Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountain Springs At Cape May Nursing & Rehab Cente during CMS and state inspections, most recent first.
A resident with chronic pain, back surgeries, and diagnoses including neuralgia and cervicalgia received PRN oxycodone multiple times when the documented pain score was 0 and once when it was 5, even though the order and the facility’s pain scale limited oxycodone to moderate-to-severe or severe pain. The CP repeatedly noted the mismatch, and an LPN, LPN/UM, and DON all stated oxycodone should not have been given for pain scores in that range.
Kitchen Equipment Not Kept Clean: During a kitchen observation with the DOD, a bagged standup mixer was found with a yellowish oily/greasy substance on the upper attachment area and dried debris on the base arm. The surveyor also noted a greasy unidentified substance on a finger after swiping the area. The DOD agreed the mixer needed cleaning, and the facility policy required kitchen equipment to be kept clean and cleaned after use.
Damaged flooring was observed in multiple resident areas, including a loose tile in the dining room, uneven flooring secured with black tape near a hall, and a loose cracked tile near a soiled utility room. The DM confirmed the loose tile was a tripping hazard, and the LNHA acknowledged the flooring should be maintained so it did not pose a fall risk. The facility's policy required a safe, clean, and functional environment.
A resident with left arm and shoulder pain had a Lidoderm patch order that was not accurately tracked for application and removal, and an incomplete Voltaren gel order was not clarified for the application site. In a separate case, a cognitively intact resident with an unstageable pressure ulcer and nutritional risk did not receive the RD-recommended double protein portions, even though the recommendation had been emailed to the facility and the meal tray reflected only a single protein portion.
The facility failed to maintain proper kitchen sanitation and food storage practices. Observations included undated and improperly stored food items, wet nesting of containers, and lack of an internal thermometer in the walk-in freezer. These deficiencies were noted during a survey, with the Food Service Director acknowledging the issues and removing affected items for re-cleaning and disposal.
The facility failed to complete Quarterly MDS assessments on time for 46 residents, with delays ranging from 32 to 117 days. The MDS Coordinator, responsible for two buildings, acknowledged the backlog. The facility's policy requires assessments to be completed within 92 days of the previous assessment, but this was not adhered to.
A facility failed to include a PICC line and Foley Catheter in a resident's care plan, despite the resident's medical needs for these devices. The resident had diagnoses including an infected sacral wound and a complicated UTI. Physician orders specified care for the catheters, but the care plan did not reflect these needs, as confirmed by the DON.
A facility failed to follow infection control measures for respiratory equipment for a resident with a history of heart failure and COPD. The resident's oxygen tubing was observed uncovered and not in use, despite a physician's order for continuous oxygen. Interviews revealed inconsistencies in policy understanding and implementation, with no documentation of the resident refusing oxygen. The facility's policy required oxygen devices to be covered when not in use, which was not adhered to.
Pain medication given outside ordered pain parameters
Penalty
Summary
The facility failed to ensure that a resident with chronic pain received pain management in accordance with physician orders and the facility’s own pain scale parameters. Resident #2 was admitted with diagnoses including chronic pain syndrome, neuralgia, neuritis, cervicalgia, paranoid schizophrenia, and low back pain. The resident’s MDS indicated occasional moderate pain and daily opioid use, and the care plan directed staff to assess pain using a 0-10 scale and administer analgesics as ordered. The physician orders included a pain scale every shift and PRN medications for pain, including acetaminophen for mild pain and oxycodone for moderate to severe pain, later revised to oxycodone for severe pain only. The consultant pharmacist repeatedly identified that documented pain levels of 0, 4, or 5 did not match the PRN oxycodone indication of moderate to severe pain and advised staff to follow the specific order. Despite these recommendations, the MAR showed oxycodone was administered multiple times when the documented pain level was 0, including on several occasions in October 2025, December 2025, February 2026, and March 2026, and once when the pain level was documented as 5. During interview, the resident stated they had ongoing pain in the neck, back, and leg and said the oxycodone dosage was too low. Nursing staff and the DON stated that the facility’s pain scale defined mild pain as 0-3, moderate as 4-6, and severe as 7-10, and they acknowledged that oxycodone should not have been administered for pain levels of 0-5. The facility’s own pain scale document also defined 0 as no pain, 1-3 as mild, 4-6 as moderate, and 7-10 as severe, with oxycodone listed under severe pain management.
Kitchen Equipment Not Kept Clean
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. During observation of the kitchen with the Director of Dietary, a standup mixer that was bagged and not in use on a metal countertop was found to have a yellowish, oily/greasy substance on the upper attachment area after the plastic bag was removed. The surveyor also observed unidentified dried debris on the base arm of the mixer, and when the surveyor swiped the area with a finger, a greasy unidentified substance was present on the finger. The Director of Dietary agreed the mixer needed cleaning and cleaned the affected areas in the surveyor's presence. The facility's Kitchen Equipment Cleaning Policy stated that kitchen equipment shall be kept clean and free of food debris and residue and that equipment and utensils used in food preparation shall be cleaned after use.
Damaged flooring left unrepaired in resident areas
Penalty
Summary
The facility failed to maintain the resident environment in a safe, sanitary, and homelike manner by not repairing damaged flooring in a timely manner. During observation in the dining room, a loose floor tile was seen near the main doors, and the Director of Maintenance confirmed it was not supposed to be popped up and stated it was a tripping hazard. He also said the floors were normally checked once per week and that staff used maintenance logs or verbal reports to communicate concerns. Additional observations identified uneven flooring secured with black tape near the [NAME]-B hall, which a family member described as looking like "break your neck tape," and a loose cracked floor tile near the soiled utility room on the [NAME] Unit. The Licensed Nursing Home Administrator stated the hallways were being renovated and acknowledged that the floor tiles should be maintained so they did not pose a fall risk to residents. The facility's policy stated that the environment shall be maintained in a safe, clean, and functional condition that promotes safety, cleanliness, and accessibility.
Medication Patch Documentation, Incomplete Order Clarification, and Diet Order Implementation Failures
Penalty
Summary
The facility failed to accurately identify when a medication administered via patch was applied and removed for a resident with left shoulder and left arm pain, a displaced fracture of the left humerus, and intact cognition. The resident had an order for Lidoderm 5% patch to be applied to the left shoulder in the evening and removed in the morning. The April 2026 MAR showed initials and check marks indicating the patch was administered eight times, but there was no designated time slot for removal. When the resident was interviewed, they stated they had never used the patch since coming to the facility, and the RN stated she had not seen it on the resident and therefore had not removed it. The medication cart contained 11 of 14 patches, indicating only 3 had been removed, while the MAR reflected 8 administrations. The same resident also had a Voltaren gel order that did not specify the location of application, and the DON stated the order should have been clarified to indicate where it should be applied. The facility also failed to ensure an incomplete physician's order was clarified before implementation for the same resident. The order for Voltaren external gel 1% directed application to the upper arm twice daily for pain, but the physician's order did not include the location where the gel should be applied. Facility staff acknowledged that the MAR should reflect the time the Lidoderm patch was to be applied and removed, and the DON stated there should have been a designated time when the order was entered into the system. The report documents that the order was not clarified as incomplete at the time it was entered. The facility further failed to accurately transcribe and implement a diet order in accordance with the Dietician's recommendations for another resident who was cognitively intact, at risk for pressure injury, and admitted with an unstageable pressure ulcer and nutritional concerns. The RD's nutritional assessment recommended double meat/protein portions, pudding or fruit cup at bedtime, juice with meals, hot tea with meals, 4 ounces of milk with meals, liberalization of the diet to regular NAS, and 30 ml liquid protein daily. The resident stated they had not received double portions of protein, and the meal tray observed by the surveyor contained only one chicken drumstick and other items, without double protein portions. CNA staff confirmed the meal ticket did not include double portions of protein, and the RN stated the RD would have to tell staff about the recommendation in order for the order to be entered. The DON later stated the RD had emailed the recommendations to the facility, but the double protein order was missed and the resident did not receive the recommended protein portions.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner, as observed by the surveyor on multiple occasions. In the dry storage room, a previously opened bag of macaroni pasta was found wrapped in plastic wrap without any open or use-by date. Additionally, the surveyor noted wet nesting of plastic Cambro containers on the spice shelf, with a clear watery substance observed on the containers, indicating they were not air-dried before stacking. Similar wet nesting was observed with deep third pans on the pot/pan storage rack. These practices can lead to bacteria growth, as acknowledged by the Food Service Director (FSD), who removed the affected items for re-cleaning, sanitizing, and air drying. In the walk-in freezer, the surveyor found that while the temperature log was up to date and within acceptable parameters, there was no internal thermometer present to monitor the freezer temperature. Furthermore, several food items were improperly stored: a previously opened bag of frozen soft pretzels and a box of bacon were not properly dated or covered, with the bacon appearing dry and exposed to air. A box of fresh chorizo was also found with torn plastic, leaving the contents exposed and undated. These items were removed to the garbage by the cook. The facility's policies on date marking and dish cleaning were reviewed, revealing non-compliance with procedures meant to ensure food safety and sanitation.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments in a timely manner for 46 out of 49 residents reviewed. The MDS is a resident assessment tool used to facilitate the management of care, and the Quarterly Assessment is considered timely if the Assessment Reference Date (ARD) is within 92 days after the ARD of the previous MDS, with completion no later than 14 days after the ARD. The report details that the facility did not meet these requirements, with assessments being overdue by a range of 32 to 117 days for various residents. The MDS Coordinator (MDSC), who has been in the role for three years, acknowledged that the MDS assessments were behind schedule. The MDSC was responsible for completing assessments in two buildings, which contributed to the delay. The facility's policy on MDS 3.0 Completion, implemented on October 15, 2024, specifies that Quarterly Assessments should be completed using an ARD no greater than 92 days from the most recent prior quarterly or comprehensive assessment. The deficiency was identified through interviews, record reviews, and a review of facility documentation and the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The MDSC admitted to the survey team that she was aware of the backlog and the need to assist the other building, which impacted the timely completion of the assessments.
Failure to Include PICC and Foley Catheter in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who required a Foley Catheter and a Peripherally Inserted Central Catheter (PICC) for antibiotic delivery. During an initial tour, the resident was observed with a PICC line in the left upper arm and a Foley Catheter. However, a review of the resident's care plan dated 10/3/2024 revealed that it did not include focus areas addressing the presence of the PICC line and Foley Catheter, which are critical components of the resident's care needs. The resident's medical records indicated diagnoses including an infected sacral wound with wound botulism, possible osteomyelitis, a complicated urinary tract infection, and dementia. Physician orders detailed specific care requirements for the Foley Catheter and PICC line, such as maintaining enhanced barrier precautions, catheter care every shift, and monitoring the PICC line for infection. Despite these detailed orders, the care plan lacked the necessary focus areas to address these medical devices, as confirmed by the Director of Nursing during an interview with the surveyor.
Failure to Implement Infection Control Measures for Respiratory Equipment
Penalty
Summary
The facility failed to implement proper infection control measures for the handling and storage of respiratory equipment for a resident. During an initial tour, a surveyor observed a resident with oxygen tubing draped uncovered on top of an oxygen concentrator and over the strap of a portable oxygen tank attached to the resident's wheelchair. The oxygen concentrator was turned off, and the resident was not using oxygen at the time, despite having a physician's order for continuous oxygen use. The resident, who had a history of heart failure, chronic obstructive pulmonary disease, and lung cancer, was waiting for a ride to a doctor's appointment. The facility's policy required oxygen delivery devices to be covered in a plastic bag when not in use, which was not adhered to in this instance. Interviews with the Registered Nurse/Unit Manager and the Director of Nursing revealed inconsistencies in the understanding and implementation of the facility's policy regarding oxygen use and storage. The RN/UM was unsure of the policy details and stated that oxygen tubing should be stored in a bag and changed weekly. The DON confirmed that if a resident is alert and oriented and removes the oxygen, it should be documented in the care plan. However, there was no documentation indicating that the resident refused oxygen, and the DON confirmed that the oxygen should have been on if not documented otherwise. A review of the facility's policy on oxygen administration highlighted the requirement for infection control measures, including keeping delivery devices covered when not in use, which was not followed in this case.
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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 Cape May Court House
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Oceanview | 4.1 mi | ★★★★★ | 1 | 0 |
| Crest Haven Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 2 | 0 |
| Complete Care At Court House, Llc | 5.8 mi | ★★★★★ | 1 | 0 |
| United Methodist Communities At The Shores | 11.5 mi | ★★★★★ | 0 | 0 |
| North Cape Center | 15.4 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.