Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 The Fountains Of Atco during CMS and state inspections, most recent first.
Staff failed to follow the facility’s Legionella Water Management Plan and national guidelines by not maintaining and documenting required filters on shower heads and the dining room ice machine, and by not involving the IP in Legionella control activities. Only one of two in-use shower heads in the shower room had a filter in place, and the CMD could not produce logs showing when shower filters or the ice machine filter were checked or replaced. The ice machine, which staff routinely used to provide ice water and beverages for residents’ meals and medications, had been cleaned but its water-line filter had not been changed since installation, contrary to expectations and manufacturer guidance. The IP reported no knowledge of current Legionella issues and had only provided general education, while the LNHA confirmed the IP was not included in remediation efforts and that the WMP still listed former leaders as team members, even though it required documented cleaning, filter changes, and participation of the IP and other key staff when Legionella-positive samples were identified.
Surveyors found that the facility did not maintain required Legionella control measures for resident showerheads and an ice machine. A resident shower room was observed without the mandated 0.2-micron point-of-use filter on the showerhead, and the CMD reported CNAs sometimes removed filters due to low water flow, with no reliable logs showing when filters were checked or replaced. An ice machine near the dining area had a filter device labeled with an installation date more than several months old, and the CMD and HVACM could not confirm that it had been changed according to manufacturer specifications, nor could they provide documentation of filter changes or ordering. The facility’s WMP and prior NJDOH CDS directives required installation and documented maintenance of these filters as Legionella control measures, but the LNHA and maintenance staff were unable to demonstrate that these requirements had been consistently implemented or documented.
The facility failed to provide adequate supervision and effective fall prevention for several high fall‑risk residents, including cognitively impaired individuals with stroke history, aphasia, Alzheimer’s disease, hemiplegia, and repeated falls. One resident, identified as impulsive and requiring supervised activities, was repeatedly observed in dayrooms without staff present while attempting to stand, and experienced numerous falls in the room, hallway, and activity areas, three of which caused head and leg injuries requiring ED evaluation. Another resident with Alzheimer’s and diabetes had multiple falls despite a fall‑risk care plan, but incident reports lacked key details and new interventions were not consistently added or evaluated. A third resident with hemiplegia fell during in‑bed turning when a leg hit the floor, yet the care plan was not updated to include the specific positioning intervention discussed by the IDT. Across these cases, fall investigations were often incomplete or missing, causal factors were not clearly identified, supervision was not ensured in activity areas, and care plans were not consistently revised in accordance with the facility’s own fall‑management policies.
Incomplete pre-hire background screening and missing personnel records: The facility failed to ensure employees and contracted dietary/housekeeping staff were screened before hire for abuse, neglect, or misappropriation findings, and it could not produce complete personnel files for most workers reviewed. Many files had background checks completed well after the start date or had no report at all, and the HRD and LNHA could not confirm that required screenings were done prior to employment.
The facility failed to provide enough competent CNA and nursing staff to meet resident needs for incontinence care, showers, feeding assistance, supervision, and safe repositioning. A resident was found with two soiled briefs on, another reported not receiving showers and having blank refusal documentation, and another said breakfast was not provided on time. Residents also reported delayed call light response, weekend staffing problems, and missed showers, while a fall occurred during turning and minimum CNA staffing ratios were not consistently met.
The facility failed to complete annual performance reviews for five CNAs and did not provide competency-based training tied to those reviews. The HRD stated that performance evaluations were handled by department heads and were not consistently provided to HR, and the DON confirmed that no CNA competencies were completed and no training was based on performance evaluations.
Menus were not prepared with standard meal planning guides, recipes, or listed portion sizes, and the FSD confirmed the meal ticket and menu did not include portion information. During lunch prep, staff used a 2-oz scoop for cucumber salad even though the portion was stated to be 4 oz. The EC said the facility did not have the recipes or a nutritional analysis for the menus, and the RD stated she did not work with the kitchen on menu development.
Food items were stored without use-by dates, including produce, muffins, and expired yogurts, while the kitchen and remote pantry had multiple sanitation issues. Surveyors observed a malfunctioning dish machine temperature gauge, incomplete dish machine logs, dirty storage areas, soiled refrigeration equipment, wet and improperly handled dishware, and staff moving between dirty and clean tasks without handwashing. The FSD also confirmed several items were expired or improperly stored.
Failure to Obtain CMS Authorization for Facility Name Change: Surveyors found the facility website and exterior signage listed The Fountains at Atco, while CMS records and the CLIA certificate identified the facility as Allegria at the Fountains. Inside the building, wall signage showed The Fountains of Atco on the LTC license. When asked for CMS confirmation of the name change, the LNHA provided only NJ DOH approval for the transfer of ownership and name change and no CMS documentation.
The facility failed to ensure its FA addressed the staff training, education, and competencies needed for the resident population. The FA completed by the prior LNHA did not describe required competencies, even though the resident matrix showed pressure ulcers, feeding tube support, falls, indwelling urinary catheters, and a colostomy. The current LNHA stated he had not reviewed the FA and could not identify the competencies and training requirements for staff.
The facility failed to maintain an effective QAPI process that identified and reviewed significant care and staffing issues. Surveyors observed a resident with urine and feces-soiled briefs, another resident reporting repeated unmet care needs and a prior 911 call for missed breakfast, and a third resident reporting wet briefs and linens for hours. Residents were also observed in activity rooms without adequate staff supervision, including a resident at high risk for falls with multiple prior injuries. The LNHA stated the QAPI plans did not include staffing concerns, missed appointments, employee file issues, PTSD identification, or other significant events, and the facility assessment did not reflect needed staff competencies for the resident population.
Failure to Track Employee Influenza Vaccination Status and Exemptions: The facility did not have an effective process to monitor staff flu vaccination status or medical exemptions. Surveyors found that 24 of 75 employees had documented refusals for the current flu season, with no medical documentation supporting the refusals, and several declination forms lacked a reason. The IP and DON stated they were unaware of current flu vaccine guidance, and the IP reported no audits were being done to verify mask use by unvaccinated staff.
Failure to Develop Staff Training and Competency Program: The facility failed to develop and implement a staff training program and failed to ensure staff were competent based on the resident population identified in the facility assessment. The LNHA could not identify the required competencies, the IP/Staff Educator stated there was no training schedule and competencies were not completed, and the DON stated only the required CNA education had been completed with no additional education or competencies based on performance evaluations.
A resident with hemiplegia, epilepsy, severely impaired cognition (BIMS 2/15), and a documented need for an interpreter in a non-English dialect did not have the care-planned communication board available in the room, and staff were unaware of any communication device. The MD and nursing staff reported they did not use translation devices or contracted translation services and instead relied on slow speech, observation, and family presence, despite a facility policy stating that a contracted translation service was maintained and that family should not routinely be used as interpreters. A communication binder with words and images was later found under the bedside table only after surveyor inquiry, demonstrating that the planned communication interventions were not implemented as documented.
A resident with a history of stroke, right hemi craniotomy, left-sided weakness, epilepsy, severe cognitive impairment, and ongoing headaches and dizziness was ordered to follow up with Neurology/Neurosurgery. The resident, dependent on staff for dressing and requiring an interpreter, reported anticipating the appointment and stated no one came to prepare them, and that they did not refuse. Staff interviews and record review showed that the appointment scheduling and communication process relied on a unit clerk, an LPN, and a whiteboard, but December appointment records were not retained, the CNA was not informed to get the resident ready, and there was no documentation of refusal, missed appointment, physician notification, or rescheduling. Physician notes recommending neurology follow-up and documenting headaches and dizziness were not visible in the facility’s eMR until after surveyor inquiry, and the facility lacked a formal policy for scheduling resident appointments.
Failure to investigate resident 911 calls related to missed care. Two cognitively intact residents who required total assistance reported being left without incontinence care or breakfast and called 911; one resident said police responded, and the other was documented in a physician note talking to 911 about not being fed. The DON and LNHA stated these events should have been documented and investigated, but no investigation was found in the record.
Failure to Provide Timely ADL Assistance: A resident dependent on staff for ADLs was found wearing two incontinence briefs, with the first saturated with urine and feces, while another resident reported repeated delays in incontinence care, missed breakfast assistance, and no showers since admission. The CNA and LPN gave conflicting accounts about care provided, the DON confirmed incontinence care should occur every 2 hours and that two briefs should not be used, and records for bathing and showering were incomplete or absent. Another resident reported being left in wet briefs and linens for hours and calling 911 for lack of care.
Expired and discharged-resident medications were found in the med refrigerator and med room, including an expired COVID-19 vaccine, medications for discharged residents, and multiple boxes of Santyl belonging to an expired resident. An LPN/CN and LPN/UM stated that overnight nursing staff and the consultant pharmacist were responsible for checking for expired meds and removing discharged residents’ meds from active inventory, but the items were still present during the survey.
A resident with acute tetraplegia, a PEG tube, and aspiration precautions did not receive ordered OT/PT evaluation or treatment after admission. The record also lacked a speech therapy evaluation and had no orders for prescribed hand splints. The DON said the facility was waiting for authorization before starting therapy, and the LNHA stated therapy should have occurred regardless of payment source.
A resident with severe cognitive impairment, hemiplegia, and a history of brain surgery reported ongoing head pain and stated that staff did not prepare them for a scheduled follow-up neurosurgical appointment, which they denied refusing. Staff interviews revealed that appointment scheduling information was kept on a white board and in progress notes, but the resident’s appointment was not on the list, and the CNA was not told to get the resident ready. The resident’s representative later arrived visibly upset about the missed appointment, and both the ADON and DON were aware of the complaint, yet no grievance was initiated, no refusal or missed appointment was documented in the progress notes, no follow-up appointment was arranged, and the physician was not notified. The grievance officer’s logs contained no entry for this event, and the only investigation document was a single LPN statement and a transport order showing the trip was cancelled as “appointment cancelled,” contrary to the facility’s written grievance policy requiring prompt resolution and communication of grievance findings.
Failure to provide SNF ABN for a resident with changed coverage status. A resident reported that rehab services had stopped without explanation, and record review showed Medicare Part A coverage had ended while benefit days remained and the resident stayed in the facility. The SSD stated the SNF ABN should have been given because it was important for continuity of care and resident/family involvement, but the form was marked not applicable.
Delayed Admission MDS Completion: A resident's comprehensive admission MDS was not completed within the required timeframe and was still in progress when reviewed. The MDSC stated she worked remotely, was behind on assessments, and prioritized Medicare assessments first, which caused this resident's admission assessment to be delayed.
Inaccurate completion of an admission MDS occurred for a resident when the MDS coordinator said she was behind, worked remotely, and prioritized Medicare assessments first. The record showed different staff completed portions of the MDS, and the RN assessment coordinator signed the assessment as complete before the transmission was accepted.
Failure to provide ordered nebulizer respiratory care: A resident admitted with acute respiratory failure with hypoxia, pleural effusion, pneumonia, and rib fractures was ordered nebulizer treatments and inhaled medications, but staff documented missed treatments because no nebulizer machine was available. Surveyors observed the resident on oxygen, found no nebulizer machines in the expected supply areas, and learned that available machines were already assigned to other residents while some MAR entries were still initialed as administered.
Failure to address a resident’s PTSD and related anxiety: A resident with a documented history of PTSD, depression, and diabetes became increasingly anxious when breakfast was delayed, reported a panic attack, and called 911 after receiving insulin. The resident’s PTSD was not included in the admission record, MDS, SS assessment, care plan, or psych eval, and no psychotherapy consults were documented. The DON and DSW stated they were unaware of the PTSD diagnosis until later and acknowledged it should have been documented and addressed.
An LPN administered Flonase incorrectly by giving one spray instead of the ordered two sprays in each nostril and then documented the dose on the eMAR. In a separate event, two opened lidocaine patch packages were found left on a resident’s bedside table instead of being properly handled after the resident declined them; the MAR/TAR documentation was incomplete, and the resident had multiple chronic conditions including quadriplegia, depression, DM1, and a history of PTSD and anxiety.
The facility failed to maintain food safety and sanitation standards, as observed by a surveyor. The inspection revealed an unclean meat slicer, unlabeled and undated food items in the refrigerator and freezer, and a dented can in dry storage. The FSAD acknowledged these issues, which were contrary to the facility's policy on proper food labeling and dating.
The facility failed to complete the Quarterly MDS assessments on time for two residents, resulting in a deficiency. One resident with congestive heart failure had their assessment completed three days late, while another with dementia had theirs completed five days late. The MDS Coordinator acknowledged the delays, which were against the facility's policy requiring timely assessments.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. One resident's care plan lacked focus on leg wraps for edema and did not document refusal. Another resident experienced two falls without care plan updates. A third resident with a urinary catheter lacked specific care plan details. Staff confirmed the care plan deficiencies.
A resident with moderate cognitive impairment refused prescribed leg wraps for edema, and the facility failed to educate the resident or notify the physician and family about the refusal. The facility's policy required such actions, but documentation and staff interviews revealed these steps were not taken, resulting in a deficiency.
A facility failed to maintain accurate records for Xanax, a controlled medication, resulting in a discrepancy between the recorded and actual pill count. An LPN admitted to counting the narcotics alone, leading to the oversight. Additionally, Xanax was improperly borrowed for another resident, contrary to facility policy, as confirmed by the DON and other staff.
A facility failed to document the assessment and administration of the influenza vaccine for a resident admitted with Diabetes Mellitus and Hypertension. The resident's MDS indicated the vaccine was not received, and the reason was not assessed. The DON confirmed the vaccine should have been assessed upon admission, but no consent or refusal form was available. Facility policy required offering the vaccine between October and March and assessing new residents' vaccination status upon admission.
Failure to Implement Legionella Water Management Controls and Involve IP in Program
Penalty
Summary
Facility staff failed to implement, maintain, and monitor control measures to prevent the growth of Legionella in accordance with the facility’s Water Management Program (WMP), CDC guidelines, and ASHRAE Guideline 12. During a tour of the skilled nursing section, surveyors observed three shower heads in the shower room, two of which were in use, and only one of those two had a filter in place. The Campus Maintenance Director (CMD) stated that CNAs may have removed a filter to get better water flow and that maintenance checked filters every three months, but he was unable to produce logs showing when shower head filters were checked or replaced. A provided “SNF Community Shower Room” log only showed a date when a new filter was installed, and the CMD could not explain what the log meant. CNAs reported no issues with low water pressure and confirmed that residents regularly received showers in the shower room and in private showers. Surveyors also observed an ice machine in the dining room/pantry area with an inspection sheet indicating it had been cleaned and sanitized by the Heating, Ventilation and Air Conditioning Mechanic (HVACM) several months earlier. A filtration device attached to the water line for the ice machine had a handwritten date that appeared to be the installation date, and the CMD was unsure if the filter had been changed since then or what the manufacturer’s specifications were for changing the filter. The HVACM confirmed he had disassembled, sanitized, and reassembled the ice machine but had not changed the filter device at that time, stated the filter should have been changed, and indicated the filter device now needed to be ordered. The CMD acknowledged he could not provide logs or an ordering schedule for the ice machine filter and attributed missing audits and documentation in part to a terminated Maintenance Supervisor. Interviews with leadership and clinical staff showed that the Infection Preventionist (IP) was not included in Legionella control measures despite the WMP and facility policy identifying the IP as part of the water management team. The IP/LPN reported having been the IP for about a year, stated she had no knowledge of any current Legionella issues in the building, and indicated that upper management and maintenance were handling Legionella. She recalled being told to provide general education on Legionella about a year earlier but had not been involved in remediation activities. The Licensed Nursing Home Administrator (LNHA) confirmed that the IP/LPN was responsible for staff education on Legionella but was not currently involved in remediation and had not been included in discussions about Legionella since he became LNHA. The LNHA also acknowledged that the WMP listed program team members who were no longer employed and that he was unaware of the magnitude of the facility’s Legionella history or the status of mitigation efforts when he assumed his role. Meanwhile, staff routinely used water from coolers and ice from the ice machine for residents’ drinks, meals, and medications, and residents confirmed receiving water with ice and regular showers, while the WMP required documented regular cleaning and filter changes for ice machines and showerheads when Legionella-positive samples were identified. A review of the facility’s WMP dated mid-2025 showed that the current CMD and former executive leadership were listed as program team members, but it did not reflect current responsible individuals. The WMP identified ice machines, medical devices, shower heads, and hoses as devices at risk for Legionella contamination and required regular cleaning, filter changes per manufacturer specifications, and documentation of these activities. It also required regular cleaning, replacing or dismantling, disinfecting, and descaling of showerheads and hoses, and called for more frequent sampling and review when Legionella-positive samples were found outside control limits. The facility’s Legionella Water Management Program policy further specified that the water management team must include at least the IP, administrator, medical director, director of maintenance, and director of environmental services. Despite this, the LNHA could not provide documentation of completed NJDOH Communicable Disease Services recommendations prior to a recent sampling event and initially provided policies that he later acknowledged were not the actual WMP, underscoring that the WMP had not been updated to include current responsible team members or fully implemented as written.
Failure to Maintain Legionella Control Measures for Showerheads and Ice Machines
Penalty
Summary
The deficiency involves the facility’s failure to implement required Legionella control measures on resident showerheads and ice machines as directed by the New Jersey Department of Health (NJDOH) Communicable Disease Service (CDS) and as outlined in the facility’s Water Management Plan (WMP). NJDOH CDS written instructions dated 01/21/2025 required immediate installation of 0.2-micron biological point-of-use filters on any showerheads intended for use, or restriction of showers with use of sponge baths instead, and specified that filters must comply with ASTM F838. The same communication directed the facility to assess for additional point-of-use filters at fixtures with elevated aerosolization risk and to follow manufacturers’ recommendations for filter replacement. The WMP, dated 07/15/2025, identified showerheads, hoses, and ice machines as devices at risk for Legionella contamination and required regular cleaning and filter changes per manufacturer specifications, with documentation. On the survey date, during an inspection of a resident shower room, the survey team, accompanied by the Campus Maintenance Director (CMD), a NJDOH CDS Water Systems Analyst, and a Local Health Department representative, observed that the resident showerhead did not have a 0.2-micron biological point-of-use filter in place. The CMD stated that CNAs sometimes removed the filters when water flow was low and that maintenance checked the filters every three months, but he could not produce logs to show when showerhead filters had been checked or replaced. The only record provided was a “SNF Community Shower Room” log indicating a date when a new filter was installed, which the CMD could not interpret. The LNHA reported he was aware filters needed to be checked and changed but relied on maintenance for the schedule and believed audits were being done. During inspection of the ice machine near the resident dining area, the survey team observed a filter device labeled with an installation date of 02/04/2025. The CMD was unsure if the filter had been changed since that date and could not speak to the manufacturer’s replacement specifications. The Heating Ventilation Air Conditioning Mechanic (HVACM) confirmed he had disassembled, sanitized, and reassembled the ice machine in November 2025 and normally would change the filter cartridge, but on that occasion did not change the filter device. He acknowledged the filter device should have been changed and that he did not handle ordering, which he believed was the responsibility of a Maintenance Supervisor who had since been terminated. The CMD was unable to provide any logs or ordering records for the ice machine filter, citing frequent vendor changes and multiple people being involved. The LNHA acknowledged awareness of a history of Legionella issues at the facility and ongoing communication with NJDOH CDS, but he was unable to provide documentation of NJDOH CDS recommendations completed before a February 2026 sampling event and believed he was following the WMP despite the lack of documented compliance with required control measures for showerheads and ice machines.
Failure to Provide Adequate Supervision and Effective Fall Prevention for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention for multiple cognitively impaired and high fall‑risk residents, and to thoroughly investigate and respond to falls. One resident with severe cognitive impairment, aphasia after stroke, repeated falls, bipolar disorder, muscle weakness, and a history of traumatic subdural hemorrhage was repeatedly placed in dayrooms without consistent staff supervision despite being identified as impulsive, at high risk for falls, and requiring supervised activities. Surveyors observed this resident multiple times in a wheelchair in the activity/dayroom areas, appearing restless, attempting to stand, and moving back and forth in the wheelchair while no staff were present in the room. The activity aide reported she was the only staff member assigned to cover two separate activity rooms, could not supervise both simultaneously, and that there were no staff physically assigned to monitor the activity area when she had to step out. This same resident sustained at least 13 falls, including several unwitnessed falls in the resident’s room and multiple falls in the activity room and hallway. Documentation showed repeated nursing notes of the resident being found on the floor in the room, in doorways, and in the activity room, sometimes with skin tears or redness, and three falls resulted in injuries requiring emergency department evaluation: a contusion and laceration to the left supraorbital and frontal scalp after a hallway transfer incident where the CNA reported the resident’s legs became caught and the resident fell forward from the wheelchair; a large intramuscular hematoma of the right thigh after a fall in the activity room where the resident stood and missed the chair; and a closed head injury and facial laceration after another fall in the activity room with active bleeding from the forehead. Despite a care plan that specified the resident was impulsive, had poor safety awareness, required prompt response to requests for assistance, should be in common areas when out of bed, should not be left alone in the room in a wheelchair, and needed supervised activities to minimize falls, the facility did not ensure supervision in the dayrooms and did not consistently revise interventions after recurrent falls. Several fall investigations were missing entirely, and when interdisciplinary team notes were present, they often stated that all current interventions remained appropriate and that no additional interventions were needed, even after serious injuries and documentation that the resident required supervision in activities. Another resident with Alzheimer’s disease, anxiety, diabetes, and a high fall‑risk score experienced multiple falls over a short period, including several falls with no injury and one fall with skin tears to the left hand and elbow. The care plan listed general fall‑prevention interventions such as reviewing past falls, attempting to determine causes, anticipating needs, ensuring call light access, prompt response to assistance requests, appropriate footwear, maintaining the bed in the lowest position, toileting schedules, therapy evaluations, and activities to promote exercise and diversion. However, for at least one documented fall, no new interventions were added, and facility accident/incident reports lacked key information such as when the resident was last seen or toileted, footwear at the time of the incident, bed position, or whether the resident had participated in activities as care‑planned. Effectiveness of interventions and root causes of falls were not clearly evaluated or documented, contrary to the facility’s own falls policies that required identification of precipitating factors, cause identification within 24 hours, and ongoing adjustment of interventions until falls were reduced. A third resident with severe cognitive impairment, hemiplegia and hemiparesis following cerebral infarction, and epilepsy had a documented fall during in‑bed repositioning. A risk management report described that while a CNA was turning the resident onto the right side, the resident’s leg hit the floor while the body remained on the bed. The interdisciplinary team later discussed this event and identified the need for staff to position the resident in the center of the bed before turning to one side or the other. However, the resident’s comprehensive care plan for falls was not updated to include this fall or the specific intervention related to proper positioning prior to turning. Overall, across these residents, the facility’s fall‑related policies did not address supervision, multiple falls were not thoroughly investigated, causal factors were often not identified, and care plans were not consistently updated with new or specific interventions in response to recurrent falls and injuries. The facility’s written policies on managing falls and fall risk, the falls clinical protocol, and the falls risk assessment policy required staff to identify interventions related to specific risks and causes, implement resident‑centered fall prevention plans, monitor and document responses to interventions, and re‑evaluate and modify interventions when falls continued. These policies also required staff to evaluate when and where falls occurred, document precipitating factors, and attempt to define possible causes within 24 hours, with physician involvement when causes were unclear or falls persisted. Despite these requirements, the policies did not address supervision as part of fall management, and in practice, the facility did not ensure adequate supervision in activity areas, did not consistently complete or document fall investigations, and did not reliably implement or update individualized interventions after falls for the residents reviewed.
Incomplete Pre-Hire Background Screening and Missing Personnel Records
Penalty
Summary
The facility failed to have a system in place to ensure that, prior to hire, employees were pre-screened to confirm they had not been found guilty in a court of law of abuse, neglect, or misappropriation, and to maintain documentation showing appropriate pre-screening for all contracted employees, including dietary and housekeeping staff. The cited policy required background checks and prohibited knowingly employing or engaging anyone with findings related to abuse, neglect, exploitation, mistreatment, or misappropriation, but the facility could not provide complete employee files for 99 of 154 employees requested. On survey, the Human Resources Director provided a list of 154 employees hired since the last recertification survey, including 35 contracted dietary and housekeeping workers, but only 55 employee files were produced. Review of those files showed multiple employees had criminal background checks completed well after their hire dates, including checks performed days to months after they had already begun working. Several files had no criminal background report at all. The surveyor documented examples such as employees hired in 2024 and 2025 whose background checks were dated long after employment began, as well as multiple employees with no report in the file. The HRD and LNHA acknowledged they could not locate all requested files and could not explain how they knew employees had not been excluded from work based on criminal background checks. The HRD also stated that background checks and references were not completed for all employees prior to date of hire. For the contracted dining services staff, the facility provided the contract showing the contractor was responsible for background checks, but the HRD stated she had never received any of the 35 requested contractor employee files and could not confirm whether the required background checks were completed prior to hire.
Insufficient Staffing and Inadequate ADL Care
Penalty
Summary
The facility failed to provide sufficient and competent nursing staff to meet residents’ needs for incontinence care, showers, feeding assistance, supervision for fall risk, and safe repositioning. During an initial tour, a strong urine odor was noted in the hallway and in a resident’s room, where a resident was found wearing two incontinence briefs that were saturated with urine and soiled with feces. A CNA initially stated the overnight staff had left the two briefs on the resident, and later admitted that she had placed the two briefs on the resident herself. The DON stated that incontinence care was to be provided every 2 hours and as needed, and that no resident should have two briefs on because the skin could be affected. The resident stated they did not request to wear two briefs and knew when they needed to use the bathroom. The facility also failed to ensure residents received showers and other ADL care as scheduled or requested. One resident reported they had not received a shower since admission and said staff repeatedly told them the water was cold when they asked for a shower. Review of the shower binder found no shower sheets for that resident, and no skin assessments were found in the medical record. The resident’s CNA stated the resident’s shower days were Wednesday and Sunday, but that she always offered a bed bath instead of a shower and would document refusal if the resident declined; however, the CNA documentation system showed the refusal column left blank every day since admission. Another resident stated staff had not fed them breakfast on one occasion until after 10:00 AM and that they had called 911 because they were not fed. A resident council meeting also revealed multiple complaints about delayed call light response, weekend staffing concerns, and residents not being offered showers on scheduled shower days. The report also documented failures related to supervision and safe care. One resident stated they had been left unattended in wet briefs and linens for hours and had previously called 911 because incontinence care was not provided. Another resident reported that staff did not come to get them dressed for a medical appointment. A Risk Management Report showed a resident fell while being turned onto their side by a CNA when the resident’s leg hit the floor while the body remained on the bed; the interdisciplinary team later discussed positioning the resident in the center of the bed before turning. In addition, the facility did not consistently meet minimum CNA staffing requirements during the two weeks before survey, with three day shifts below the required ratio. The facility assessment identified resident needs including pressure ulcers, feeding tube support, falls, indwelling urinary catheters, and a colostomy, but the LNHA could not identify the competencies and training requirements tied to those needs, and the IP/Staff Educator stated there was no training schedule and competencies were not completed.
Missing CNA Performance Reviews and Competency Training
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for Certified Nurse Aides (CNAs) and that education was provided based on the outcome of those reviews. During record review, performance reviews were not found for all five CNA files reviewed: CNA #1 with a date of hire of 7/29/24, CNA #2 with a date of hire of 7/30/2024, CNA #3 with a date of hire of 8/08/2024, CNA #4 with a date of hire of 9/06/2024, and CNA #5 with a date of hire of 11/07/2024. The Human Resources Director confirmed that she did not have the performance reviews and stated that performance evaluations were the responsibility of the department heads where the employees worked, noting that sometimes department heads provided copies and sometimes they did not. The DON confirmed that no competencies were completed for any CNAs and that there was no training based on performance evaluations.
Menus Lacked Portion Sizes, Recipes, and RD Review
Penalty
Summary
The facility failed to have a system in place to ensure menus were prepared using standard meal planning guides and recipes with portion sizes so the menus would be nutritionally adequate. During review of the weekly menu cycle, the surveyor requested the extensions/portion sizes for all diets, but they were not provided. When the surveyor observed lunch preparation in the remote dining pantry, staff used a 2-ounce scoop to portion cucumber salad into plastic cups, even though the staff member stated the portion should be 4 ounces and showed the blue-handled scoop that was only 2 ounces. The Food Service Director confirmed that portion sizes were not listed on the meal ticket and were not listed on the menu. The Executive Chef stated that the facility did not have the recipes used for the menu items and that he and the Food Service Director made the menus. He also stated that the Registered Dietitian did not work with the kitchen and that he did not have a nutritional analysis or a process used to develop the menus. When asked whether nutritional analysis would be important, he stated yes, for maintaining nutritional value of the menu. The Registered Dietitian stated she did not work with the kitchen on the menus and confirmed that portion sizes, recipes, and a nutritional analysis were important to ensure residents were adequately served and the menus met dietary guidelines.
Food Storage and Sanitation Deficiencies in Kitchen and Pantry
Penalty
Summary
Food was not stored in a manner to ensure it was used by a safe use-by date, and the kitchen and remote service kitchen were not maintained in a sanitary manner. During an initial kitchen tour, the Executive Chef was observed wearing a hair net that did not cover all facial hair above the lip and on the sides. The dish machine was in use, but the wash gauge did not register a temperature, and the temperature log posted on the wall had 5 of 13 entries without staff initials. The Food Service Director stated the facility was not aware of the issue with the dish machine, and the staff member using it stated he had just found out that morning and was doing what he was told. A hot water booster was observed directly under the dish machine, and later documentation from the service company showed broken temperature gauges and two fuses in the booster were replaced. The walk-in refrigerator fan and ceiling were soiled with embedded dust-like debris, the dry storage racks had visible debris, and dark crumb-like debris was observed behind the cooking area and under the pass-through shelf. Several food items, including scallions, celery, carrots, onions, English muffins, and yogurts, were observed without use-by dates, and some yogurts were expired. In the remote food service pantry, one staff member was observed handling dirty and clean dishes without washing hands between tasks. Insulated bowls were visibly wet and stacked on top of one another, and the Food Service Director stated they should have been air dried. The pantry refrigerator had an internal thermometer that did not register temperature, ripped gaskets, visible splatter and debris inside, and eight expired yogurts that staff said had been brought from the main kitchen. The kitchen ceiling had visible splatters, the blender equipment was stored wet inside, and meal trays used for room delivery were observed in the pantry during meal preparation. The facility policies reviewed stated staff were to use proper hand washing and glove use, avoid contamination during food preparation, and keep an accurate thermometer in each refrigerator.
Failure to Obtain CMS Authorization for Facility Name Change
Penalty
Summary
The facility failed to notify CMS and obtain authorization for a change in the facility’s name in accordance with 42 CFR 424.516. Prior to the survey, the surveyor reviewed the facility website and found the name listed as The Fountains at Atco at the address associated with the registered name Allegria at the Fountains. Upon arrival, surveyors observed exterior signage reading The Fountains at Atco, which did not match the CMS licensed, approved name and provider registered name Allegria at the Fountains. Inside the facility, surveyors observed wall signage documenting the license for 60 LTC beds, issued by the New Jersey Department of Health and expired on [DATE], that listed the facility name as The Fountains of Atco, which differed from the exterior signage. The CMS Clinical Laboratory Improvement Amendments certificate identified the facility name as Allegria at the Fountains. When asked for communication from CMS confirming acceptance of the name change, the LNHA provided only a New Jersey Department of Health Certificate of Need and Licensing approval for transfer of ownership and name change to The Fountains of Atco and did not provide any CMS documentation. No additional information regarding the facility’s name change was provided to the survey team.
Facility assessment did not address staff competencies for resident care needs
Penalty
Summary
The facility failed to ensure its facility assessment addressed the skill sets and competencies required of staff to provide care to the resident population. On 1/5/26, the facility provided a copy of the facility assessment completed by the prior LNHA on 2/10/25, and under staff training/education and competencies it did not describe the staff training, education, and competencies necessary to provide the level and types of support and care needed for the residents. A review of the Matrix for Provided showed residents with pressure ulcers, feeding tube nutritional support, falls, indwelling urinary catheters, and one resident with a colostomy. On 1/9/26, the LNHA stated the facility assessment identified the care and services the facility offered and acknowledged it had been completed before his arrival; when asked whether he had reviewed it, he said he had not. When the surveyor asked him to show the competencies and training requirements identified for staff based on the resident population, he stated, "I can't say I see it."
QAPI Program Failed to Identify and Review Significant Care and Staffing Issues
Penalty
Summary
The facility failed to maintain an effective QAPI process that identified and reviewed systems and events affecting resident care and quality of life. During the survey, the QAPI committee did not identify concerns related to staffing, resident care issues, missed appointments, employee file availability, or residents calling 911 for unmet needs. The LNHA stated that QAPI was based on department heads identifying issues and bringing them to meetings, but the current QAPI plans reviewed did not include several significant events and concerns observed by surveyors. Multiple resident observations and interviews showed care concerns that were not reflected in the facility’s QAPI process. Resident #22 was found lying in bed with a strong urine odor in the room and was observed wearing two incontinent briefs that were saturated with urine and soiled with feces. Resident #74 stated the facility was "bad," reported calling 911 a couple of weeks earlier because staff did not feed breakfast, and the record showed a history of PTSD that the facility had not identified. Resident #9 reported being left in a wet brief and wet linens for hours and stated that at one time police responded after the resident called 911 because staff did not help. Additional observations showed staffing and supervision concerns in the activity rooms. One activity aide was responsible for monitoring both dayrooms, and residents were observed without staff present while one resident was restless and attempted to stand. Resident #7 was identified as high risk for falls, impulsive, required supervision, and had 13 falls, including three with injury requiring emergency room transfer. The facility assessment provided by the prior LNHA also did not identify the staff training, education, and competencies needed for the resident population, despite residents having pressure ulcers, feeding tubes, falls, indwelling urinary catheters, and a colostomy. The LNHA also stated he had not reviewed the facility assessment and could not identify the competencies and training requirements listed for staff.
Failure to Track Employee Influenza Vaccination Status and Exemptions
Penalty
Summary
The facility failed to develop and implement a system to prevent the spread of potential influenza by ensuring there was a process to monitor employee flu vaccination status. Surveyors found that the facility did not have a reliable process in place to track employee influenza vaccinations or medical exemptions, even though the facility policy stated that employees who were not vaccinated were to have the refusal documented and that vaccination information should be maintained in the employee record. The report also cited New Jersey requirements that covered healthcare facilities maintain records or attestations of influenza vaccinations and medical exemptions for each employee. During the survey, the Infection Preventionist stated that there were many exemptions for the flu vaccine and that those staff members must wear a mask during flu season. However, when the surveyor reviewed the facility’s documentation for staff flu vaccinations, 24 of 75 employees were documented as refusing the flu vaccine for the current flu season, and no medical documentation was found for these refusals. The declination forms contained no reason for refusal in some cases, while others listed reasons such as believing the vaccine would make them sick, personal beliefs, religious reasons, not believing it was effective, or family history of not receiving it. The DON stated she was unaware of employee flu vaccine refusals and later stated she was unaware of current guidance for the flu vaccine, including the New Jersey statute of 2020. The Infection Preventionist also stated she was not aware of the current guidance for the flu vaccine and said she reminded managers to ensure employees were wearing masks, but she had no audits and would only address issues if she saw a problem. No further information was provided by the facility.
Failure to Develop Staff Training and Competency Program
Penalty
Summary
The facility failed to develop and implement a staff training program and failed to ensure staff were competent to provide care and services for the resident population identified in the facility assessment. The facility assessment completed on 2/10/25 listed staff training, education, and competencies needed for the resident population, and the Matrix for Provided showed residents with pressure ulcers, feeding tubes, falls, indwelling urinary catheters, and one resident with a colostomy. When asked to review the facility assessment and identify the competencies and training requirements for staff based on the resident population, the LNHA stated, "I can't say I see it." The Infection Preventionist/Staff Educator stated she did not have a schedule of training for staff and confirmed that competencies were not completed. She provided a binder of education that had been completed and stated the education was done in response to specific incidents involving residents. The DON stated she was aware that the 12 hours of CNA education had been completed, and there was no additional staff education or competencies based on the CNAs performance evaluation.
Failure to Provide and Implement Communication Devices and Translation Services for Non-English-Speaking Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide an effective communication device for a resident with a known language barrier and severe cognitive impairment. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and epilepsy. The most recent quarterly MDS showed a BIMS score of 2/15, indicating severely impaired cognition, and documented that the resident’s preferred language was a non-English dialect and that an interpreter was needed. The comprehensive care plan for communication, initiated/revised on 8/22/25, specified that staff who spoke the same dialect could translate, that the family was available by phone to translate, and that the resident had a communication board in the room. However, during an observation on 1/5/26, the CNA assigned to the resident could not locate a communication device and confirmed there was no communication board in the room. Interviews and record review further showed that the facility did not effectively implement its own translation services policy. A family representative reported arriving at the hospital for an appointment with the resident and being told the facility had cancelled the appointment, then going to the facility and speaking with the resident, who spoke minimal English. Staff interviews revealed that the MD did not speak the resident’s language and communicated only by speaking slowly and observing the resident, without using any translation device or service, and that the facility did not provide such services. An LPN/charge nurse stated there was no translation or ancillary communication device in the facility. Later, in the presence of the DON, the LPN produced binders with words and images that she stated she found under the bedside table, and the surveyor noted staff were not aware of this communication device and it could not be located prior to the surveyor’s inquiry. The facility’s written policy, revised 1/2020, stated that the facility maintained a contracted relationship with a translation service and that family and friends should not be relied upon for interpretation unless explicitly requested by the resident and with written consent, but no further information was provided to demonstrate implementation of this policy.
Failure to Ensure Resident Attended Ordered Neurology Appointment and to Document Missed Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure a system was in place and implemented to enable a resident to attend an outside neurology/neurosurgery appointment as ordered and needed. The resident had a history of stroke with right hemi craniotomy, left-sided weakness, epilepsy, and severe cognitive impairment, and was dependent on staff for upper and lower body dressing. The resident’s preferred language required an interpreter. Physician progress notes from late 2024 and 2025 documented ongoing headaches, dizziness, left-sided weakness, and recommendations for follow-up with Neurology/Neurosurgery. However, these 2025 notes were not visible in the facility’s eMR until after surveyor inquiry due to a transcription/transfer issue between the physician’s own eMR and the facility’s system. The resident reported anticipating a neurology appointment the night before and being eager to attend due to persistent deep head pain, dizziness, cramping pain, and headache radiating from the base of the neck to the area of the prior craniotomy. On the morning of the scheduled appointment, the resident stated that no one came to get them dressed or ready and that they did not refuse the appointment. The MDS indicated the resident did not exhibit rejection-of-care behaviors and required total assistance for dressing, meaning staff preparation was necessary for the resident to attend the appointment. Staff interviews confirmed that the resident did not refuse the appointment and that there was no documentation of refusal. Interviews with the ADON, LPN/Charge Nurse, CNA, and DON revealed that appointment scheduling and communication processes were informal and inconsistently implemented. The unit clerk and LPN/Charge Nurse scheduled appointments and were supposed to document them in progress notes and on a white appointment board, but December appointment records were not kept. The CNA stated she was not informed to get the resident ready and did not recall the resident’s name on the appointment board. Review of the resident’s progress notes showed no entry that the appointment was missed, no documentation that the physician was notified of the missed appointment, and no evidence of a rescheduled neurology appointment prior to surveyor inquiry. The facility also could not provide a policy for scheduling resident appointments, despite having a documentation policy that required recording refusals and physician notifications, contributing to the failure to ensure the resident attended the ordered neurology follow-up.
Failure to Investigate Resident 911 Calls Related to Missed Care
Penalty
Summary
The facility failed to ensure that investigations were initiated when two residents who were dependent on staff for care contacted 911 after not receiving needed assistance. The deficiency involved Resident #9 and Resident #74, both of whom were cognitively intact according to their most recent MDS assessments and required total assistance from staff for toileting or dining. The report states that neither resident’s 911 call was documented in the medical record at the time of the events, and no investigation was found for either incident when reviewed by surveyors. Resident #9 was observed in bed and reported multiple occasions of being left in wet incontinence briefs and linens for hours. The resident also stated that one time they called 911 because they were not provided incontinence care and police responded to the facility. The resident’s care plan identified total assistance with toileting, but the EMR from 11/30/25 through 1/6/26 contained no progress notes or care plan entries related to the 911 call. The DON later stated that the resident had called 911 about ten days earlier and acknowledged that such an event should be investigated and could represent neglect. Resident #74, who had quadriplegia, C1-C4 complete, Type 1 DM, depression, hypothyroidism, GERD, and anemia, reported that staff did not feed breakfast and that they called 911 after becoming worried and feeling unwell as a diabetic. The medical record included a care plan stating the resident needed total assistance with dining, and a physician note documented that the resident was seen in bed talking to 911 and reporting not being fed breakfast. The DON stated that if a resident called 911, the incident should have been documented and investigated, but she was not aware of the call and had no investigation to provide. The LNHA stated he was the abuse coordinator and that he would have to investigate if a resident was not being changed or assisted with meals to the point of calling 911, but he was not aware of either resident’s 911 call.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for ADLs received timely and appropriate incontinence care, showers, and feeding assistance. During an initial tour, a strong urine odor was noted in the hallway and in Resident #22’s room. Resident #22 was observed wearing two incontinence briefs, with the first brief saturated with urine and soiled with feces. CNA #1 later stated that overnight staff had provided care and left the two briefs on the resident, and the LPN charge nurse stated the resident should not have been wearing two briefs. The DON stated incontinence care was to be provided every 2 hours and as needed, and that no resident should have 2 incontinence briefs on because the skin could be affected. Resident #74 stated that staff had not fed breakfast on one occasion until after 10:00 AM, and the resident reported calling 911 because they were diabetic and started feeling unwell. Resident #74 also stated they had not received a shower since admission and said staff told them the water was cold when they asked for a shower. The surveyor reviewed the shower binder and found no shower sheets for Resident #74, and no skin assessments were found in the medical record. The CNA stated the resident’s shower days were Wednesday and Sunday, but that she always offered a bed bath instead of a shower and would document refusal if the resident declined; however, the CNA task record for bathing showed the resident refused column was left blank every day since admission. Resident #9 stated there had been multiple times they were left unattended in wet incontinence briefs and linens for hours, and that they once called 911 because they were not provided incontinence care and police responded to the facility. The report also identified Resident #73 and Resident #74 among the four residents reviewed for ADLs. The facility policy stated residents unable to perform ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, and that if residents with cognitive impairment or dementia resist care, staff should attempt to identify the underlying cause rather than assume refusal.
Expired and Discharged-Resident Medications Found in Storage
Penalty
Summary
Drugs and biologicals were not properly removed from active inventory and stored in accordance with accepted medication storage principles in the medication refrigerator and medication room. During inspection, the surveyor observed Spikevax (Moderna COVID-19 Vaccine) with a pharmacy label showing it had been thawed on 10/10/25 and expired on 12/10/25, along with one box of Brovana that belonged to a discharged resident, one box of Cosentyx that belonged to another discharged resident, and one box of Wegovy that belonged to a discharged resident. The Licensed Practical Nurse/Charge Nurse and the Licensed Practical Nurse/Unit Manager stated that overnight nursing staff and the consultant pharmacist were responsible for checking for expired medications and removing discharged residents’ medications from active inventory. The surveyor also observed eight boxes of Santyl in the medication room that belonged to an expired/unsampled resident who had expired on 7/24/25. The LPN/UM stated she would remove the items from active inventory. A review of the most recent consultant pharmacist unit inspection dated 12/11/25 reflected no expired medication in the storage area, and the facility’s compliance rate for December 2025 was 95.12%. The facility policy titled Medication Labeling and Storage stated that the dispensing pharmacy is contacted for instruction regarding returning or destroying discontinued, outdated, or deteriorated medications or biologicals.
Failure to Provide Ordered Rehab Services
Penalty
Summary
The facility failed to provide rehabilitation services per physician order for Resident #74, who had been admitted after treatment for acute tetraplegia secondary to a spinal epidural abscess due to ESBL E. coli bacteremia. The hospital discharge summary noted upper extremity swelling, spinal cord injury, occupational therapy for upper extremity splints and positioning, aspiration precautions during meals, and the need for bilateral resting hand splints after dinner and removal in the morning before breakfast. The resident also had a PEG tube and was identified as needing speech-related precautions, but there was no speech therapy evaluation documented. The medical record showed active physician orders for occupational and physical therapy evaluation and treatment as indicated, but there was no therapy documentation or assessment completed after the order date. There were also no orders related to the hand splints. During interview, the DON stated the resident had not received any therapy since admission and that the facility was waiting for authorization before providing therapy services. The LNHA stated therapy should have been performed and that an evaluation and treatment should have occurred regardless of payment source.
Failure to Log and Process Resident Grievance Regarding Missed Medical Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its method for filing and handling grievances was consistent with its own grievance policy and actual practice. A resident with a history of hemiplegia and hemiparesis following a cerebral infarction, epilepsy, and a severely impaired cognition (BIMS score of 2/15) reported to surveyors that they had anticipated a follow-up brain surgery appointment scheduled for 12/29/25 due to persistent deep head pain radiating from the base of the neck to the area of a right hemi craniotomy. The resident stated that no one from the facility came to get them dressed and ready for the appointment and confirmed they did not refuse to go. The resident was dependent for upper and lower body dressing and did not exhibit behaviors such as rejection of care per the most recent MDS. Staff interviews and record reviews showed that the facility did not document or process the missed appointment as a grievance, despite the resident and the resident representative voicing concerns. The Social Services Director, who served as the grievance officer, provided grievance logs for several months that contained no entries for this resident, and no grievance report was initiated. The CNA recalled that the resident had a missed appointment and that she was not informed to get the resident ready; she also stated that the resident’s name was not on the appointment list on the white board. The CNA further reported that the resident representative came into the facility visibly upset about the missed appointment and that both the ADON and DON were aware of this. The ADON stated she recalled the missed appointment and that the resident representative arrived visibly upset and yelling in the hallway, but she believed the resident had refused the appointment and acknowledged that she did not speak with the resident or family about the incident and did not think a grievance was made. Review of the progress notes with the ADON confirmed there was no documentation that the resident refused the appointment, no follow-up appointment was made, and the physician was not notified of the missed appointment. The DON confirmed she only learned of the missed appointment when the resident representative arrived angry and that she did not initiate a grievance. An investigation file contained only a single signed statement from an LPN indicating the resident refused to go after transport arrived, and a trip order showed the transport was cancelled by the same LPN with the reason documented as “appointment cancelled.” The facility’s written grievance policy stated that residents and their representatives have the right to file grievances orally or in writing and that the administrator and staff would make prompt efforts to resolve grievances and inform the complainant verbally and in writing of the findings and corrective actions, but no grievance was initiated or resolved for this resident’s complaint.
Failure to Provide SNF ABN for Resident with Changed Coverage Status
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for one resident who had a change in insurance coverage status and remained in the facility. The resident was observed in bed, awake, alert, and conversant, and stated that rehabilitative services had stopped in the past without explanation. A review of the facility’s Beneficiary Protection Notification Review (BPNR) forms showed that the last covered day for Medicare Part A services was 11/9/25, and the form stated that the SNF ABN was not applicable. During interview, the Social Services Director stated the resident should have received the SNF ABN because benefit days remained and the resident chose to stay in the facility. The Social Services Director also stated the notification was important for continuity of care and for involving the resident and family in the choice to continue receiving care. When asked for the SNF ABN policy, the Licensed Nursing Home Administrator was informed of the concern, and the facility provided a policy titled Notice Advance Beneficiary Notifications (ABN), which stated that an ABN is issued to transfer potential financial liability to the Medicare beneficiary in certain instances and should be provided before delivery of the item or service with enough time for an informed decision.
Delayed Admission MDS Completion
Penalty
Summary
The facility failed to complete the admission MDS within the required time frame for Resident #74, who was admitted to the facility on [DATE]. A review of the EHR on 1/05/26 showed the comprehensive admission MDS was still in progress. During an interview on 1/07/2026, the MDS coordinator stated she worked remotely, was rarely in the facility, and knew she was behind on assessments. She explained that she was hired part time for this facility while also working full time at another facility, which made it difficult to keep up with the work. She further stated that she prioritized Medicare assessments, which she described as revenue generating, so they were completed first and this resident's admission MDS did not get done. The CMS RAI User's Manual states the comprehensive admission assessment must be completed no later than admission date plus 13 calendar days, and the report identified the required completion date as 12/21/25 for Resident #74.
Inaccurate Completion of Admission MDS
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, identified in the report as Resident #74. The resident was admitted to the facility and the comprehensive admission MDS was noted to be in progress. During an interview, the MDS coordinator stated she worked remotely, was rarely in the facility, and was behind on her work. She said she was hired part time for this facility while also working full time at another facility, which made it difficult to keep up with the assessments. The MDS coordinator further stated that she prioritized Medicare assessments because they were revenue generating, and said that was why this resident's assessment did not get done first. Review of the record showed section F was completed by the Activities Director, section K by the dietician, and multiple other sections were completed by the MDS coordinator. The report also noted that the MDS coordinator signed section Z0500 certifying completion, while the validation report showed the admission MDS was transmitted and accepted later. The report cited CMS RAI User's Manual guidance that all staff who complete parts of the MDS must sign and date their sections and that the RN assessment coordinator must sign when the assessment is complete.
Failure to Provide Ordered Nebulizer Respiratory Care
Penalty
Summary
Respiratory care services were not provided per physician orders for a resident admitted with multiple rib fractures, acute respiratory failure with hypoxia, pleural effusion, and pneumonia. The resident had intact cognition and a BIMS score of 13 out of 15. Physician orders included nebulizer treatments every 6 hours, acetylcysteine inhalation solution every 6 hours, and PRN albuterol and ipratropium-albuterol via nebulizer for wheezing. Survey observations showed the resident receiving oxygen at 4 liters via nasal cannula while in bed, and the resident asked for the head of the bed to be adjusted. The record showed that a nebulizer treatment was not administered because a nebulizer machine was unavailable, and staff documented that the physician was informed with no new orders received. During interviews, unit staff stated nebulizer machines were stored in supply areas, but none were found in the unit supply room or on the 3rd floor central supply area. Central supply staff stated the facility had 5 nebulizer machines, all assigned to other residents, and that additional nebulizers were ordered after the concern was identified. The MAR also showed acetylcysteine doses not administered on multiple occasions, while the charge nurse stated there was no nebulizer machine available even though some MAR entries had been initialed as given.
Failure to Address Resident PTSD and Panic Episode
Penalty
Summary
The facility failed to ensure a resident with a history of PTSD received appropriate treatments and services. The resident was admitted with diagnoses including quadriplegia, complete C1-C4 spinal cord injury, depression, type 1 diabetes mellitus, hypothyroidism, GERD, and anemia. Although the hospital record documented a history of PTSD, alcohol use disorder, opioid use, neurosis, and generalized anxiety disorder, the facility admission record did not include PTSD, and the most recent MDS left active diagnoses blank in Section I. The resident’s comprehensive care plan did not include a focus area, interventions, or goals related to PTSD. The initial psychiatric evaluation documented depression and supportive non-pharmacologic interventions, but did not include PTSD, and there were no psychotherapy consults in the record. Social Services documentation also did not reflect PTSD, and the Social Work Director stated she was not aware of the diagnosis until later, acknowledged that PTSD should have been listed in the diagnosis list, included in the Social Service Initial Assessment, and addressed in an individualized plan of care. On 12/21/25, the resident became increasingly anxious when breakfast was not provided timely, reported having a panic attack, and called 911 because they were diabetic and had received insulin. The physician history and physical noted the resident was seen in bed talking to 911 and reporting not being fed breakfast. The DON stated the incident should have been documented and investigated, but she was not aware the resident had called 911 and no investigation was initiated or completed. A grievance later documented that the resident became increasingly anxious when breakfast had not been received and called 911 after having a panic attack.
Medication Administration and Treatment Handling Errors
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and acceptable standards of practice. During medication administration observation, an LPN prepared Fluticasone for a resident with an order for two sprays in each nostril one time daily for nasal congestion and allergy, but administered only one spray into each nostril. After the dose was given, the LPN signed the eMAR and acknowledged that the ordered dose should have been two sprays into each nostril. The facility also failed to properly manage a resident's ordered lidocaine patches. Two 4% lidocaine patch packages were observed cut open and left on the bedside table in the resident's room. The resident stated the patches had been applied to the shoulder about two days earlier and that they had not wanted them applied at that time. The resident was awake, seated, and conversant at the time of observation, and the record showed a BIMS score of 15 out of 15, indicating cognitive intactness. Record review showed the resident had diagnoses including quadriplegia, depression, type 1 diabetes mellitus, hypothyroidism, GERD, and anemia, and hospital records also noted a history of PTSD, alcohol use disorder, opioid use, neurosis, and generalized anxiety disorder. The MAR for January 2026 showed the order for lidocaine external gel 4% to apply two patches to bilateral shoulders was not signed on one scheduled date, and the ADON stated that if the resident refused the patches, the refusal should have been documented on the TAR. The UM confirmed the patches were left open on the bedside table, and the ADON stated the patches should not have been left there.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by a surveyor. During an inspection of the kitchen, the surveyor, along with the Food Service Assistant Director (FSAD), noted several deficiencies. The meat slicer was found uncovered with pink food scraps on it, indicating it had not been cleaned after use. In the walk-in refrigerator, an open package of hard-boiled eggs was wrapped in plastic wrap without an open or use-by date label. Similarly, an unidentified frozen food item in the freezer was wrapped in plastic wrap without a label or date. Additionally, a dented can of baked beans was found in the dry storage area. The FSAD acknowledged these issues, stating that the items should have been labeled and the dented can should not have been on the rack. The facility's policy on labeling and dating emphasizes the importance of proper labeling to ensure food safety and minimize waste, which was not adhered to in these instances.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (QMDS) assessments in a timely manner for two residents, resulting in a deficiency. Resident #43, who was admitted with diagnoses including congestive heart failure and muscle weakness, had their QMDS assessment completed three days late. The Assessment Reference Date (ARD) for this resident was 5/26/2024, but the assessment was not completed until 6/12/2024. Similarly, Resident #4, diagnosed with dementia and anxiety, had their QMDS assessment completed five days late. The ARD for this resident was 5/24/2024, and the assessment was completed on 6/12/2024. During an interview, the MDS Coordinator acknowledged the delay in completing the QMDS assessments for both residents. The facility's policy, revised in March 2022, requires timely and appropriate resident assessments, including quarterly assessments. Additionally, the facility's policy on MDS Completion and Submission Timeframes, revised in October 2023, mandates adherence to federal and state submission timeframes. The deficiency was identified during a survey, and the facility's failure to comply with these requirements was noted.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in addressing their medical and nursing needs. For one resident with a diagnosis of edema, the care plan did not include a focus area for the use of bilateral leg wraps, nor did it address the resident's refusal of the wraps. The Treatment Administration Record showed inconsistencies in the application and removal of the wraps, and there was no documentation of the physician or representative being informed of the refusal. Another resident, who had diagnoses including anxiety, mood disorder, and dementia, experienced two un-witnessed falls. The care plan did not include focus areas, goals, or interventions for these actual falls, despite the resident being identified as high risk for falls. The post-fall evaluations documented the incidents, but the care plan was not updated to reflect these events or to implement measures to prevent future falls. A third resident with an indwelling urinary catheter did not have a care plan focus specifically addressing the catheter, its care, or related interventions. The care plan only mentioned enhanced barrier precautions without detailing catheter care, size, or frequency of changes. Interviews with facility staff confirmed the lack of appropriate care plan documentation for the catheter, and the facility's policies were not followed in developing comprehensive care plans for these residents.
Failure to Educate and Notify Regarding Treatment Refusal
Penalty
Summary
The facility failed to provide necessary education to a resident who was refusing a prescribed treatment and did not notify the resident's physician or family about the refusal. This deficiency was identified for a resident with a history of skin conditions, including cellulitis, localized edema, gout, and local infection of the skin and subcutaneous tissue. The resident, who had moderate cognitive impairment, was observed refusing leg wraps that were prescribed for edema. The Treatment Administration Record indicated that the wraps were not applied or removed on several occasions, and the refusal was documented without evidence of education or notification to the physician or family. The facility's policy required that when a resident refuses treatment, the interdisciplinary team should educate the resident about the risks and benefits, document the refusal, and notify the physician. However, there were no progress notes indicating that the physician or family was informed of the refusal before a specific date, nor was there documentation that the resident was educated about the potential outcomes of refusing the treatment. Interviews with staff confirmed that the process for handling treatment refusals was not followed, leading to the deficiency.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate accountability of a controlled medication, specifically Xanax, for an unsampled resident. During a review of a medication cart, it was found that the Individual Patient Controlled Substance Administration (IPCSA) record indicated 29 Xanax pills should be available, but only 28 were present. The Licensed Practical Nurse (LPN) acknowledged the discrepancy and admitted to counting the narcotics alone, which may have led to the oversight. The Director of Nursing (DON) later confirmed that the extra Xanax was administered to the resident but was not properly documented on the IPCSA. Additionally, the facility improperly acquired a controlled drug by borrowing Xanax for another unsampled resident. The IPCSA record showed that Xanax was borrowed for a resident, and the Medication Administration Record (MAR) confirmed its administration. Both the Unit Manager/Charge Nurse and a Registered Nurse stated that borrowing medication is not permitted. The facility's policy on controlled substances requires individual records for each resident receiving such medications, which was not adhered to in this instance.
Failure to Document Influenza Vaccine Assessment and Administration
Penalty
Summary
The facility failed to ensure proper documentation in a resident's medical record regarding the benefits and risks of immunization, as well as the administration or refusal of the influenza vaccine. This deficiency was identified for one resident who was admitted with diagnoses including Diabetes Mellitus and Hypertension. The resident's admission Minimum Data Set (MDS) indicated that the influenza vaccine was not received, and the reason for not administering the vaccine was not assessed. The resident was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 14/15. During interviews with the surveyor, the Director of Nursing (DON) acknowledged that the influenza vaccine should have been assessed upon the resident's admission. The facility was unable to produce a consent or refusal form for the influenza vaccine. The facility's policy stated that the influenza vaccine should be offered to residents between October 1st and March 31st each year, unless medically contraindicated or if the resident had already been immunized. Additionally, the policy required that all new residents be assessed for current vaccination status upon admission.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 909 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Atco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berlin Rehabilitation And Healthcare Center | 1.2 mi | ★★★★★ | 1 | 1 |
| The Subacute At Autumn Lake Healthcare | 6.4 mi | ★★★★★ | 19 | 3 |
| Autumn Lake Healthcare At Voorhees | 6.6 mi | ★★★★★ | 3 | 1 |
| Lions Gate | 6.7 mi | ★★★★★ | 0 | 0 |
| Echelon Care & Rehab | 6.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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