Atlas Rehabilitation and Healthcare at Maywood

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices as well as store, and label in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following:On 8/5/25 at 9:29 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the initial kitchen tour:1. Two rectangular pans wet nesting on the racks. The surveyor asked when the pans were washed and the Main [NAME] (MC) responded, They were washed last night. The FSD confirmed the wet nesting on the pans and stated, I'm obviously upset right now and will talk to pot washer.2. In the dry storage room: two cans of stewed tomatoes each dented half an inch on the side; [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to; a.) follow the facility's policy and procedure with regard to overseeing the grievance process, receiving, and tracking grievances through their conclusions; leading any investigations by the facility, b.) issue a written grievance decisions to the resident, and c.) ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete the comprehensive Minimum Data Set (MDS) assessment in accordance with the Resident Assessment Instrument (RAI) manual and facility policy for 6 of 6 (Residents #15, #17, #61, #74, #92, and #105) residents reviewed for comprehensive resident assessments. This deficient practice was evidenced by the following:Reference: Centers For Medicare and Medicaid Services (CMS), RAI manual, Version 3.0, last revised in October 2024 indicated in Chapter 2, pages 2-8 to 2-9 revealed: .admission refers to the date a person enters the facility and is admitted as a resident. A day begins at 12:00 AM (12 AM) and ends at 11:59 PM. Regardless of whether admission occurs at 12 AM or 11:59 PM, this date is considered the 1st day of admission. [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide a copy of the resident and the resident's representative's written notification of the reason for transfer to the hospital to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for 1 of 2 resident's (Resident #130) reviewed for hospitalization. This deficient practice was evidenced by the following:A review of Resident #130's closed electronic medical record included the following:Resident #130's discharge return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, reflected that the resident was transferred to the hospital. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documentation, it was determined that the facility failed to submit the Minimum Data Set (MDS) assessments in a timely manner for 1 of 2 residents reviewed for hospitalization (Resident #11). The deficient practice was evidenced by the following:On 8/7/25 at 11:42 AM, the surveyor reviewed the closed medical record of Resident #11. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to consistently document resident refusal for daily weights and notify the physician regarding the resident's refusal for 1 of 26 residents (Resident #77) reviewed. This deficient practice was evidenced by the following:On 8/5/25 at 10:26 AM, the surveyor observed Resident #77, lying in bed, alert and verbally responsive. The resident was being attended to by a Certified Nurse's Aide (CNA). On 8/6/25 at 10:25 AM, the surveyor reviewed the paper chart and the Electronic Medical Record (EMR) of Resident #77. A review of the admission Record (an admission summary) documented Resident #77 had diagnoses that included but were not limited to; heart failure, adjustment disorder with depressed mood, visual loss, atrial fibrillation, and vertebra fracture. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to provide appropriate Activities of Daily Living (ADLs) care, for residents who were dependent on staff assistance for care, by failing to provide incontinence care. This deficient practice was identified for 1 of 2 residents reviewed for ADL care (Resident #14). This deficient practice was evidenced by the following: On 8/5/25 at 11:07 AM, the surveyor asked the Licensed Practical Nurse/Unit Manager (LPN/UM) to accompany the surveyor inside Resident #14's room. Both the surveyor and the LPN/UM observed the resident lying on bed with one clean diaper and clothing on top of the bed near resident's right side of the head. The resident was wearing a night gown and was covered by a blanket. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, by failing to; a.) follow the physician's order, document, and notify the physician if medications were not administered for 1 of 26 residents (Resident #4) reviewed and b.) ensure accurate documentation of wound assessment and description of skin impairment for 1 of 23 residents (Resident #8) reviewed, in accordance to facility's protocol and policies. 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 observation, interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of practice for a resident with pressure ulcers. This deficient practice was identified in 1 of 2 residents (Resident #113), reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following:On 8/5/25 at 10:24 AM, the surveyor observed Resident #113 lying in the bed in their room. Resident #113 was alert and verbally responsive. The resident had no concerns with their care. On 8/8/25 at 8:50 AM, the surveyor reviewed the hybrid (paper and electronic) medical records of Resident #113. A review of the admission Record (an admission summary) reflected that the resident had diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that staff provided adequate routine monitoring for a resident after returning from receiving offsite hemodialysis and provided care and services in accordance with professional standards clinical practice for 1 of 2 residents (Resident #4), reviewed for dialysis services. 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 interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to act on the Consultant Pharmacist (CP) Medication Regimen Review (MRR) in a timely manner for 1 of 23 residents, (Resident #134), reviewed. This deficient practice was evidenced by the following:The surveyor reviewed the hybrid medical record (electronic and paper) for resident #134, and revealed the following:A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility on with diagnoses of, but not limited to, essential hypertension (high blood pressure) and malignant carcinoma of the lung (lung cancer). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more during medication administration, two (2) nurses administered medications to four (4) residents. There were thirty (30) opportunities for error, three (3) errors were observed which calculated to a medication administration error rate of 10%. This deficient practice was identified for 2 of 4 residents, (Resident #73, Resident #81), that was administered medications by (one) 1 of two (2) nurses that were observed. 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 other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to, a.) cover the garbage container and b.) keep the garbage container area free of garbage and debris. This deficient practice was identified for 1 of 1 garbage containers. This was evidenced by:On 8/5/25 at 10:20 AM, in the presence of the Food Service Director (FSD), the surveyor toured the loading dock and dumpster area. Both the surveyor and the FSD observed the compactor was currently being dropped off. The Maintenance Director (MD), who stated that the compactor was being picked up every other week on Thursdays. On 8/6/25 at 12:58 PM, the surveyor and the FSD toured the refuse/dumpsters area and observed the following:1. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, the facility failed to maintain infection control practices to reduce the risk of infection, specifically by failing to ensure Alcohol Based Hand Rub (ABHR) was available to perform hand hygiene (HH) upon entering the facility and for use before and after signing in on the kiosk or provide disinfecting wipes to clean the kiosk after each use in between visitors. This deficient practice was observed for 2 of 5 days. This deficient practice was evidenced by the following:Reference: Centers for Disease Control (CDC) under the Healthcare-Associated Infections (HAIs) topic; [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection control program for one of four residents (Resident (R) 5) reviewed for transmission-based precautions (TBP) out of 29 sampled residents. Staff failed to wear the required personal protective equipment (PPE) while performing catheter care for R5 on enhanced barrier precautions.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 4 of 5 medication carts and 2 of 2 medication refrigerators that were inspected. This deficient practice was evidenced by the following: On 11/23/21 at 10:35 AM, the surveyor, in the presence of Registered Nurse#1 (RN#1), inspected the 3-South medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services of a resident who was receiving oxygen, BiPAP (a device to assist asleep apnea patient with breathing at night), and nebulizer (neb) according to the standard of practice. This deficient practice was identified for 1 of 1 resident (Resident #417) and was evidenced by the following: On 11/21/21 at 9:41 AM, the surveyor observed Resident #417 laying on a bed with eyes closed with oxygen ongoing at two liters per minute (2LPM) via nasal cannula (NC) that was attached to an oxygen concentrator (a medical device used for delivering oxygen). The oxygen NC was not dated. The resident's neb mask was directly touching the floor with no date. The BiPAP mask was on top of the heater directly touching the surrounding environment. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow transmission-based precautions and appropriate infection control practices in accordance with the Center for Disease Control guidance (CDC) and facility guidelines. This deficient practice was identified for 1 of 7 Certified Nursing Assistants (CNAs) on 1 of 2 units. This deficient practice was evidenced by the following: On 11/21/21 during the entrance conference, the Director of Nursing (DON) told the Team Coordinator (TC) that rooms 217 through 228 was a PUI (person under investigation) unit. On 11/21/21 at 9:35 AM, during the initial tour of the PUI unit, the surveyor observed rooms 217 through 228 with a sign on each door that indicated ISOLATION .Droplet and contact PRECAUTIONS everyone must: Clean their hands, including before entering and when leaving the room. [...]