Alaris Health At The Fountains

F-F689 was removed as of 1/22/2025.

The Removal Plan is as follows:

1. The facility implemented 24/7 monitoring of Unit 11's stairwell door from the first floor to ensure that Residents at risk of wandering and elopement will have the necessary supervision for preventing unsafe access to the stairwell door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 2. The Administrator reviewed the daily staffing sheet for 1/30/2025 with surveyor for Unit 11 section which contained: 1 nurse, 4 CNAs and 2 Behavioral Specialists (BSPEC) The role of the BSPEC is to monitor the Level of Harm - Immediate door. Further review of the daily staffing noted 3-11 shift 1 BSPEC and 11-7 shift 1 BSPEC. An Elopement jeopardy to resident health or Binder was put in place for high-risk Residents including photos of residents who are not allowed upstairs. safety 3. Initiating in-services for all staff on the facility's policy on Elopement and Wandering. Residents Affected - Few

The Immediate Jeopardy began on 12/13/2024 to 1/22/2024 and was lowered to no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy.

N.J.A.C 8:39: 27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50919

Residents Affected - Few Complaint #: NJ00182050

Based on interviews, review of medical records, and other pertinent facility documentation on 1/16/2025 and 1/17/2025, it was determined that the facility failed to: a.) administer medications as prescribed within the appropriate medication administration timeframe and b.) notify the physician when a medication was not available for administration. The facility also failed to follow its policy titled Medication Administration Policy.

This deficient practice was identified for 2 of 3 residents reviewed for medication administration documentation.

This deficient practice was evidenced by the following:

1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE REDACTED], with diagnoses that included but were not limited to: Parkinson's Disease, Unspecified Dementia, and Unspecified Depression.

A review of Resident #1's Minimum Data Set (MDS), an assessment tool dated 10/12/2024, revealed a Brief

Interview of Mental Status (BIMS) of 14 out of 15, which indicated the resident's cognition was intact.

A review of Resident #1's Order Summary Sheet (OSR) with active orders as of 12/1/2024 revealed the following medication orders:

Ativan 0.5 milligrams (mg)-give one tablet by mouth every 12 hours with an active order date of 04/07/2024.

Carbidopa-Levodopa 25-100mg-give one tablet by mouth three times a day with an active order date of 04/05/2024.

Mirtazapine 7.5mg-give one tablet by mouth at bedtime with an active order date of 04/05/2024.

Rosuvastatin Calcium 10mg- give one tablet by mouth in the evening with an active order date of 07/29/2024.

A review of Resident #1's Medication Administration Record (MAR) for December 2024 revealed a code of NN for Ativan 0.5mgs at 8:00 PM, Carbidopa-Levodopa 25-100mg at 9:00 PM, Mirtazapine 7.5mgs at 9:00 PM, and Rosuvastatin Calcium 10mg at 10:00 PM on 12/9/2024, 12/12/2024, 12/19/2024, 12/22/2024 at 9:00 PM. Further review of the MAR revealed that code NN meant other/see nurse notes.

A review of Resident #1's Progress Notes (PNs) dated 12/9/2024 at 6:43 PM, 12/12/2024 at 6:59 PM and 12/22/2024 at 6:35 PM revealed a note from the nurse that stated, due meds given. A PN dated 12/12/2024 at 6:59 PM revealed a note from the nurse that stated, meds given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During an interview with the surveyor on 1/16/2025 at 2:18 PM, the Assistant Director of Nursing (ADON) stated that the standard of practice was that medications should be administered an hour before or an hour Level of Harm - Minimal harm or after the administration time. The ADON stated that medications should not be given outside the medication potential for actual harm administration timeframe. The ADON indicated she could not speak to why the nurse documented in the progress note that medications were administered to the resident more than one hour before the Residents Affected - Few administration time. The ADON indicated that if the resident requested medications outside of the medication administration timeframe, then it was the nurse's responsibility to notify the physician to get an order to change the administration time. The ADON further stated it was important to stay within the hour before and

the hour after administration timeframe to ensure there were no potential medication interactions.

During a follow-up interview with the surveyor on 1/17/2025 at 11:30 AM, the ADON indicated that the code NN' on the MAR meant the nurse had to document a reason to why a medication was not given at that time.

The ADON further stated that if there was a check mark on the MAR that indicated the medication was administered.

2. According to the AR, Resident #4 was admitted to the facility on [DATE REDACTED], with diagnoses that included but were not limited to: Human Immunodeficiency Virus (HIV), Diabetes, and Anxiety Disorder.

A review of Resident #4's MDS dated [DATE REDACTED] revealed a BIMS of 8 out of 15, which indicated the resident's cognition was moderately impaired.

A review of Resident #4's OSR with active orders as of 12/20/2024 revealed the following medication orders:

Dolutegravir Sodium 50 mg-give one tablet by mouth one time a day for HIV with an active order date of 12/20/2024.

Emtricitabine-Tenofovir Disoproxil Fumarate 200-300 mg- give one tablet by mouth one time a day for HIV with an active order date of 12/20/2024.

Sitagliptin 50mg-give one tablet by mouth one time a day for diabetes with an active order date of 12/20/2024.

A review of Resident #4's MAR for December 2024 revealed a code NN for the following medications:

Dolutegravir Sodium 50 mg on 12/21/2024, 12/22/2024, and 12/25/2024 at 8:00 AM.

Emtricitabine-Tenofovir Disoproxil Fumarate 200-300 mg and Sitagliptin 50mg on 12/25/2024 at 8:00 AM.

A review of Resident #4's PN dated 12/21/2024 at 9:56 AM revealed a nurse's note that indicated Dolutegravir Sodium 50 mg was just ordered, has not arrived yet from pharmacy. PNs on 12/25/2024 at 11:07 AM, 11:08 AM, and 11:10 AM revealed a nurse's note that the medication was on order. There was no PN dated 12/22/2024 for a reason to why the medications were not given. There were no PNs which indicated the physician was notified about the medications not being available for the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During an interview with the surveyor on 1/16/2025 at 1:42 PM, the Licensed Practical Nurse (LPN#1) stated if a medication was not delivered by the pharmacy and not in the facility back up, the nurse should have Level of Harm - Minimal harm or called the pharmacy and then notified the physician. LPN #1 further stated that the nurse should document in potential for actual harm the progress notes that they contacted the physician, and the medication was not given.

Residents Affected - Few During an interview with the surveyor on 1/17/2025 at 11:30 AM, the ADON stated that if medications were not available, the nurse was responsible for calling the pharmacy to find out when medication would be delivered. The ADON stated the nurse would call the physician and make them aware that the medication was not available. She further stated that the nurse was responsible for documenting that the physician was made aware that a resident's medication was not available for administration. The ADON confirmed that there was no documentation in the resident's medical record that reflected the nurses' notified the physician that Resident #4's medications were not given on the dates specified. The ADON stated Resident #4's HIV medications were delivered and that it was the nurses' fault for not looking for the medications. The ADON stated she could not speak to why the nurses did not notify the physician or administer the medications that had been delivered.

Review of the facility policy titled Medication Administration Policy, dated 3/2023, reflected under Policy, It is

the policy of this facility to ensure that facility staff follows the guidelines for a safe, timely and accurate administration of resident medications. Under Procedure, 2. Medications are to be administered in a timely manner following physician's order. 6. The licensed nurse is responsible to follow: e. follows appropriate medication administration guidelines. 18. Uses prudent professional judgement by informing physician in a timely manner when medications held, refused, or otherwise unavailable for administration.

Review of the facility document titled Medication Pass Observation, revised 12/6/2019, reflected Medications are given one hour before to one hour after the charted time.

NJAC 8:39-29.2 (d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50919

Residents Affected - Few Complaint #: NJ00182050

Based on interviews, medical record review, and review of other pertinent facility documents on 1/16/2025 and 1/17/2025 it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents. This deficient practice was identified for 3 of 3 residents reviewed for ADL documentation.

This deficient practice was evidenced by the following:

1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE REDACTED], with diagnoses that included but were not limited to: Parkinson's Disease, Unspecified Dementia, and Unspecified Depression.

A review of Resident #1's Minimum Data Set (MDS), an assessment tool dated 10/12/2024, revealed a Brief

Interview of Mental Status (BIMS) of 14 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident was independent with toileting hygiene and dressing but requires supervision and set-up assistance with bathing and personal hygiene.

A review of Resident #1's Care Plan (CP) initiated on 4/5/2024 revealed that the resident had an ADL self-care performance deficit related to weakness.

A review of Resident #1's DSR (ADL Record) and the progress notes (PN) for the month of December 2024 revealed lack of documentation to indicate that the resident's ADL care was provided and/or the resident refused care on the following dates and shifts:

Bed Bath:

7:00 AM- 3:00 PM shift on 12/23/2024 and 12/29/2024.

Bed Mobility:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024, 12/12/2024, 12/23/2024, 12/27/2024, and 12/29/2024.

Bladder and Bowel Continence:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 3:00 PM-11:00 PM shift on 12/31/2024.

Level of Harm - Minimal harm or 11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024, 12/12/2024, 12/23/2024, 12/27/2024, and potential for actual harm 12/29/2024.

Residents Affected - Few Dressing:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

Personal Hygiene:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

Toilet Use:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024. 12/12/2024, 12/23/2024, 12/27/2024, and 12/29/2024.

GG Mobility:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024. 12/12/2024, 12/23/2024, 12/27/2024, and 12/29/2024.

GG Self Care (includes dressing, oral hygiene, personal hygiene, and toilet hygiene):

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024. 12/12/2024, 12/23/2024, 12/27/2024, and 12/29/2024.

Locomotion on and off unit:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 3:00 PM-11:00 PM shift on 12/31/2024.

Level of Harm - Minimal harm or 11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024. 12/12/2024, 12/23/2024, 12/27/2024, and potential for actual harm 12/29/2024.

Residents Affected - Few Transferring:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024. 12/12/2024, 12/23/2024, 12/27/2024, and 12/29/2024.

Walk in Room/ Walk in Corridor:

7:00 AM-3:00 PM shift on 12/23/2024 and 12/29/2024.

3:00 PM-11:00 PM shift on 12/31/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024. 12/12/2024, 12/23/2024, 12/27/2024, and 12/29/2024.

Eating:

7:15 AM on 12/23/2024 and 12/29/2024.

11:30 AM on 12/23/2024 and 12/29/2024.

4:30 PM on 12/31/2024.

2. According to the AR, Resident #4 was admitted to the facility on [DATE REDACTED] with diagnoses that included but were not limited to: Human Immunodeficiency Virus (HIV), Diabetes, and Anxiety Disorder.

A review of Resident #4's MDS dated [DATE REDACTED] revealed a BIMS of 8 out of 15 which indicated the resident's cognition was impaired. The MDS further revealed that the resident needed assistance with ADLs.

A review of Resident #4's CP initiated on 12/21/2024 revealed that the resident had deficits with performing ADLs related to intermittent confusion and weakness.

A review of Resident #4's DSR (ADL Record) and the progress notes (PN) for the month of December 2024 revealed lack of documentation to indicate that the resident's ADL care was provided and/or the resident refused care on the following dates and shifts:

Bed Bath:

7:00 AM- 3:00 PM shift on 12/29/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Bed Mobility:

Level of Harm - Minimal harm or 7:00 AM- 3:00 PM shift on 12/29/2024. potential for actual harm 3:00 PM-11:00 PM shift on 12/21/2024. Residents Affected - Few 11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

Bladder Continence:

7:00 AM-3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

Toilet Use:

7:00 AM-3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

Locomotion on Unit:

7:00 AM- 3:00 PM shift on 12/29/2024.

3:00 PM- 11:30 PM shift on 12/21/2024.

11:00 PM- 7:00 Am shift on 12/20/2024 and 12/29/2024.

Personal Hygiene:

7:00 AM- 3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

Bowel Continence and Movements:

7:00 AM- 3:00 PM shift on 12/29/2024.

3:00 PM- 11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AAM shift on 12/20/2024 and 12/29/2024.

Dressing:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 7:00 AM-3:00 PM shift on 12/29/2024.

Level of Harm - Minimal harm or 3:00 PM-11:00 PM shift on 12/21/2024. potential for actual harm GG Mobility: Residents Affected - Few 7:00 AM -3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

GG Self Care (includes dressing, oral hygiene, personal hygiene, and toilet hygiene):

7:00 AM -3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

Locomotion on and off Unit:

7:00 AM -3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

Transferring:

7:00 AM -3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

Walk In Room/Walk in Corridor:

7:00 AM -3:00 PM shift on 12/29/2024.

3:00 PM-11:00 PM shift on 12/21/2024.

11:00 PM- 7:00 AM shift on 12/20/2024 and 12/29/2024.

Eating:

7:15 AM on 12/29/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 11:30 AM on 12/29/2024.

Level of Harm - Minimal harm or 4:30 PM on 12/21/2024. potential for actual harm 3. According to the AR, Resident #5 was admitted to the facility on [DATE REDACTED] with diagnoses that include but Residents Affected - Few were not limited to: Unspecified Dementia, Anemia, and Anxiety.

A review of Resident #5's MDS dated [DATE REDACTED] revealed a BIMS of 13 out of 15 which indicated the resident's cognition was intact. The MDS further revealed the resident required assistance with ADLs.

A review of Resident #5's CP initiated on 09/06/2024 revealed that the resident had an ADL self-care performance deficit related to weakness and deconditioning.

A review of Resident #5's DSR (ADL Record) and the progress notes (PN) for the month of December 2024 revealed lack of documentation to indicate that the resident's ADL care was provided and/or the resident refused care on the following dates and shifts:

Bladder Continence:

7:00 AM- 3:00 PM shift on 12/1/2024, 12/7/2024, 12/11/2024, 12/28/2024, 12/29/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024, 12/12/2024.

Bowel Continence and Movements:

7:00 AM-3:00 PM shift on 12/1/2024, 12/7/2024, 12/11/2024, 12/28/2024, and 12/29/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024, 12/12/2024.

GG Mobility:

7:00 AM-3:00 PM shift on 12/1/2024, 12/7/2024, 12/11/2024, 12/28/2024, and 12/29/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024, and 12/12/2024.

GG Self Care (includes dressing, oral hygiene, personal hygiene, and toilet hygiene):

7:00 AM-3:00 PM shift on 12/1/2024, 12/7/2024, 12/11/2024, 12/28/2024, and 12/29/2024.

11:00 PM- 7:00 AM shift on 12/5/2024, 12/6/2024, 12/11/2024, and 12/12/2024.

Eating:

7:15 AM on 12/1/2024, 12/7/2024, 12/11/2024, 12/28/2024, and 12/29/2024.

11:30 AM on 12/1/2024, 12/7/2024, 12/11/2024, 12/28/2024, and 12/29/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 315476 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315476 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optima Care Fountains 505 County Avenue Secaucus, NJ 07094

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During an interview with the surveyor on 1/16/2025 at 11:05 AM, the Certified Nursing Assistant (CNA #1) stated that the CNAs were responsible for documenting showers and ADL care into the Point of Care (POC), Level of Harm - Minimal harm or a mobile enable app that runs on wall mounted kiosks that enables care staff to document ADLs at the end potential for actual harm of their shift. CNA #1 stated that every task on the POC must be addressed, and blank spaces were not acceptable. CNA #1 further stated that if there were a blank space on the DSR that would mean either Residents Affected - Few someone did not do the task in the POC, or they had not completed the task yet.

During an interview with the surveyor on 1/17/2025 at 11:30 AM, the Assistant Director of Nursing (ADON) stated the CNAs were responsible for completing all ADL documentation before the end of their shift. The ADON could not explain why there was blank spaces in the residents' DSRs. The ADON indicated that it was

the CNAs, nurses, supervisor, and Unit Manager (UM) responsibility to ensure that ADL documentation was completed at the end of each shift and reflected on the DSR.

The facility was unable to provide the surveyor with a policy on ADL documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 315476