Fountain Springs At Cape May Nursing & Rehab Cente

Based on interview, record review, and other pertinent facility documents, it was determined that the facility failed to ensure that residents received appropriate pain management and that pain medication was administered in accordance with the physician's orders for pain level parameters. This deficient practice was identified for 1 of 5 residents (Resident #2) reviewed for unnecessary medications and was evidenced by the following:On 4/10/2026 at 8:53 AM, the surveyor observed Resident #2 lying on the bed watching television. Resident #2 was pleasant and cooperative and alerted the surveyor that they were hard of hearing. No resident behaviors, or distress were observed.On 4/10/2026 at 9:52 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #2.A review of the admission Record revealed that Resident #2 was admitted with the following but not limited to diagnoses: Chronic pain syndrome, atherosclerotic heart disease, morbid obesity, neuralgia (intense, stabbing, or burning pain caused by damaged , irritated, or compressed nerves) and neuritis (the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 4/14/2026 at 10:03 AM the surveyor, accompanied by the Director of Dietary (DOD), observed the following in the kitchen:A standup mixer was observed to be bagged and not in use on a metal countertop, The DOD confirmed to the surveyor that the mixer was cleaned and sanitized and was bagged when not in use. The surveyor and DOD removed the plastic bag to observe the mixer. Upon removal of the bag the surveyor observed a yellowish, oily/greasy substance on the upper attachment area. The surveyor used their finger to swipe the area, and a greasy, unidentified substance was observed on the surveyor's finger. In addition, there was unidentified, dried debris on the base arm of the mixer. When interviewed, the DOD agreed that the mixer needed cleaning and immediately cleaned the affected areas in the surveyor's presence.A review of the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain the resident's environment in a safe, sanitary, and homelike manner by ensuring that damaged flooring was repaired in a timely manner. This deficient practice was identified on 1 of 2 units (West Unit) and 1 of 1 dining rooms and was evidenced by the following: 1.) On 4/13/2026 at 10:42 AM, while conducting an observation in the dining room, the surveyor observed a loose floor tile near the main doors. On 4/13/2026 at 10:48 AM, the surveyor and the Director of Maintenance (DM) returned to the dining room. He confirmed the surveyor's findings. At that time, the surveyor interviewed the DM who stated, it should not be popped up like that. I will address it right away because it is a tripping hazard. He added that normally they checked the floors once per week and they have a maintenance log on each unit for staff to report any issues. He added that most times they just told him verbally if there were any concerns. On 4/13/2026 at 10:54 AM, near the [NAME] -B hall,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to: a.) accurately identify when a medication administered via a patch was applied and removed, b.) ensure an incomplete physician's order was clarified c.) accurately transcribe and implement a diet order in accordance with the Dietician's recommendations. This deficient practice was identified for 1 of 1 resident, (Resident #86) reviewed for Pain and for 1 of 1 resident (Resident #87), reviewed for meal tray accuracy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/20/24 at 09:21 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage room on a middle shelf a previously opened bag of macaroni pasta was wrapped in plastic wrap. The pasta had no open or use by date. 2. On a middle rack of the spice shelf a stack of four (4) plastic Cambro containers were stacked on top of each other. The surveyor removed the top Cambro container and observed a clear watery substance on the bottom of the container below and a clear watery substance on the interior of the Cambro container that was on the top. In addition, a second stack of two (2) Cambro containers was also observed to be wet with a clear liquid substance, a practice known as wet nesting (the practice of stacking wet dishes, pots, or pans together, which prevents them from drying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review and review of other facility documentation and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete the Quarterly Minimum Data Set (MDS) assessments, a resident assessment tool used to facilitate the management of care, in a timely manner for 46 of 49 residents reviewed for system selected MDS over 120 days for late submissions., (Residents #49, #24, #29, #55, #32, #33, #48, #13, #8, #51, #11, #22, #27, #3, #50, #72, #18, #19, #9, #54, #57, #64, #70, #58, #37, #36, #45, #337, #187, 336, #21, #5, #4, #20, #69, #34, #16, #28, #66, #15, #25, #30, #17, #38, #42, #67). This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to develop and implement a comprehensive person-centered care plan specifically for a resident who required a Foley Catheter and a Peripherally Inserted Central Catheter (PICC) used to deliver the antibiotic. This deficient practice was identified for 1 of 26 sampled residents, (Resident #1) and was evidenced by the following: On 11/20/2024 at 10:43 AM, during the initial tour, Resident #1 was observed as having a left upper arm Peripherally Inserted Central Catheter (PICC), (used for administration of an Intravenous Medication or fluids). Resident #1 was also noted to have a Foley Catheter ( a thin, flexible tube that drains urine from the bladder into a collection bag outside the body), hanging to the left side of the bed in a privacy bag. A review of the Electronic Medial Record for Resident #1 revealed the following: A review of Resident #1's admission Record revealed that he/she had diagnoses that included but not limited to, infected sacral wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care, (Resident # 7) and was evidenced by the following: During the initial tour on 11/20/2024 at 10:20 AM, Resident #7 was observed sitting in the dayroom with a high back wheelchair. The surveyor observed the oxygen tubing draped on top of the concentrator uncovered and exposed. The concentrator was turned off. Resident #7 also had an e cylinder (portable oxygen tank) secured on the back of the wheelchair with oxygen tubing draped over the strap used to secure the cylinder to the wheelchair. Resident #7 said he/she was waiting for his/her ride to the Dr. as he/she had lung cancer and was going for a follow-up. Resident #7 was not currently using oxygen. On 11/20/2024 at 11:04 AM, Resident #7 was observed on the unit self-propelling his/her wheelchair with no oxygen in use. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review it was determined the facility failed to develop a person-centered comprehensive care plan to address the residents medical, physical, mental, and psychosocial needs. This practice was identified in 1 of 23 residents reviewed for care plans (Resident #27) and was evidenced by the following: On 04/17/2023 at 11:38 AM, during the initial tour of the facility, the surveyor observed Resident #27 sitting in the hallway on a rolling seat walker crouched over. The resident told the surveyor he/she has a lot of pain all the time. The resident did not say the location of the pain. Review of the admission Record revealed Resident #27 was admitted to the facility 10/2018. Medical diagnoses included, but not limited to asthma (inflammed airways making it difficult to breathe), depressive disorder, hypertension (high blood pressure), and Hepatitis C (chronic virus of the liver). Review of the Comprehensive Minimum Data Set (MDS), an annual assessment tool dated 02/08/2023, indicated the resident had a Brief Interview of Mental Status of 13,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services according to standards of practice by a.) ensuring a residents oxygen tubing was stored in a manner to prevent the spread of infection b.) follow physicians orders by assessing a residents oxygen saturation every shift and documenting the results and c.) failing to document administration of oxygen. This deficient practice was identified for 3 of 3 residents reviewed for respiratory care (Residents #28, #42, and #74) and was evidenced by the following: a. On 04/17/23 at 12:04 PM, during the initial tour of the facility Resident #74 was sitting in a wheelchair on the side of the bed having lunch. There was a portable oxygen tank with nasal cannula (device worn in the nares to deliver supplemental oxygen) tubing connected to the tank and wrapped around the left handle on the back of the wheelchair. The resident was not wearing the oxygen. The tubing did not have a date and was not in a plastic bag. The surveyor also observed an oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policy, it was determined that the facility failed to properly store medications and maintain clean and sanitary medication storage areas. This deficient practice was observed in 2 of 2 observed medication carts on 2 of 2 nursing units and was evidenced by the following: On 04/20/23 at 12:29 PM, the surveyor in the presence of Licensed Practical Nurse (LPN #1) observed the East wing nursing unit's B medication cart which contained a total of 78 loose medication pills of various colors and sizes in the bottom of the drawers. LPN #1 collected these pills as they were discovered and were counted. At this time, LPN #1 informed the surveyor that medication carts were cleaned weekly and that the nurses assigned to each cart should be checking when starting each shift for cart cleanliness and ensured medication pills were not loose in the drawers. LPN #1 further stated that there should not be loose pills in the cart as they could possibly fall out and be picked up and consumed by residents. She also stated the possible reason for so…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.