Inspection Reports for
Fountain Springs At Cape May Nursing & Rehab Cente
502 Route 9 North, Cape May Court House, NJ, 08210
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
89% occupied
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, including how personal health information is used, disclosed, and protected.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, legal duties of the department, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Annual Inspection
Census: 103
Capacity: 116
Deficiencies: 7
Date: Nov 26, 2024
Visit Reason
The inspection was a standard annual survey conducted to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities. The facility was evaluated for compliance with federal regulations including resident assessments, care plans, infection control, emergency preparedness, and life safety code requirements.
Findings
The facility was found not in substantial compliance with several deficiencies cited related to quarterly resident assessments, comprehensive care plans, infection control, emergency preparedness, food safety, and life safety code violations. Deficiencies affected multiple residents and areas of the facility, with corrective actions and completion dates provided.
Deficiencies (7)
Failed to complete Quarterly Minimum Data Set (MDS) assessments timely for 46 of 49 residents reviewed.
Failed to develop and implement comprehensive person-centered care plan for Resident #1.
Failed to implement infection control measures for handling and storage of equipment for Resident #7.
Failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness.
Failed to ensure fire system sprinkler heads were maintained and ceiling smoke barriers intact.
Failed to ensure smoke barrier doors resisted passage of smoke and had positive latching hardware.
Failed to ensure electrical equipment was tested and maintained per NFPA 99 standards.
Report Facts
Census: 103
Total Capacity: 116
Sample Size: 26
Number of residents with late MDS submissions: 46
Number of residents affected by fire safety deficiencies: 103
Inspection Report
Abbreviated Survey
Census: 97
Deficiencies: 0
Date: Aug 25, 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 and preparedness for COVID-19.
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 to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 7
Date: Apr 27, 2023
Visit Reason
A complaint survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, based on complaint numbers NJ00161342 and NJ00158976.
Complaint Details
Complaint numbers NJ00161342 and NJ00158976 triggered this complaint investigation. The facility was found to be in compliance with 42 CFR Part 483, Subpart B, based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey. However, deficiencies were cited related to comprehensive care plans, respiratory/tracheostomy care and suctioning, and labeling and storage of drugs and biologics.
Deficiencies (7)
The facility failed to develop a person-centered comprehensive care plan to address the resident's medical, physical, mental, and psychosocial needs, specifically for resident #27 regarding pain care.
The facility failed to maintain the necessary respiratory care and services according to standards of practice for residents #28, #42, and #74.
The facility failed to properly label and store medications and maintain clean and sanitary medication storage areas, observed in medication carts on 2 nursing units.
The facility failed to ensure smoke detection sensitivity was checked every alternate year for smoke detectors, potentially affecting all 98 residents.
The facility failed to ensure that fire doors were inspected annually by an individual who could demonstrate knowledge and understanding of the operating components, potentially affecting all 98 residents.
The facility failed to ensure that an electrical wiring splice was made in a junction box in accordance with NFPA 70, potentially affecting 44 residents.
The facility failed to notify CMS and receive authorization for a change in the facility's name in accordance with 42 CFR 424.516.
Report Facts
Sample size: 20
Sample size: 23
Residents affected: 98
Residents affected: 44
Residents affected: 98
Medication cart pills: 78
Census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided surveyor with in-service attendance sign in sheet for care plan education and re-educated nursing staff on pain assessment and infection control |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed regarding resident's pain and medication cart cleaning |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Interviewed regarding resident pain care plans and medication cart cleaning |
| Unit Manager/Licensed Practical Nurse | Unit Manager/Licensed Practical Nurse (UM/LPN) | Interviewed regarding resident pain care plans |
| Maintenance Director | Maintenance Director | Reviewed fire alarm system, smoke detector testing, fire door inspections, and electrical wiring splice deficiencies |
| Administrator | Administrator | Reviewed and was in serviced on licensure and medication storage deficiencies; responsible for implementing plan of correction |
Inspection Report
Life Safety
Census: 98
Capacity: 120
Deficiencies: 3
Date: Apr 18, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions on behalf of the New Jersey Department of Health on 04/18/23 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including failure to conduct smoke detection sensitivity testing every alternate year, improper electrical wiring splice not enclosed in a junction box, and failure to inspect fire doors annually. These deficiencies had the potential to affect all residents.
Deficiencies (3)
Failure to ensure smoke detection sensitivity was checked every alternate year of the facility smoke detectors in accordance with NFPA 72.
Failure to ensure that an electrical wiring splice was made in a junction box in accordance with NFPA 70.
Failure to ensure fire doors were inspected annually by an individual demonstrating knowledge and understanding of operating components in accordance with NFPA 101.
Report Facts
Residents present: 98
Total licensed capacity: 120
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed deficiencies related to smoke detector testing, electrical wiring splice, and fire door inspections | |
| Administrator | Reviewed and was in serviced on regulations related to fire alarm system, gas and electric, and maintenance inspection/testing of doors |
Inspection Report
Abbreviated Survey
Census: 97
Capacity: 99
Deficiencies: 1
Date: Jul 6, 2022
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 related to CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with infection control regulations related to COVID-19. However, a separate deficiency was noted regarding failure to maintain required minimum direct care staff-to-resident ratios for day and overnight shifts as mandated by New Jersey law.
Deficiencies (1)
Facility failed to maintain the required minimum direct care staff-to-resident ratios for the day shift and overnight shift as mandated by the State of New Jersey.
Report Facts
Census: 97
Total Capacity: 99
Days with insufficient CNA staffing: 7
Nights with insufficient total staff: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resource/Scheduler | Interviewed regarding staffing ratio mandate and daily census dependency | |
| Administrator | Reviewed staffing issues and plan of correction | |
| Director of Nursing | Director of Nursing | Reviewed staffing issues, conducted weekly meetings, and monthly audits of staffing patterns |
| Staffing Coordinator | Reviewed staffing issues and plan of correction |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 13
Date: Feb 18, 2022
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 deficient in multiple areas including failure to complete timely Minimum Data Set (MDS) assessments, failure to implement individualized care plans, inadequate supervision and safety measures, failure to maintain required staffing ratios, deficiencies in medication management, fire safety code violations, and food safety issues.
Deficiencies (13)
Failed to complete annual and quarterly Minimum Data Set (MDS) assessments timely for multiple residents.
Failed to implement interventions in accordance with residents' individualized person-centered care plans for pain management and tobacco use.
Failed to accurately assess and implement smoking policy for a resident who smoked cigarettes.
Failed to maintain resident environment free of accident hazards and ensure adequate supervision and assistance devices to prevent accidents related to urinary catheter care.
Failed to follow physician's order for respiratory care administration.
Failed to follow physician's order and facility policy for dialysis care and documentation.
Failed to ensure timely physician visits and progress notes at least every 30 days for long-term care residents.
Failed to ensure accurate narcotic shift count logs and proper completion of DEA 222 forms for controlled substances.
Failed to label and date opened insulin pens and dispose of controlled medications for deceased resident properly.
Failed to maintain kitchen equipment to prevent microbial growth and failed to label and date potentially hazardous food to prevent foodborne illness.
Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions.
Failed to provide audible and visible fire alarm notification signals in three outside enclosed courtyards.
Failed to ensure corridor doors resist passage of smoke and fully close into their frames.
Report Facts
Census: 107
Staffing ratios: 24
Narcotic shift log errors: 24
DEA 222 forms with missing data: 3
Insulin pens unlabeled or undated: 3
Fire rated door gap: 2.25
Room size: 100.879
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and narcotic shift logs |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding MDS assessments, medication administration, smoking policy, and narcotic shift logs |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding MDS assessments, medication administration, smoking policy, narcotic shift logs, physician visits, dialysis care, and fire safety |
| Licensed Nursing Home Administrator | Administrator | Interviewed regarding staffing, smoking assessments, and fire safety |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessments and facility compliance |
| Social Worker | Social Worker | Interviewed regarding smoking assessments |
| Director of Maintenance | Director of Maintenance (DOM) | Interviewed regarding fire safety door deficiencies and fire alarm system |
| Dietary Director | Dietary Director (DD) | Interviewed regarding kitchen and food safety deficiencies |
| Physician #1 | Physician / Medical Director | Interviewed regarding physician visits and documentation |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Dec 12, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ150306 and NJ149758. Additionally, a COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations.
Complaint Details
Complaint #: NJ150306 and NJ149758. The facility was found to be in compliance based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities and with 42 CFR §483.80 infection control regulations. The facility has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 13
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Date: Nov 10, 2021
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The survey was complaint-related and the facility was found to be in compliance with the requirements.
Findings
The facility was found to be in compliance with the regulatory requirements on this complaint survey.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 101
Deficiencies: 0
Date: Aug 24, 2021
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 related to COVID-19.
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.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Date: Feb 5, 2021
Visit Reason
The inspection was conducted based on Complaint #NJ142676 to investigate concerns regarding the facility's failure to maintain a safe, clean, comfortable, and homelike environment.
Complaint Details
Complaint #NJ142676 was substantiated based on observations, interviews, and review of facility documentation indicating failure to maintain a clean and safe environment.
Findings
The facility failed to maintain the residents' environment in good repair and in a clean and sanitary condition, including issues such as holes in window screens, leaking sprinkler pipes, stained ceiling tiles, feces on shower chairs, chipped bathroom door frames, and black dirt buildup. The facility conducted immediate repairs and cleaning and provided in-service training to staff to address these deficiencies.
Deficiencies (1)
Failure to maintain a safe, clean, comfortable, and homelike environment including holes in window screens, leaking sprinkler pipes, stained ceiling tiles, feces on shower chairs, chipped bathroom door frames, and black dirt buildup.
Report Facts
Census: 105
Sample size: 4
Date of correction completion: Mar 9, 2021
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a Complaint survey were conducted by the New Jersey Department of Health.
Complaint Details
Complaint #NJ00142485 was investigated during the survey.
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.
Report Facts
Sample size: 5
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