Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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.
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 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.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near 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 | — | 0 | 0 |
| 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 |
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