. Interviews with facility leadership revealed that there was no clear documentation or explanation as to why the LPN was not removed from the resident's care team following the family's request. The Director of Nursing stated that the usual procedure would involve a meeting with the family to discuss concerns, but could not provide further information about this specific case. The facility's policy on resident rights, which includes the right to reasonable accommodation of needs and preferences, was reviewed but not followed in this instance.
Failure to Notify Family of Resident's Pressure Sore
Penalty
Summary
The facility failed to notify the representative of a resident about a significant change in the resident's skin condition. The resident, who had a history of atherosclerotic heart disease, cardiomyopathy, atrial fibrillation, severe aortic stenosis, congestive heart failure, peripheral vascular disease, and dementia, was readmitted to the facility with a new unstageable pressure sore on the left heel. Despite the facility's policy requiring notification of significant changes, there was no documentation that the resident's family member was informed about this new pressure area. The deficiency was identified during a review of the resident's records and interviews with the family member and facility staff. The family member stated they were unaware of the pressure sore on the left heel, and the facility's records did not show any notification to the family. Although the MDS/Care Plan Coordinator recalled discussing the wound with the family during an IDT meeting, the meeting notes did not document this discussion. This lack of documentation and communication led to the deficiency being cited.
Incomplete Investigation of Alleged Staff Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged incident of staff neglect involving a resident who required assistance for transfers. The resident, who was admitted to the facility and required staff assistance for transfers, was transferred by staff on the morning of the incident before a scheduled podiatrist appointment. After returning from the appointment, the resident complained of pain in the right leg and was subsequently diagnosed with a right femur fracture at the hospital. The family reported that the resident mentioned being dropped during a transfer by staff, which was not thoroughly investigated by the facility. The facility's investigation, dated a few days after the incident, did not include interviews with all staff involved in the resident's transfers on the morning of the incident. Only the two certified nurse aides who assisted with the transfer before the resident's appointment were identified and interviewed. The Administrator acknowledged that the investigation was incomplete, as not all staff involved in the transfers were interviewed. The Administrator also mentioned a belief that the fracture might have been caused by the weight of the resident's braces, but confirmed that a thorough investigation should have included interviews with all staff involved in the transfers.
Inaccurate PASARR Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Preadmission Screening and Resident Review (PASARR) Level I Assessment for two residents, which could potentially delay necessary services. Resident 108 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and hallucinations. Despite these diagnoses, her PASARR Level I Assessment incorrectly indicated no mental illness, and a Level II assessment was not pursued. The Social Services Director acknowledged the error, noting that a former employee completed the assessment inaccurately. Resident 79 was admitted with major depressive disorder and schizoaffective disorder. The PASARR Level I Assessment for this resident was incomplete, as it did not address questions related to mental illness, despite the resident's history of psychiatric hospitalization. The Social Services Director admitted that the PASARR was not reviewed for accuracy, and the Psychiatric Doctor confirmed the resident's history of inpatient psychiatric care. The facility did not ensure the PASARR was complete and accurate, which was acknowledged by the staff.
Failure to Accommodate Resident's Food Allergy
Penalty
Summary
The facility failed to provide food that accommodated a resident's allergies, specifically for a resident with a known allergy to fish. The resident, who was cognitively intact with a BIMS score of 14 out of 15, was served fish for lunch despite having an allergy noted in their care plan and on their meal ticket. The resident consumed some of the fish and subsequently requested to go to the hospital after experiencing some redness on the face. The Assistant Director of Nursing confirmed that the resident was given Benadryl and later prednisone before being sent to the hospital. Interviews with facility staff, including the Assistant Director of Nursing, a Registered Nurse, the Dietary Manager, and the Assistant Dietary Manager, revealed that the resident's meal ticket correctly identified the fish allergy and an alternate meal was specified. However, the resident was still served the incorrect meal. The Dietary Manager acknowledged the error and noted that the meal ticket system had functioned correctly, but the meal was not plated accurately. The Assistant Dietary Manager admitted that there was no policy or procedure in place to ensure the accuracy of meal plating and that residents receive the correct meals.
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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.
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Nursing homes near Jersey City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hoboken University Medical Center Tcu | 0.6 mi | ★★★★★ | 0 | 0 |
| Alaris Health At Hamilton Park | 0.8 mi | ★★★★★ | 0 | 0 |
| Peace Care St Joseph's | 0.9 mi | ★★★★★ | 14 | 0 |
| Optima Care Castle Hill | 2 mi | ★★★★★ | 2 | 1 |
| Manhattanview Ctr For Rehabilitation And Healthcar | 2.3 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.