Atlas Rehabilitation and Healthcare at Daughters O

Inspectors wroteComplaint #185733 (397779)Based on interview, review of medical record, and other pertinent documentation, it was determined that the facility failed to ensure, a.) appropriate incontinence care was provided for 2 of 3 residents, (Residents #1 and #2) reviewed for quality of care and b.) meal trays delivered timely to residents in 1 of 1 nursing unit observed (2 [NAME] unit) in accordance with standard of clinical practice facility's practice. 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: [...]

Inspectors wroteComplaint NJ#185733 (397779) Based on interview and record review, it was determined that the facility failed to maintain a complete record for 2 of 4 residents records reviewed (Residents #1 and #2). The deficient practice was evidenced by the following: 1. On 10/30/25 at 9:40 AM, both Surveyor #1 (S #1) and the Registered Nurse (RN) observed Resident #1 in the dining room seated in a wheelchair with other eight residents. The RN informed S #1 that Resident #1 was cognitively impaired, required extensive assistance with adls (activities of daily living), and incontinent of both bladder and bowel elimination. S #1 reviewed the medical records of Resident #1 and revealed: [...]

Inspectors wroteREPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 14 of 38 residents, (Residents #13, #18, #48, #60, #68, #77, #102, #103, #121, #162, #172, #175, #180, and #187), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following: 1. Surveyor#1 (S#1) reviewed the medical records of the following residents and their MDS and revealed: A review of Resident #18's comprehensive MDS (cMDS) with an assessment reference date (ARD) of 7/11/24, was completed on 7/18/24. A review of Resident #77's cMDS with an ARD of 10/31/24, was completed on 11/12/24. A review of Resident #162's cMDS with an ARD of 9/27/24, was completed on 10/9/24. [...]

Inspectors wroteBased on interviews and review of other facility documentation, it was determined that the facility failed to ensure that the physicians must review the residents' total program of care including medications and treatments, and write, sign, and date progress notes at each visit. This deficient practice was identified for 14 of 35 residents, (Residents#10, #13, #16, #18, #50, #60, #68, #102, #103, #121, #131, #149, #175, and #180), reviewed for physician services. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:49 AM, Surveyor #1 (S#1) observed Resident #18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical record of Resident #18 and revealed: [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to a.) treat each resident with respect and dignity in a manner that promotes their quality of life during breakfast and b.) provide privacy during med administration for 1 of 6 residents, (Resident #39), observed during medication pass administration. This deficient practice was evidenced by the following: On 2/10/25 at 8:44 AM, during the medication administration pass observation, the surveyor observed the Licensed Practical Nurse (LPN), prepared medications (meds) for Resident #39, and brought them inside the dining area in the 2 East unit. The surveyor observed that there was a total of five residents inside the dining area eating their breakfast including Resident #39. The LPN also checked Resident #39's blood pressure inside the dining room. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure a licensed staff credentials were verified upon hire. This deficient practice was identified for 1 of 9 newly hired licensed staff reviewed. This deficient practice was evidenced by the following: On [DATE] at 1:30 PM, the surveyor reviewed ten randomly selected new employee files. The review for license verification/renewal for one of the new licensed employees, Social Worker (SW), revealed no license in her employee file. On [DATE] at 12:19 PM, the surveyor requested from the Regional Nurse, the SW's license. The Regional Nurse stated, She works full time as a SW. I think something with pending status on her license, the License Nursing Home Administrator (LNHA) will come in and give more information. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold notices for 1 of 1 resident, (Resident #175), reviewed for hospitalizations. This deficient practice was evidenced by the following: On 2/7/25 at 11:33 AM, the surveyor observed Resident #175's outside door with a posted sign for Enhanced Barrier Precautions (EBP are measures implemented in healthcare settings to prevent the transmission of infections, particularly in situations where standard precautions alone may not be sufficient) and the resident was not inside the room. On that same date and time, the Certified Nursing Aide (CNA) informed the surveyor that the resident was in therapy. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for 1 of 38 residents, (Resident #18), reviewed for Minimum Data Set (MDS). This deficient practice was evidenced by the following: According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2024 showed: An SCSA must be completed within 14 days of determining a significant change from baseline. The resident's condition is not expected to return to baseline within two weeks. Comparison with the most recent comprehensive and quarterly assessments is crucial. Criteria for SCSA include two areas of decline or improvement, or IDT (Interdisciplinary team) recommendation. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 38 residents, (Residents #18 and #190), reviewed for MDS accuracy. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:49 AM, the surveyor observed Resident #18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical records of Resident #18 and revealed: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; [...]

Inspectors wroteComplaint#: NJ175914 Based on observations, interviews, review of medical records, and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical and psychosocial needs. This deficient practice was identified for 4 of 38 residents (Residents #111, #172, #180, and #442), reviewed for a care plan. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:26 AM, the surveyor interviewed Resident #111 who was seated in a wheelchair, and stated that they had just returned from a physical therapy (PT)session. Resident #111 further stated that they had several falls and that they banged up knee and it was still bruised maybe because of diabetes. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure that a.) the monthly Psychoactive Review (behavior monitoring) was done routinely and accurately and b.) identified behaviors were discussed with the interdisciplinary team for 1 of 5 residents, (Resident #175), reviewed for unnecessary medications, according to the standard of clinical practice and facility policy. 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: [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a) the resident's current active care plan (CP) contained the interventions that were implemented after each resident's fall, in order to prevent any additional falls; and b) ensure a fall risk assessment was done quarterly in accordance with their facility policy for 1 of 2 residents reviewed for accidents/falls (Resident #111). The deficient practice was evidenced by the following: On 2/7/25 at 11:26 AM, the surveyor interviewed Resident #111 who was seated in a wheelchair. Resident #111 stated that they had just returned from a physical therapy session. Resident #111 stated that they had several falls and that they banged up knee and it was still bruised maybe because of diabetes. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to monitor enteral tube feeding administration to assure the total volume (TV) administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 resident, (Residents #172), reviewed for enteral tube feeding. This deficient practice was evidenced by the following: On 2/7/25 at 10:45 AM, the surveyor observed Resident #172 lying in bed with the head of the bed elevated and their eyes were closed. The resident had enteral feeding equipment and supplies at the bedside. On 2/11/25 at 9:05 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #172. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to, a.) maintain the necessary respiratory care and services of residents and b.) develop an individualized care plan in accordance with professional standards of practice for one 1 of 4 residents, (Resident #187), reviewed for respiratory care. This deficient practice was evidenced by the following: On 2/7/25 at 11:00 AM, the surveyor observed the Resident #187 sitting on the bed, nebulizer (neb) machine on top of the bedside table, mask in the drawer and not in the bag. The resident stated they placed the neb in the drawer and did not put it back in the plastic bag. The plastic bag was dated 2/1/25. The resident stated, I had an infection before, not now. I use that for breathing. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to, a.) ensure a resident's medication, blood sugar check, and times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 2 of 3 residents (Residents #77 and #121) and b.) clarify duplicate orders for 1 of 3 residents, (Resident #77), reviewed for dialysis, according to facility's policy and standard of clinical practice. The 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: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 7 days in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: 1. On 2/7/25 at 8:47 AM, upon entry to the facility, Surveyor #1 (S#1) observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main lobby. The NHRCSR posted was dated 2/6/25 for the [7:00 AM to 3:00 PM] day shift. There was no NHRCSR for 2/7/25 posted. On 2/7/25 at 9:20 AM, S#1 interviewed the receptionist by the main lobby, who stated, I am responsible for posting the staffing. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored for 1 of 1 resident, (Resident #48), reviewed for food concerns. This deficient practice was evidenced by the following: On 2/7/25 at 10:41 AM, the surveyor observed Resident #48 lying in their bed with the head of the bed elevated. The resident was alert, and verbally responsive. Resident #48 expressed concerns with their meals. The resident stated that they selected from a menu the food items they wanted and did not get what was requested most of the time. The resident further explained that if they received a food item they did not request, the staff would call the kitchen, and the resident would just get what's available .whatever they have left at the time. [...]

Inspectors wroteCOMPLAINT #: NJ173918 Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 4 of the 38 residents reviewed, (Residents #131, #162, #175, and #493). This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:47 AM, the surveyor observed Resident #162 seated in a wheelchair outside their room with a right leg prosthesis in use. The surveyor reviewed the medical records of Resident #162, and revealed the following: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene, use of personal protective equipment (PPE) practices, and use of disinfecting wipes for 3 of 6 staff (1 Certified Nursing Aide and 2 Nurses) and b.) ensure that the COVID-19 infection precaution was posted and ensure the physician order for transmission based precautions (TBP) was followed for 1 of 1 resident, (Resident #292), and follow appropriate infection control practices, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: [...]

Inspectors wroteComplaint # NJ183033 Based on interviews, medical record reviews, and review of other pertinent facility documents, it was determined that the facility failed to ensure that the physician was consulted and notified immediately of resident's change in condition and follow the facility's policy and protocol with regard to notification of changes. This deficient practice was identified for 1 of 3 residents, (Resident #443), reviewed. This deficient practice was evidence by the following: A review of the admission Record (an admission summary) revealed that Resident #443 was admitted to facility with diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint # 165432 Based on interview, record review, and facility policy review, the facility failed to report an injury of unknown origin to the state survey agency for one (Resident (R) 9) of 12 sampled residents reviewed for abuse. Findings Include: Review of R9's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed R9 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance and mood disturbance, repeated falls, muscle weakness, and age-related osteoporosis. Review of R9's Care Plan, located under the Care Plan tab of the EMR and dated 10/02/22, revealed, R9 is using a psychotropic medication Seroquel to manage target symptoms of fighting and being combative during care. It was recorded R9 had behavioral issues of hitting and pushing on tables. [...]

Inspectors wroteComplaint # NJ 164077 Based on resident and staff interview and medical record review, the facility staff failed to administer physician ordered medications as scheduled for one (Resident (R) 6) of 12 sampled residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to sanitize glucometers between uses for one (Resident (R) 111) of two residents (R152 and R111) observed receiving blood glucose testing out of a total sample of 43 residents. The failure to sanitize glucometers between residents resulted in an Immediate Jeopardy (IJ) at F880-J: Infection Control due to the increased likelihood to cause serious harm due to the potential of cross-contamination of blood-borne pathogens. On 05/04/23 at 7:15 PM, the Administrator and Director of Nursing (DON) were notified of the IJ at F880-K: Infection Control. The Immediate Jeopardy began on 05/03/23 when the survey team identified glucometers were not being sanitized between uses for R111. [...]

Inspectors wrote2. During an observation on 05/01/23 at 1:35 PM, R2 was lying in bed and R2 had facial hair on her upper lip. R2 said she could not talk as she couldn't hear. During an observation on 05/01/23 at 3:45 PM, R2 was observed in bed with facial hair on her upper lip. On 05/02/23 at 11:52 AM, R2 was observed seated in the dining room. R2 was observed to have facial hair on her upper lip. During an observation on 05/02/23 at 1:00 PM, R2 was observed in the dining room with facial hair on her upper lip. 05/03/23 at 9:19 AM, R2 was observed with facial hair on her upper lip. Review of R2's Face Sheet, located in the EMR under the Resident tab, revealed an admission date of 05/24/18 with medical diagnoses that included spondylosis (degenerative changes in spine). [...]

Inspectors wroteBased on interviews, record reviews, and review of the facility's policy, the facility failed to provide timely Minimum Data Set (MDS) data submission in one (Resident (R) 343) of six residents reviewed for MDS transmission out of a total sample of 43 residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a hearing aid was in place in one of 43 sampled residents (Resident (R) 2) in order to maintain her hearing abilities. This deficient practice created a potential for a lack of communication to occur.

Inspectors wroteBased on observation, interview, record review, and review of policy, the facility failed to consistently provide daily range of motion (ROM) services for one (Resident (R) 126) of two residents sampled for limited ROM out of a total sample of 43 residents. This failure had the potential for the resident to lose mobility and independence.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to obtain physician orders and develop a care plan with interventions for one of two residents (Resident (R) 292) reviewed for oxygen therapy from a total sample of 43 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a medication regimen review was completed by a pharmacist at least once a month in one resident (Resident (R) 150) out of five residents reviewed for unnecessary medications out of a total sample of 43 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure psychotropic medication efficacy was monitored for one of five residents (Resident (R) 15) reviewed for unnecessary medications. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication.