Inspection Reports for
Optima Care Fountains

Complaint #NJ183884 involved failure to develop an oxygen care plan for Resident #2. Complaint #NJ183644 involved failure to maintain complete and accurate medical records for Resident #3. Both complaints were substantiated based on interviews, medical record review, and facility document review conducted on 7/18/2025 and 7/21/2025.

The facility failed to develop and implement an oxygen care plan for Resident #2 despite an order for oxygen, and failed to maintain complete and accurate medical records for Resident #3, including blank spots on ADL records indicating incomplete documentation.

Complaint investigation based on complaints NJ00181697, NJ00181722, and NJ00182050. Immediate Jeopardy was identified related to Resident #2's safety but was removed after corrective action. The facility was found deficient in staffing and medication administration practices.

The facility was found not in substantial compliance with long term care requirements, with deficiencies related to ensuring a safe environment for residents, medication administration errors, and inadequate staffing levels. Immediate Jeopardy was identified and later removed after corrective actions. The facility failed to secure residents from unsafe areas and did not consistently document care and medication administration.

Complaint numbers NJ00181722, NJ00181697, and NJ00182050 were investigated. The immediate jeopardy related to Resident #2's elopement was removed as of 2025-01-22. Medication administration and ADL documentation complaints were substantiated.

The facility failed to provide adequate supervision to prevent elopement of a cognitively impaired resident, resulting in immediate jeopardy. Additionally, the facility failed to administer medications within the appropriate timeframe and notify physicians when medications were unavailable. Documentation of Activities of Daily Living (ADL) care was also inconsistent and incomplete for multiple residents.

Complaint numbers NJ00181722, NJ00181697, and NJ00182050 triggered the investigation. The immediate jeopardy related to Resident #2's elopement was substantiated and removed after corrective actions. Medication administration and ADL documentation complaints were also investigated.

The facility failed to provide adequate supervision to prevent elopement of a cognitively impaired resident, resulting in immediate jeopardy. Additionally, the facility failed to administer medications within the appropriate timeframe and notify physicians when medications were unavailable. There were also deficiencies in documenting residents' Activities of Daily Living (ADLs).

The survey was a Recertification and Complaint Survey. Complaints #NJ136113, NJ166137, NJ168809, NJ170019, NJ172459, NJ175436, NJ176328, NJ176501, NJ176722, NJ177353, NJ177725, and NJ178658 were investigated. Multiple substantiated findings of abuse, neglect, and failure to protect residents were identified.

The facility was found not in substantial compliance with resident rights, privacy and confidentiality, abuse and neglect protections, safe environment, infection control, and other regulatory requirements. Multiple deficiencies were identified related to resident dignity, privacy breaches, abuse investigations, staffing, medication administration, food safety, and fire safety.

The complaint investigation involved multiple allegations including unsanitary conditions, resident abuse, grievance process failures, medication security, and food quality. Several resident-to-resident abuse incidents were reviewed involving multiple residents. Some abuse allegations were not reported timely to the state agency, and investigations were incomplete. The grievance process did not inform residents about anonymous complaint options. Medication security was compromised when medications were left unattended or with residents. Food was often cold, tasteless, and not maintained at proper temperatures.

The facility was found deficient in multiple areas including failure to maintain sanitary conditions in a public bathroom, inadequate grievance process information for residents, failure to protect residents from physical abuse by other residents, delayed and incomplete reporting and investigation of abuse allegations, unsecured medications, and failure to provide palatable, properly heated food.

The facility was found deficient in multiple areas including resident dignity during feeding, privacy breaches, failure to protect residents from abuse, delayed reporting and investigation of abuse allegations, failure to provide bed-hold notices, inadequate pressure ulcer care and pain management, medication security lapses, poor food quality and temperature control, incomplete arbitration agreement disclosures, lack of documented QAPI meeting minutes, and failure to consistently implement infection control precautions.

Complaint #: NJ 00176328. The facility was found deficient in CNA staffing for residents on 11 of 14-day shifts during 06/23/2024 to 07/06/2024 and on 7 of 14-day shifts plus 1 of 14 evening shifts during 09/08/2024 to 09/21/2024. The complaint investigation concluded the facility failed to meet minimum staffing requirements as per New Jersey statutes.

The facility was found not in compliance with New Jersey staffing regulations, failing to meet minimum Certified Nurse Aide (CNA) staffing ratios on multiple day shifts during the review period. The facility submitted a plan of correction and recognized staffing shortages on several shifts.

Complaint numbers NJ000163659 and NJ000164821 triggered the investigation. The deficiencies were substantiated based on interviews and record reviews showing lack of documentation for care provided to residents.

The facility failed to consistently implement their policy on Charting and Documentation for 2 of 4 residents reviewed, with no documented evidence that care was provided on multiple dates and shifts, contrary to policy requirements.

Complaint numbers NJ00163659 and NJ00164821 triggered the investigation. The complaint was substantiated as the facility failed to consistently implement policies on charting and documentation for residents and failed to maintain required CNA staffing ratios on multiple shifts.

The facility was found not in compliance with requirements for maintaining resident-identifiable information and medical records documentation. Additionally, the facility failed to maintain required minimum staffing ratios for Certified Nurse Aides (CNAs) during multiple shifts over several periods.

Complaint NJ00164286 was substantiated with findings that emergency exit doors were blocked by medical equipment, posing a fire hazard and evacuation delay risk.

The facility failed to ensure that 3 of 10 emergency exit doors on Units 7, 8, and 9 were unobstructed due to wheelchairs and patient lifts blocking the exits, posing a fire hazard and potential delay in evacuation.

Complaint #: NJ00164286. The complaint survey found the facility not in compliance with accident hazard and supervision requirements, specifically regarding blocked emergency exits. The complaint also included staffing deficiencies.

The facility failed to ensure that emergency exit doors were unobstructed on Units 7, 8, and 9, with wheelchairs and patient lifts blocking the exits, posing a fire hazard. Additionally, the facility failed to maintain required minimum staff-to-resident ratios for 6 of 21 day shifts reviewed.

The facility was found non-compliant with minimum direct care staff-to-resident ratios as mandated by New Jersey state law, failing to meet required CNA staffing levels on all 14 day shifts reviewed. Additionally, the facility failed to provide residents with two evening activity programs per week on two resident units for four consecutive months.

The facility was found deficient in multiple areas including failure to follow physician orders for blood sugar monitoring, failure to weigh residents as ordered, improper respiratory equipment sanitation, unsigned physician orders for multiple residents, lack of annual performance evaluations for CNAs, unlabeled multidose medication containers, and improper use of personal protective equipment by staff.

Complaint #: NJ00158740. The complaint investigation found deficiencies related to medication administration by unauthorized staff and medication errors, as well as food safety violations.

The facility was found non-compliant due to medication administration errors involving unauthorized staff administering medications to residents and failure to follow physician orders and facility policies on medication administration for two residents. Additionally, the facility failed to maintain appropriate food temperatures during service, risking food safety hazards.

The complaint investigation revealed that the facility failed to report an allegation of abuse involving Resident #1 to the New Jersey Department of Health as required. Interviews and record reviews confirmed the incident was not reported, and the facility did not follow its Abuse Prevention Program policy. Additional complaints involved failure to document care for Residents #2 and #3 as per facility policy.

The facility was found not in compliance with 42 CFR Part 483, Subpart B, due to failure to report alleged abuse incidents to the New Jersey Department of Health, inadequate investigation and reporting procedures, and failure to consistently document care and assistance provided to residents.

Complaint NJ 00117978 was investigated and substantiated with findings of unsafe and unsanitary conditions in the dining room.

The surveyor observed a vertical crack in a wood panel in the main dining room, revealing damp sheetrock and a dark substance possibly mold behind it. The facility's Maintenance Director and Regional Physical Plant Manager were unaware of the issue and confirmed the walls were not water-proofed, creating conditions conducive to mold growth that could affect resident and staff health.