Inspection Reports for
Optima Care Castle Hill

The complaint investigation was substantiated. The resident eloped on 2025-12-30 at approximately 3:25 PM and was found by police at 9:00 PM. The facility was notified of the immediate jeopardy on 2026-01-12 and submitted a removal plan on 2026-01-13. The immediate jeopardy was removed as of 2026-01-13.

The facility failed to maintain a safe environment and adequate supervision for a high-risk resident who exited the building unsupervised, resulting in immediate jeopardy to resident health and safety. The resident was found by police and returned to the facility with no injury. The facility implemented corrective actions including increased monitoring and staff re-education.

The investigation was complaint-related, focusing on an alleged injury of unknown origin on Resident #2. The complaint was substantiated as the facility failed to obtain complete staff statements, but no evidence of neglect or abuse was found.

The facility failed to thoroughly investigate the incident by not obtaining complete statements from all involved staff, specifically missing a statement from the agency CNA assigned to the resident. The investigation concluded no evidence of neglect or abuse, and the probable cause was related to the resident's medical conditions and medication side effects.

The inspection identified multiple deficiencies including failure to provide dignified care, inadequate incontinence care, delayed abuse reporting, incomplete care plans, improper medication disposal, inconsistent restorative care documentation, failure to monitor dialysis access sites, and improper dish machine rinse temperatures.

Complaint NJ #167926 and NJ #169842 involved allegations of abuse, neglect, and failure to provide adequate care. The complaints were substantiated with findings of delayed reporting, incomplete investigations, and inadequate care provision.

The facility failed to report allegations of abuse within the required timeframe, failed to conduct thorough investigations to rule out abuse or neglect, and failed to provide appropriate incontinence care and bathing for residents. These deficiencies affected multiple residents and involved inadequate staff response and documentation.

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.

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.

The facility failed to ensure staff followed enhanced barrier precautions and standard nursing precautions. Staff did not wear required personal protective equipment when transferring a resident and failed to perform proper hand hygiene during meal services.

Complaint numbers NJ00176536 and NJ00176590 triggered the inspection. The facility was found not in substantial compliance based on these complaints.

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.

The investigation was complaint-related, focusing on HVAC failures affecting COVID-19 positive and exposed residents. The complaint was substantiated with findings of non-functional air conditioning units and resident complaints of heat.

The facility failed to maintain a functional heating, ventilation, and air conditioning unit on the 3rd floor, resulting in uncomfortable temperatures for residents. Portable air conditioners and fans were deployed, but residents still reported the rooms being hot.

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.

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.

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.

The facility was found deficient in multiple areas including failure to issue required Medicare Beneficiary Protection Notices, incomplete and untimely care plans for residents, medication administration errors, inadequate infection control practices, failure to maintain proper documentation for dietitian assessments, and failure to notify CMS of a facility name change.

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.

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.

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.

Complaint numbers NJ 143297, NJ 143376, and NJ 143406 were investigated and substantiated based on observations, resident interviews, and review of pest control documentation.

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.

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.