Inspection Reports for Allegria at The Fountains
114 Hayes Mill Rd, Atco, NJ 08004, United States, NJ, 08004
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 60
Deficiencies: 17
Jun 28, 2024
Visit Reason
Complaint investigation triggered by complaint numbers NJ 160674, 165435, 165750, 174925 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with requirements based on complaint visit. Deficiencies were cited including failure to complete timely quarterly assessments, failure to develop and implement comprehensive care plans, failure to provide education and notification regarding resident treatment refusals, failure to maintain accurate medication records, food safety violations, incomplete immunization documentation, and multiple life safety code violations including staffing shortages, fire safety, emergency lighting, and electrical system maintenance.
Complaint Details
Complaint investigation based on complaint numbers NJ 160674, 165435, 165750, 174925. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 7
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to complete Quarterly Minimum Data Set assessments timely for residents #43 and #4. | SS=D |
| Failure to develop and implement comprehensive person-centered care plans with measurable objectives and timelines for residents #47, #19, and #207. | SS=D |
| Failure to provide education to resident #47 who refused treatment and failure to notify physician and family. | SS=D |
| Failure to maintain accurate medication administration records and controlled substance accountability. | SS=D |
| Failure to maintain food safety including unlabeled food, unclean meat slicer, and dented canned goods. | SS=F |
| Failure to document influenza and pneumococcal immunization education and administration/refusal for resident #45. | SS=D |
| Failure to maintain required minimum direct care staff to resident ratios for day, evening, and night shifts. | — |
| Egress door with delayed egress feature lacked required signage. | SS=D |
| Failure to provide emergency illumination that operates automatically along means of egress. | SS=E |
| Failure to maintain battery back-up emergency lighting over interior emergency generator and fire pump transfer switches. | SS=F |
| Failure to ensure monthly and annual fire alarm system testing and smoke detector sensitivity testing. | SS=F |
| Failure to ensure testing and maintenance of battery-operated smoke detectors in resident rooms. | SS=F |
| Failure to ensure automatic sprinkler system inspected/tested at required intervals and electric fire pump monthly flow test performed. | SS=F |
| Failure to ensure corridor walls resist passage of smoke; missing fire rated glass in corridor window. | SS=D |
| Failure to ensure corridor doors resist passage of smoke; multiple resident room doors warped or damaged. | SS=E |
| Failure to functionally test non-hospital grade electrical receptacles in resident rooms annually for grounding, polarity, and blade tension. | SS=F |
| Failure to certify generator transfer time within 10 seconds and perform monthly load tests. | SS=F |
Report Facts
Residents present: 54
Licensed capacity: 60
Deficiency count: 16
Staffing ratios: 8
Staffing ratios: 10
Staffing ratios: 14
Inspection date: Jun 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to education and oversight of care plan implementation and medication refusal | |
| Maintenance Director | Named in relation to fire safety, emergency lighting, sprinkler system, and monthly audits | |
| Staffing Coordinator | Named in relation to staffing ratio compliance | |
| Administrator | Named in relation to immunization documentation and fire safety education | |
| Registered Nurse #1 | Named in relation to care plan review and medication administration |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 3
Dec 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ161922 and NJ169428 regarding medication delivery and staffing issues.
Findings
The facility failed to follow proper procedures for receiving medications from an outside pharmacy, resulting in a resident receiving an opened bottle of medication and requiring emergency care. Additionally, the facility failed to provide complete access to electronic medical records for surveyors and did not meet required staffing ratios on several day shifts.
Complaint Details
Complaint numbers NJ161922 and NJ169428 triggered the investigation. The complaint involved medication delivery errors and staffing shortages. The medication delivery complaint was substantiated, with evidence of a resident receiving an opened bottle of medication leading to emergency room transfer. Staffing shortages were documented for multiple day shifts.
Severity Breakdown
SS=J: 1
SS=B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure proper process for receiving medications from an outside pharmacy, resulting in a resident receiving an opened bottle of medication. | SS=J |
| Failure to provide complete and readily accessible electronic medical records for all residents. | SS=B |
| Failure to meet mandatory staffing ratios for Certified Nurse Aides on 6 of 14 day shifts reviewed. | — |
Report Facts
Census: 49
Medication quantity: 30
Staffing deficiency counts: 6
Residents on deficient shifts: 51
Residents on deficient shifts: 54
Residents on deficient shifts: 52
Inspection Report
Routine
Census: 54
Deficiencies: 0
Aug 15, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 1
Sep 15, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing requirements.
Findings
The facility was found not in compliance with mandatory direct care staff-to-resident ratios as required by New Jersey state law, with documented deficiencies in certified nurse aide staffing on multiple day shifts.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
Report Facts
Residents present: 52
Residents present: 48
Residents present: 53
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 4
May 18, 2022
Visit Reason
The inspection was conducted based on multiple complaints (NJ149005, NJ149006, NJ149159, NJ149310) alleging deficiencies in care and staffing at the facility.
Findings
The facility was found not in substantial compliance with federal and state regulations. Deficiencies included failure to keep call bells within reach for dependent residents, failure to develop and implement comprehensive care plans, and failure to administer medications according to physician orders with proper documentation. Additionally, the facility failed to maintain required minimum staffing ratios for Certified Nurse Aides (CNAs) over multiple shifts.
Complaint Details
The visit was complaint-related based on complaints NJ149005, NJ149006, NJ149159, and NJ149310. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on these complaints.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to keep call system within reach for a resident dependent on staff for transfers and able to use call bell. | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan for a resident, including measurable objectives and timeframes. | SS=D |
| Failed to administer medications according to physician's orders, maintain accurate medication administration documentation, and adhere to nursing practice standards. | SS=D |
| Failed to maintain required minimum staffing ratios for Certified Nurse Aides (CNAs) on 28 of 28 day shifts. | — |
Report Facts
Census: 50
Deficiency count: 4
Staffing deficiency days: 28
Required CNAs: 7
Actual CNAs: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charge Nurse | Provided statements regarding call bell placement and medication administration | |
| Director of Nursing | Provided statements regarding call bell expectations, care plan updates, and medication administration deficiencies | |
| Licensed Practical Nurse (LPN) | Allegedly combined medication doses and administered incorrectly; no longer employed at facility |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Jan 12, 2022
Visit Reason
The inspection was conducted based on complaint NJ150666 to investigate staffing ratio compliance at the facility.
Findings
The facility was found deficient in maintaining the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 11 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint NJ150666 was investigated and the facility was found non-compliant with staffing ratio requirements, specifically failing to meet CNA staffing ratios on 11 of 14 day shifts reviewed.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 11 of 14 day shifts for CNAs. |
Report Facts
Residents present: 47
Day shifts with deficient CNA staffing: 11
CNA staffing on 12/26/21: 5
CNA staffing on 12/27/21: 3
CNA staffing on 12/28/21: 5
CNA staffing on 12/29/21: 6
CNA staffing on 12/30/21: 6
CNA staffing on 01/02/22: 5
CNA staffing on 01/03/22: 4
CNA staffing on 01/04/22: 4
CNA staffing on 01/05/22: 6
CNA staffing on 01/06/22: 5
CNA staffing on 01/07/22: 3
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Sep 28, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ148292, NJ147724, NJ147726, and NJ146614) to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to ensure adequate supervision and adherence to the care plan for resident transfers, resulting in a resident being transferred alone despite requiring two-person assistance, which caused injury. The facility re-educated staff and implemented audits to prevent recurrence.
Complaint Details
The complaint investigation found that a resident was transferred alone by a CNA despite the care plan requiring two-person assistance, resulting in the resident sustaining an injury. The CNA was unaware of the injury at the time. The facility conducted interviews, reviewed medical and incident reports, and confirmed the deficiency. The CNA and other staff were re-educated on safe transfer practices.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident received adequate supervision to prevent accidents, specifically failure to ensure a two-person transfer for a resident who sustained an injury during transfer. | SS=D |
Report Facts
Census: 52
Sample Size: 8
Residents potentially affected: 16
Audit sample: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Transferred resident alone despite care plan requiring two-person assistance; acknowledged the error during interview |
| Director of Nurses | DON | Provided statements regarding facility safety priorities and staff education on transfer protocols |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Jun 16, 2021
Visit Reason
The inspection was conducted based on complaint intakes NJ144279 and NJ143061 to investigate staffing ratio compliance and related regulatory requirements at the facility.
Findings
The facility failed to meet required staffing ratios for all 63 shifts reviewed, did not post required direct resident care staffing information prior to shifts, and failed to report staff-to-resident ratios monthly to the New Jersey Department of Health web-based portal. These deficiencies potentially affected all residents.
Complaint Details
Complaint intakes NJ144279 and NJ143061 triggered the investigation. The complaints involved staffing ratio deficiencies and failure to post and report staffing information. The facility was found non-compliant with these requirements.
Deficiencies (3)
| Description |
|---|
| Failure to ensure staffing ratios were met for 63 of 63 shifts reviewed, resulting in inability to meet residents' needs timely. |
| Failure to complete and post direct resident care staffing information prior to the start of shifts as required. |
| Failure to report staff-to-resident ratios monthly to the NJDOH web-based portal. |
Report Facts
Number of shifts with unmet staffing ratios: 63
Facility licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #4 | Interviewed and reported staffing shortages and inability to meet resident needs timely. | |
| Administrator | Interviewed; acknowledged failure to calculate and report staffing ratios and lack of awareness of posting requirements. | |
| Unit Clerk/Scheduler | Interviewed; responsible for scheduling and staffing report completion, but lacked training initially. |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 2
May 3, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to have been in Immediate Jeopardy for infection control deficiencies related to COVID-19 PPE use, signage, and disposal. The Immediate Jeopardy was removed after the facility implemented a removal plan. Additional deficiencies included failure to ensure pharmacist recommendations were properly documented and acted upon, and failure to maintain an effective infection prevention and control program consistent with CDC and NJ DOH guidelines.
Severity Breakdown
SS=D: 1
SS=K: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure rationale was provided in response to Consultant Pharmacist recommendations during monthly medication review. | SS=D |
| Failure to implement appropriate infection control practices related to hand hygiene and use of PPE, post appropriate transmission-based precaution signage, and provide appropriate PPE storage and disposal bins to prevent COVID-19 transmission. | SS=K |
Report Facts
Census: 43
Sample Size: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Described process for handling Consultant Pharmacist recommendations |
| Director of Nursing | Director of Nursing | Interviewed regarding medication review process and infection control practices |
| Infection Preventionist | Infection Preventionist | Interviewed regarding PPE requirements and infection control program |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding COVID-19 testing and quarantine policies |
| Admissions Nurse Liaison | Admissions Nurse Liaison | Interviewed regarding COVID-19 testing and exposure assessment for admissions |
Inspection Report
Life Safety
Deficiencies: 4
May 3, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with Life Safety Code 101:2012 and other regulatory requirements related to fire safety, emergency preparedness, and facility maintenance.
Findings
The facility was found not in substantial compliance with the Life Safety Code 101:2012 due to deficiencies including improper locking arrangements on egress doors, inadequate fire sprinkler coverage in certain areas, failure to document monthly visual inspections of fire extinguishers, and failure to maintain clean filters in Packaged Terminal Air Conditioner (PTAC) units.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide exit access that was readily accessible due to locking arrangements on 1 of 4 exit discharge doors, which only staff could open using a coded keypad and push button lockset, not compliant with Life Safety Code. | SS=D |
| Facility failed to provide proper fire sprinkler coverage in housekeeping closet and residents' shower room; sprinkler head placement did not meet NFPA 13 requirements. | SS=D |
| Facility failed to perform and document monthly visual inspections on 4 of 11 fire extinguishers as required by NFPA 10. | SS=D |
| Facility failed to maintain PTAC units in safe and optimal condition; clogged and dirty filters were observed in sampled resident rooms, and cleaning logs were missing. | SS=D |
Report Facts
Number of exit discharge doors with locking issues: 1
Number of fire extinguishers lacking documented monthly inspection: 4
Number of residential sleeping rooms on unit: 32
Distance from sprinkler deflector to ceiling in housekeeping closet: 13
Shower stall dimensions lacking sprinkler coverage: 3 feet wide by 3 feet 4-inch deep shower stall without sprinkler coverage
Number of PTAC units inspected for filter condition: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present during observations and involved in corrective actions | |
| Licensed Nursing Home Administrator | Present during survey entrance and notified of deficiencies |
Inspection Report
Routine
Census: 23
Deficiencies: 0
Nov 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
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