Inspection Reports for Optima Care Castle Hill
615 23rd St, Union City, NJ 07087, USA, NJ, 07087
Back to Facility Profile
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 216
Deficiencies: 7
Mar 10, 2025
Visit Reason
The survey was conducted based on complaints NJ 167925, 168942, and 181072 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to be out of compliance with multiple federal and state regulations including resident rights, abuse prevention, care planning, quality of care, and life safety code requirements. Deficiencies were identified in areas such as resident dignity, abuse reporting, care planning, medication administration, staffing, emergency preparedness, and fire safety.
Complaint Details
Complaint numbers NJ 167925, 168942, and 181072 triggered the investigation. The complaint was substantiated with findings of deficient practices related to resident rights, abuse reporting, care planning, and safety.
Deficiencies (7)
| Description |
|---|
| Failure to ensure residents were treated in a dignified manner and free from interference, coercion, discrimination, or reprisal. |
| Failure to report alleged violations of abuse, neglect, exploitation, or mistreatment to appropriate authorities. |
| Failure to complete comprehensive baseline care plans for residents. |
| Failure to provide adequate care and services to maintain resident safety and dignity, including medication administration and assistance with activities of daily living. |
| Failure to maintain adequate staffing levels consistent with state requirements. |
| Failure to maintain a comprehensive emergency preparedness plan and communication plan. |
| Failure to maintain fire safety requirements including proper maintenance of fire doors, sprinkler systems, and emergency lighting. |
Report Facts
Complaint numbers: 3
Census: 130
Total capacity: 216
Staffing ratios: 14
Staffing ratios: 16
Deficiency correction dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #129 | Certified Nurse Aide (CNA) | Named in findings related to resident care and meal service. |
| Resident #343 | Registered Nurse (RN) #1 | Involved in investigation and care related to abuse allegations. |
| Resident #290 | Certified Nurse Aides (CNAs) | Named in abuse investigation and staff interviews. |
| Resident #73 | Certified Nurse Aide (CNA) #1 | Named in findings related to care planning and assistance. |
| Resident #38 | Registered Nurse (RN) #1 | Named in medication administration and care planning findings. |
| Resident #110 | Certified Nurse Aide (CNA) #1 | Named in medication administration and incident report findings. |
| Resident #51 | Registered Nurse (RN) #1 | Named in findings related to mobility and care planning. |
| Resident #122 | Registered Nurse/Unit Manager | Named in findings related to indwelling catheter care. |
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 2
Aug 30, 2024
Visit Reason
The inspection was conducted based on complaints NJ00176536 and NJ00176590 regarding facility compliance with regulatory standards.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long-term care facilities. Deficiencies included failure to maintain required minimum staffing ratios on 3 of 14-day shifts and failure to maintain a functional HVAC system on the 3rd floor, resulting in uncomfortable temperatures for residents.
Complaint Details
Complaint numbers NJ00176536 and NJ00176590 triggered the inspection. The facility was found not in substantial compliance based on these complaints.
Deficiencies (2)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 3 of 14-day shifts. |
| Failure to consistently maintain a functional Heating, Ventilation and Air Condition Unit (HVAC) in good repair on 1 of 3 nursing units (3rd floor) to maintain a comfortable environment for residents, staff, and visitors. |
Report Facts
CNA staffing deficiency days: 3
Resident census: 134
Temperature readings: 74
Temperature readings: 76
Temperature readings: 78
Temperature readings: 79
Inspection Report
Routine
Census: 127
Deficiencies: 0
Aug 2, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 1
Jun 20, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers NJ00163752, NJ00157585, NJ00159733, and NJ00160398.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet required minimum staff-to-resident ratios, specifically deficient CNA staffing on 4 of 14 day shifts during the review period. The facility was otherwise in substantial compliance with federal long term care requirements based on this complaint visit.
Complaint Details
Complaint numbers NJ00163752, NJ00157585, NJ00159733, and NJ00160398 were investigated. The facility was found to have staffing deficiencies but no reported negative outcomes resulted from the citation. The facility was required to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey, specifically CNA staffing shortages on 4 of 14 day shifts. |
Report Facts
Survey Census: 136
Sample Size: 14
Deficient CNA staffing days: 4
CNA staffing on 06/04/23: 15
CNA staffing on 06/05/23: 13
CNA staffing on 06/11/23: 16
CNA staffing on 06/12/23: 16
Inspection Report
Annual Inspection
Census: 127
Capacity: 215
Deficiencies: 22
Jan 13, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited in multiple areas including Medicaid/Medicare coverage notifications, baseline and comprehensive care plans, medication administration, infection control, life safety code violations, and facility licensing compliance.
Severity Breakdown
SS=D: 17
SS=E: 7
SS=C: 1
SS=F: 2
Deficiencies (22)
| Description | Severity |
|---|---|
| Failed to issue required Medicare Beneficiary Protection Notification for 1 of 3 residents. | SS=D |
| Failed to develop and implement person-centered baseline and comprehensive care plans for residents, including communication needs and management of diabetes. | SS=D |
| Failed to review and revise care plans to reflect changes in residents' conditions for 2 of 28 residents. | SS=D |
| Failed to administer and document physician ordered medications appropriately for 3 of 5 residents observed. | SS=D |
| Failed to ensure drug regimens were free from unnecessary drugs for 1 of 5 residents. | SS=D |
| Failed to maintain medication error rate below 5%, with 2 errors in 28 doses observed. | SS=D |
| Failed to employ a fully qualified registered dietitian or ensure dietitian eligibility and co-signing of nutritional assessments for 11 of 16 residents. | SS=E |
| Failed to notify CMS and receive authorization for facility name change from Alaris Health at Castle Hill to Optima Care Castle Hill. | SS=C |
| Failed to maintain proper infection control practices including hand hygiene, PPE use, COVID testing procedures, and clean linen storage. | SS=E |
| Failed to provide emergency illumination automatically along means of egress in accordance with NFPA 101. | SS=E |
| Failed to provide battery back-up emergency light above fire pump transfer switches independent of building electrical system and emergency generator. | SS=E |
| Failed to maintain vertical openings (stairwell doors) with positive latching to maintain 1-1/2 hour fire resistance rating. | SS=E |
| Failed to install supervised smoke/heat detection in kitchen area as required by NFPA 101 and NFPA 70. | SS=E |
| Failed to maintain automatic sprinkler system and fire pump in optimal condition, including replacing difficult to operate valve and installing recommended components. | SS=E |
| Failed to ensure fire extinguishers were not blocked and were inspected monthly as required. | SS=E |
| Failed to maintain smoking areas in accordance with NFPA 101, including improper disposal of cigarette butts and lack of approved ashtrays. | SS=F |
| Failed to maintain proper infection control practices during wound care and COVID testing procedures. | SS=E |
| Failed to provide complete sprinkler coverage in shower rooms and storage areas, and failed to maintain sprinkler system in optimal condition. | SS=E |
| Failed to maintain smoke barrier doors to resist transfer of smoke when closed, with excessive clearance at bottom of doors. | SS=D |
| Failed to ensure electrical outlets near water sources were equipped with GFCI protection. | SS=D |
| Failed to perform and document annual functional testing of electrical receptacles in resident rooms. | SS=F |
| Failed to maintain emergency generator in optimal condition, including cleaning clogged radiator fins. | SS=D |
Report Facts
Census: 127
Total Capacity: 215
Deficiencies cited: 27
Medication error rate: 7.14
Staffing ratio deficiency: 3
Fire sprinkler inspection dates: 4
Fire extinguisher obstruction: 1
Smoke barrier doors tested: 18
Smoke barrier doors deficient: 6
Electrical outlets tested: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control findings |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and infection control findings |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies |
| Licensed Nursing Home Administrator | Administrator | Interviewed regarding multiple deficiencies and facility operations |
| Maintenance Director | Maintenance Director | Interviewed regarding life safety and electrical system deficiencies |
| Registered Dietitian Eligible | Dietitian | Named in nutritional assessment deficiencies |
| MDS Coordinator | MDS Coordinator | Named in discharge summary and care plan deficiencies |
| Licensed Practical Nurse/Unit Manager | LPN/Unit Manager | Named in communication and infection control deficiencies |
| Licensed Practical Nurse | LPN | Named in infection control and wound care deficiencies |
| Registered Nurse | RN | Named in infection control deficiencies |
| Housekeeping Director | Housekeeping Director | Named in clean linen storage deficiencies |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in clean linen storage deficiencies |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding blood sugar monitoring rationale |
| Director of Maintenance | Maintenance Director | Named in multiple life safety and electrical system deficiencies |
| Licensed Nursing Home Administrator | Administrator | Named in facility name change and multiple deficiencies |
| Chief Operations Officer | COO | Interviewed regarding facility name change |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies and interviews |
| Infection Preventionist | Infection Preventionist | Named in infection control deficiencies |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 3
Aug 18, 2022
Visit Reason
Complaint survey conducted due to complaint #156814 regarding the use of physical restraints on a resident and failure to follow care plan interventions and facility policies.
Findings
The facility was found not in substantial compliance with requirements related to the improper use of physical restraints on Resident #2, failure to follow the resident's care plan, and failure to conduct a timely and thorough abuse investigation. Resident #2 was found restrained behind a table and chairs in the dining room, which was deemed a physical restraint. The facility failed to provide proper supervision and follow policies, resulting in Resident #2 being taken to the hospital. The investigation into the abuse allegation was delayed beyond the required timeframe.
Complaint Details
Complaint #156814 involved allegations of improper physical restraint of Resident #2, who was found restrained behind tables and chairs in the dining room. The complaint investigation confirmed the use of restraints and failure to follow care plans and policies. The investigation was not completed within the required 5-day timeframe.
Severity Breakdown
Level D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from physical restraints imposed for purposes of discipline or convenience. | Level D |
| Failure to develop and implement a comprehensive care plan consistent with resident needs and rights. | Level D |
| Failure of facility administration to complete a thorough investigation of abuse allegations within 5 days as required by policy. | Level D |
Report Facts
Census: 127
Sample Size: 5
Investigation completion timeframe: 5
Clock out time discrepancy: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in restraint incident and investigation; placed Resident #2 behind table and left resident unsupervised. |
| CNA #2 | Certified Nursing Assistant | Assisted CNA #1 in moving table; was removed from schedule pending investigation. |
| RN #1 | Registered Nurse | Documented resident's condition and supervision status. |
| RN #2 | Registered Nurse | Observed Resident #2 restrained and provided statements about the incident. |
| UM/LPN | Unit Manager/Licensed Practical Nurse | Provided statements about Resident #2's behavior and supervision. |
| Administrator | Facility Administrator | Responsible for investigation and oversight; acknowledged ongoing investigation and policy failures. |
| ADON | Assistant Director of Nursing | Involved in investigation and staff education; confirmed restraint was considered abuse. |
| Staffing Coordinator | Staffing Coordinator | Provided information on time clock and staff scheduling. |
| Police Officer #1 | Police Officer | Responded to 911 call, found Resident #2 restrained, and arrested CNA #2. |
| Police Officer #2 | Police Officer | Responded to 911 call and described restraint setup. |
Inspection Report
Abbreviated Survey
Census: 123
Deficiencies: 2
Jul 7, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and COVID-19 vaccination requirements.
Findings
The facility was found to be in compliance with infection control regulations but was not in compliance with New Jersey staffing ratio requirements and COVID-19 booster vaccination mandates for staff. Four staff members had not received their COVID-19 booster shots as required by Executive Directive 290, and the facility failed to maintain minimum direct care staff-to-resident ratios on 2 of 42 shifts reviewed.
Deficiencies (2)
| Description |
|---|
| Failed to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 2 of 42 shifts reviewed. |
| Failed to ensure all staff eligible for COVID-19 booster vaccination received it by the required date, with 4 of 160 staff members non-compliant. |
Report Facts
Census: 123
Staffing shifts reviewed: 42
Shifts with deficient staffing: 2
Staff reviewed for COVID-19 booster status: 160
Staff non-compliant with booster: 4
CNAs on 06/20/22 day shift: 13
CNAs required on 06/20/22 day shift: 15
CNAs on 06/27/22 day shift: 13
CNAs required on 06/27/22 day shift: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Provided information about staffing and COVID-19 testing procedures | |
| Licensed Nursing Home Administrator (LNHA) | Provided information about staffing, COVID-19 vaccination policy, and acknowledged misinterpretation of Executive Directive 290 | |
| Infection Preventionist (IP/RN) | In charge of the facility's COVID-19 vaccination efforts | |
| Employee #1 | Provided evidence of COVID-19 booster on 7/19/2022 | |
| Employee #2 | Provided evidence of COVID-19 booster on 7/22/2022 | |
| Employee #3 | Provided evidence of COVID-19 booster on 7/28/2022 | |
| Employee #4 | Placed on inactive work status beginning 7/8/2022 pending COVID-19 booster vaccination |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Jun 9, 2022
Visit Reason
The inspection was conducted as a complaint survey to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 1
Mar 5, 2021
Visit Reason
The inspection was conducted based on complaints NJ 143297, NJ 143376, and NJ 143406 regarding pest control issues at the facility.
Findings
The facility failed to maintain an effective pest control program as evidenced by multiple resident reports and documented sightings of mice and roaches across several floors. The pest control logs showed ongoing rodent problems, and the facility had not adequately sealed holes or prevented infestations.
Complaint Details
Complaint numbers NJ 143297, NJ 143376, and NJ 143406 were investigated and substantiated based on observations, resident interviews, and review of pest control documentation.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain an effective pest control program resulting in presence of mice and roaches in multiple resident areas. | SS=F |
Report Facts
Sample size: 4
Dates of pest sightings: Multiple dates from December 2020 through March 2021 documented in pest control logs
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Dec 10, 2020
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00131677, NJ00136405, NJ00130612, NJ00135833, and NJ00134463.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
The survey was complaint-driven with multiple complaints referenced. The facility was found compliant, indicating no substantiated deficiencies.
Report Facts
Sample Size: 8
Inspection Report
Abbreviated Survey
Census: 117
Deficiencies: 3
Dec 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to disinfect and sanitize screening equipment, inadequately educate staff on screening and disinfecting processes, and improper hand hygiene practices among staff.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to disinfect and sanitize equipment used in the COVID-19 screening process. | SS=D |
| Failure to ensure a staff member was educated regarding the screening and disinfecting process in the workplace. | SS=D |
| Failure to practice appropriate hand hygiene for staff in accordance with CDC guidelines. | SS=D |
Report Facts
Census: 117
Sample size: 3
Frequency of observation: 5
Frequency of observation: 10
Completion date for plan of correction: Dec 30, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Present during survey and involved in discussions about thermometer disinfection and hand hygiene | |
| Registered Nurse/Assistant Director of Nursing Educator (RN/ADON-E) | Provided information about proper thermometer disinfection and storage | |
| Food Service Director (FSD) | Observed performing improper hand hygiene and received in-service training | |
| Infection Preventionist Nurse (IPN) | Acknowledged hand hygiene deficiencies and planned revisions to competency checklist | |
| Certified Nursing Assistant (CNA) | Observed failing to sanitize hands after doffing PPE on COVID-19 unit |
Inspection Report
Abbreviated Survey
Census: 123
Deficiencies: 0
Nov 25, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Annual Inspection
Census: 122
Deficiencies: 0
Nov 24, 2020
Visit Reason
The inspection was a standard annual survey conducted to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities.
Report Facts
Sample Size: 27
Inspection Report
Life Safety
Deficiencies: 0
Nov 24, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Loading inspection reports...
