The Fountains of Atco

In the surveyor’s words

From the most serious findings on record at The Fountains of Atco, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jun 8, 2026

  Complaint #3041277 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and implement an effective water management plan in accordance with nationally accepted standards to mitigate the growth of Legionella bacteria in the facility's water system, b.) follow the recommended guidance from the New Jersey Department of Health's (NJDOH) Communicable Disease Service (CDS) including biweekly water testing and conducting a root cause analysis to identify and address any hazardous conditions, and c.) implement corrective actions for nine occupied resident rooms that tested positive for Legionella. This deficient practice had the potential to affect all 53 residents. […]

• Immediate jeopardy, patternF880May 3, 2021

  Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to: a.) implement appropriate infection control practices related to hand hygiene and the use of Personal Protective Equipment (PPE); b.) post appropriate transmission-based precaution signage; and, c.) provide the appropriate bins for PPE storage and disposal in a manner to prevent the transmission of COVID-19 in accordance with the Center for Disease Control and Prevention (CDC) and New Jersey Department of Health (NJ DOH) guidelines. This deficient practice was identified for 1 of 3 units (200 Unit) during the Recertification survey conducted 05/03/21. The 200 Unit was the designated unit for Persons Under Investigations (PUI) for COVID-19. […]

• Immediate jeopardy, isolatedF689Dec 6, 2023

  Complaint #: NJ161922, NJ169428 Based on interviews, medical record review, and review of other pertinent facility documentation on 12/5/2023 and 12/6/2023, it was determined that the facility failed to ensure that the process of receiving medications from an outside pharmacy vendor was followed by staff. It was determined on 3/4/2023 that a Security Guard (SG) working at the main lobby of the facility received a mailed package addressed to Resident #2 with his/her name and room number on the unopened package. The SG delivered the unopened package to Resident #2 . Resident #2 is cognitively impaired and SG failed to give this package to nursing staff , so the package could be opened by resident with staff present. […]

• Immediate jeopardy, isolatedF678Jun 16, 2021

  Based on interviews, record review, and facility policy review, it was determined that the facility failed to perform cardiopulmonary resuscitation (CPR) in an effort to prevent death when a resident was found without a pulse or respirations. Resident #2 was a full code, as directed by the resident's POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired. This affected 1 of 14 residents (Resident #2) reviewed for code status. The facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy was related to State Operations Manual, Appendix PP, §483.24(a)(3) (Quality of Life) at a scope and severity of J. […]

• Actual harm, patternF689Jan 9, 2026

  Complaint #: 2704937; 414412 Based on observation, interview, and record review, it was determined that the facility failed to ensure a) adequate supervision was provided to a cognitively impaired resident (Resident #7) identified as being at high risk for falls, impulsive, and required supervision. Resident #7 sustained 13 falls including three falls with injury that required transfer to the emergency room on 8/10/25, for a contusion and laceration to the left supraorbital and frontal scalp; on 10/28/25, for a large intramuscular hematoma to the right thigh, and on 11/14/25, for a closed head injury and laceration to the forehead which required sutures; b) ensure each fall was thoroughly investigated to prevent additional falls; and c.) consistently initiate and implement new fall… […]