Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountainview Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including obstructive sleep apnea, did not have physician's orders in place for weekly CPAP tubing changes, machine cleaning, or daily filling of the water chamber with distilled water. Although staff reported performing these tasks, there was no documentation or orders to support this, as confirmed by interviews with the LPN, Unit Manager, and DON. Facility policy required such orders, but they were not present in the resident's record.
A resident with severe cognitive impairment was verbally abused and videotaped by a housekeeping aide during a medical appointment. The aide yelled and cursed at the resident, causing distress and confusion. The ENT staff intervened, and the facility's investigation confirmed the abuse, highlighting a failure in implementing the abuse prevention policy.
A facility failed to thoroughly investigate an incident where a Housekeeping Aide verbally abused and videotaped a resident with severe cognitive impairment during a doctor's appointment. The resident, diagnosed with bipolar disorder and schizoaffective disorder, appeared visibly upset and confused. The facility's investigation was inadequate, lacking interviews with all witnesses, including other residents escorted by the aide. This failure resulted in an Immediate Jeopardy situation.
The facility breached confidentiality by leaving residents' EMRs open during medication administration, exposing private information to potential onlookers. Both an RN and an LPN acknowledged the oversight, and the DON confirmed it violated HIPAA and resident privacy rights.
A facility failed to attempt alternative measures before installing bedrails for a resident with hemiplegia and hemiparesis. The resident's care plan required a left bedrail for safety, but no alternatives were explored prior to its use. Staff confirmed that assessments were completed without considering other options, and the DON acknowledged this oversight.
A resident with a DNR order was mistakenly given CPR due to the facility's failure to maintain a complete medical record. The resident's POLST form was not included in the official records, leading to the resident being treated as a full code. The Social Service Director kept relevant documentation in a separate file, unaware that it should have been part of the medical record.
A resident with severe cognitive impairment was video recorded without consent by a Housekeeping Aide at an ENT doctor's office. The resident appeared upset and confused, believing they had been kidnapped. The transport driver continued recording after taking the aide's phone. ENT staff witnessed the aide yelling and belittling the resident. The DON confirmed staff were trained not to record residents, indicating a breach of the resident's rights to dignity and privacy.
A resident with severe cognitive impairment was improperly restrained with a wheelchair lap seatbelt during a visit to an ENT office, without proper documentation or physician orders. The facility's policy requires a physician's written order for restraints, which was not obtained, leading to a violation of regulatory requirements.
A resident with severe cognitive impairment was allegedly sexually assaulted by an unidentified staff member. The facility was informed of the allegation by the ombudsman but failed to report it to the NJDOH or police, as required by their policy. The Director of Nursing believed reporting was unnecessary since the ombudsman had investigated and closed the case.
The facility failed to securely store medications during administration, as observed in two incidents. An RN left a medication cart unlocked and a vial of insulin unsecured, while an LPN also left a cart unlocked without supervision. The DON confirmed the policy requiring carts to be locked when out of sight.
A resident with multiple diagnoses, including COPD and diabetes, was transferred to a hospital for an emergency without the required New Jersey Universal Transfer Form (NJUTF) in their medical record. The Director of Nursing confirmed the absence of the NJUTF, which is against the facility's policy for emergency transfers.
Failure to Obtain Physician Orders for CPAP Maintenance
Penalty
Summary
The facility failed to obtain physician's orders for the weekly cleaning and tubing changes of a resident's CPAP machine, as well as for the daily filling of the CPAP machine's chamber with distilled water, from March 2025 through the resident's discharge. The deficiency was identified through interviews and record reviews, which revealed that although the facility's staff, including the Infection Preventionist and Unit Manager, stated that these tasks were performed by the night shift nurses, there were no corresponding physician's orders or documentation in the resident's medical record. The Medication Administration Records showed daily administration of the CPAP machine but did not include documentation for cleaning, tubing changes, or water chamber maintenance. The resident involved had multiple medical conditions, including obstructive sleep apnea, multiple rib fractures, a prosthetic heart valve, depression, and a history of falls, and required assistance with all activities of daily living. Interviews with the Unit Manager and Director of Nursing confirmed that physician's orders were required for CPAP maintenance tasks, but none were present in the record. The facility's policy also indicated that such procedures should be performed according to physician's orders and manufacturer instructions, but this was not followed in practice for the resident in question.
Verbal Abuse Incident Involving Resident and Housekeeping Aide
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a housekeeping aide (HA #1) and a resident with severe cognitive impairment. The resident, who had diagnoses of bipolar disorder, schizoaffective disorder, and anxiety, was verbally abused and exploited by HA #1 during an appointment at an Ear, Nose, and Throat (ENT) doctor's office. HA #1 was observed yelling, cursing, and videotaping the resident, causing the resident to become visibly upset and confused, believing they were being kidnapped. The ENT staff witnessed the incident and reported that HA #1 was belittling and yelling at the resident without providing any reassurance of safety. The ENT office requested HA #1 to leave and contacted the facility to send a new escort for the resident. The facility's Director of Nursing (DON) was informed of the incident and advised the ENT office to call the police to have HA #1 removed. The facility's investigation confirmed the abuse, as HA #1's actions were captured on video, which was later deleted. The resident's medical records indicated a severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The resident's care plan included interventions for cognitive deficits, such as verbalizing safety rules and engaging in appropriate social conversations. Despite these interventions, the resident was subjected to verbal abuse and exploitation, highlighting a failure in the facility's implementation of its abuse prevention policy.
Removal Plan
- HA #1 was terminated
- Resident #239 received a psychosocial evaluation
- All staff were in-serviced on the facility's abuse prevention and reporting policies
Inadequate Investigation of Verbal Abuse and Exploitation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse and exploitation involving a Housekeeping Aide (HA #1) and a resident with severe cognitive impairment. The incident occurred during an Ear, Nose, and Throat (ENT) doctor's office appointment, where HA #1 was observed verbally abusing and videotaping the resident. The ENT staff reported that HA #1 was belittling and yelling at the resident, who appeared visibly upset and confused, believing they were being kidnapped. The facility's investigation was inadequate as it did not include statements from all witnesses, including other residents escorted by HA #1. The resident involved had diagnoses of bipolar disorder, schizoaffective disorder, and anxiety disorder, with a Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Upon returning from the doctor's office, the resident appeared calm and in no emotional distress, unable to recall the incident. However, the ENT's surveillance video confirmed HA #1's inappropriate behavior, including yelling, cursing, and videotaping the resident without consent. The facility's investigation concluded that the abuse allegation was substantiated, but it lacked thoroughness as it did not interview all relevant parties. The Director of Nursing (DON) received a call from the ENT's office about the incident, but the investigation did not include interviews with the ENT staff, the driver of the contracted transportation company, or other residents who had been escorted by HA #1. The facility's failure to conduct a comprehensive investigation and implement their abuse policy posed a likelihood of serious harm to all residents, resulting in an Immediate Jeopardy situation.
Removal Plan
- A complete investigation was initiated.
- The Licensed Nursing Home Administrator and Director of Nursing were educated on the facility's abuse policy, customer service, professionalism, and complete and thorough investigations.
- The Social Services Director was in-serviced on proper investigation of abuse including interviews of other residents.
- All staff were in-serviced on abuse.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records during medication administration, as observed in two instances. On March 5, 2025, at 11:27 AM, a Registered Nurse (RN) left the electronic medical records (EMR) of a resident open, making confidential information visible to anyone in the hallway outside the dining room. Similarly, at 1:02 PM, a Licensed Practical Nurse (LPN) left another resident's EMR open, exposing private medical information to potential onlookers. Both nurses acknowledged the oversight during interviews, with the RN expressing nervousness and the LPN recognizing the risk of exposure. The Director of Nursing confirmed that leaving computer screens open violates HIPAA and resident privacy rights, as outlined in the facility's Resident Rights policy.
Failure to Attempt Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted before the installation of bedrails for a resident. This deficiency was identified for a resident who was readmitted to the facility with diagnoses including hemiplegia and hemiparesis. The resident's comprehensive care plan indicated the need for a left bedrail for mobility and safety, but the Bed Rail Evaluation revealed that no alternatives were attempted prior to the placement of the bedrails. During observations and interviews, it was confirmed that the nursing staff completed the bedrail assessment but did not explore alternative options before implementing the use of the bedrail. The Director of Nursing acknowledged that the facility did not explore alternative options and allowed residents to use bedrails upon request. This practice was not in compliance with the requirement to try different approaches before using a bedrail.
Incomplete Medical Record Leads to CPR on DNR Resident
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for a resident, identified as Resident #87. The resident was admitted with diagnoses including atherosclerosis of native arteries of bilateral legs, restless leg syndrome, and nerve pain. A critical incident occurred when the resident was found unresponsive, and CPR was initiated due to the absence of a Practitioner Orders for Life-Sustaining Treatment (POLST) form in the facility's records. The resident's power of attorney (POA) indicated that a POLST form had been signed, specifying a do not resuscitate (DNR) order, but the facility did not have a copy, leading to the resident being treated as a full code. The Social Service Director (SSD) confirmed during an interview that she maintained a soft file with all documentation related to the resident, including discussions with the POA about the POLST. However, this information was not included in the resident's official medical record, which should have been complete, accurately documented, and readily accessible. The facility's policy on medical records emphasized the need for accurate, current, and complete documentation, but the SSD was unaware of the requirement to include all relevant information in the medical record. This oversight resulted in a failure to comply with the facility's policy and applicable regulations.
Resident's Rights Violated by Unauthorized Video Recording
Penalty
Summary
The facility failed to protect a resident's rights when a staff member video recorded the resident without consent. This incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, and diagnoses including bipolar disorder, schizoaffective disorder, and anxiety disorder. The resident was recorded by a Housekeeping Aide (HA #1) at an Ear, Nose, and Throat (ENT) doctor's office, where the resident appeared upset and confused, expressing a belief that they had been kidnapped by HA #1. The situation escalated when the transport driver took HA #1's cell phone and continued recording the resident. ENT staff members witnessed HA #1 yelling and belittling the resident while recording. The Director of Nursing (DON) confirmed that staff were prohibited from recording residents and had been trained on this policy. The incident was reported to the DON by ENT staff, highlighting a breach of the resident's rights to dignity and privacy.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a wheelchair lap seatbelt that restricted the resident's movement. The resident, who had diagnoses including bipolar disorder, schizoaffective disorder, and anxiety disorder, was observed in a video recording at an ENT doctor's office with a lap seatbelt applied, preventing them from standing up independently. The resident's comprehensive care plan and physician orders did not include any mention of restraints or a wheelchair seatbelt, indicating a lack of proper documentation and authorization for the use of such restraints. Interviews with staff revealed that the seatbelt was applied by the transport driver, and the facility's Director of Nursing confirmed that the use of the lap seatbelt constituted a restraint. The facility's policy requires a physician's written order for the application of restraints, specifying the type, medical justification, duration, and conditions for use, none of which were present in this case. This oversight led to the resident being improperly restrained without the necessary documentation and authorization, violating the facility's policy and regulatory requirements.
Failure to Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of staff-to-resident sexual abuse to the New Jersey Department of Health (NJDOH) as required by their policies and procedures. This deficiency was identified in the case of a resident who had been admitted with diagnoses including anxiety disorder, dementia with agitation, social phobia, and cognitive communication deficit. The resident, who had a severely impaired cognition with a BIMS score of 4 out of 15, was reported to have been sexually assaulted by an unidentified staff member approximately two weeks before their death. The facility was notified of the allegation by the ombudsman, but the Director of Nursing (DON) did not report the incident to the NJDOH or the police, believing it unnecessary since the ombudsman had investigated and closed the case. The facility's Abuse Prevention policy mandates that all occurrences of abuse, neglect, mistreatment, and other grievances be reported to the appropriate agencies, including the NJDOH and local police. The policy specifies that any suspected crime resulting in serious bodily injury must be reported immediately, and no later than two hours after forming the suspicion. In this case, the DON acknowledged the responsibility for reporting such allegations but failed to do so, keeping only a soft file of the investigation and educating staff on abuse. The failure to report the allegation as per the facility's policy and state regulations constitutes a significant deficiency in the facility's handling of abuse allegations.
Medication Storage Deficiency During Administration
Penalty
Summary
The facility failed to properly store medications safely and securely during medication administration, as observed in two separate incidents. In the first incident, a Registered Nurse (RN) left the medication cart unlocked in the hallway outside of the dining room and left a vial of insulin unsecured on top of the cart while administering medication to a resident. The RN admitted to being nervous and acknowledged that this was not her usual practice. In the second incident, a Licensed Practical Nurse (LPN) also left the medication cart unlocked in the hallway during medication administration, without keeping it in sight. The LPN recognized the risk of someone accessing the medications if the cart was left unlocked. The Director of Nursing (DON) confirmed that the facility's policy required medication carts to be locked when not in the nurse's line of sight during medication administration. The DON acknowledged that leaving the cart unlocked could allow unauthorized access to medications. The facility's Medication Administration policy, dated March 2017, specified that medication carts should be kept closed and locked when out of sight, with no medications left on top of the cart, and all sides inaccessible to residents or passersby.
Failure to Maintain Complete Medical Record for Emergency Transfer
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was sent out for an emergent hospitalization. Specifically, the New Jersey Universal Transfer Form (NJUTF) was not included in the medical record for the resident's transfer to the hospital. The resident, who had multiple diagnoses including benign neoplasm of cerebral meninges, hypertension, atrial fibrillation, chronic obstructive pulmonary disease (COPD), and diabetes mellitus type 2, experienced an emergency situation where they were noted to be yelling "I can't breathe." The resident's vital signs were recorded, and a call was placed to the physician, resulting in an order to send the resident to the emergency room for evaluation and treatment. Emergency medical technicians arrived immediately, and the resident was transported to the hospital. Upon review, it was found that the NJUTF was missing from the resident's medical record for the transfer that occurred on the specified date. During interviews, the Director of Nursing (DON) confirmed the absence of the NJUTF and stated that they did not see the resident when they were transferred out. The facility's policy on emergency transfers requires the preparation of a transfer form to accompany the resident, which was not adhered to in this instance. This deficiency was identified during a complaint investigation and was based on interviews, record reviews, and other pertinent facility documentation.
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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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Illustrative
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlantic Coast Rehab & Health | 0 mi | ★★★★★ | 2 | 1 |
| Leisure Chateau Rehabilitation | 1 mi | ★★★★★ | 15 | 0 |
| Harrogate Village | 2 mi | ★★★★★ | 15 | 0 |
| Concord Healthcare & Rehabilitation Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Shore Gardens Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.