Atlas Rehabilitation and Healthcare at Washington

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the ice machine and kitchen environment in a clean and sanitary manner to prevent potential contamination and foodborne illness. This deficient practice was evidenced by the following:On 04/13/2026 at 9:19 AM, during a kitchen observation conducted with the Dietary Director (DD), the surveyor observed that the interior compartment of the ice machine, where ice was dispensed, contained a light yellow, slimy, film-like substance. The interior tray contained brown and black debris. The exterior compartment beneath the ice chute, used to catch ice, contained brown debris within the drainage tray. Additionally, the front surface of the ice machine contained brown, dry, powdery particles. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a medication was administered per the physicians order (PO) with blood pressure parameters. This deficient practice was identified for 1 of 2 residents (Resident # 114) reviewed for dialysis and was evidenced by the following: On 04/12/26 at 10:32 AM, the surveyor observed Resident #114 lying in bed with his/her eyes open. The resident was unable to answer any questions. Resident #114's family member was at the bedside and stated that the resident attended dialysis three times a week. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to adhere to established menus to ensure nutritional adequacy for Resident #34. This deficient practice was evidenced by the following:On 04/13/2026 at 11:43 AM, during the lunch observation in the Grenloch dining room, Resident #34 had a meal ticket that did not match the meal served. The meal ticket included pureed beef stir fry, cream of rice, pureed stir fry vegetables, vanilla pudding, fortified mashed potatoes with gravy, [NAME REDACTED] (a high calorie frozen dessert supplement), ice cream, sherbet, and whole milk 4 ounces (oz). The resident did not receive the a high calorie frozen dessert supplement as listed on the ticket. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner intended to prevent food borne illness. This deficient practice was evidenced by the following: On 9/15/24 from 9:19 AM until 10:00 AM, the surveyor observed the following in the presence of the Assistant Food Service Director (AFSD): 1. The AFSD turned on the faucet, wet her hands, applied soap to her hands, and lathered her hands with soap for a period of time too briefly to be counted, before she rinsed her hands under the running water, and dried her hands with a paper towel. The AFSD discarded the paper towel and obtained a second paper towel to turn off the faucet and then discarded it. 2. The oven was noted with heavy black soiling both inside the oven, on the outer ledge, and on the glass doors. [...]

Inspectors wroteComplaint #NJ172198 Based on interview, review of the medical record and other pertinent facility documentation, it was determined that the facility failed follow their policy to develop and implement a person-centered, comprehensive baseline care plan within 48 hours of a resident's admission. This deficient practice was identified for 1 of 35 residents (Resident #154) reviewed for baseline care plan implementation. This deficient practice was identified by the following: Refer to F684 A review of Resident #154's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: [...]

Inspectors wroteComplaint #NJ172198 Based on interview, record review, and review of other pertinent documentation, it was determined that the facility failed to ensure that a resident was provided with a discharge summary and post discharge instructions to ensure a safe and effective transition of care for 1 of 2 closed records (Resident #155) reviewed for appropriate discharge planning. This deficient practice was evidenced by the following: A review of Resident #155's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: [...]

Inspectors wroteComplaint #NJ168202 and NJ172198 Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to a.) document a physician notification in response to a resident's change of condition, b.) obtain an order for supplemental oxygen use, c.) obtain an order to send the resident to the hospital, d.) document a Registered Nurse (RN) assessment, and e.) document a resident's clinical status after the resident was sent to the hospital in accordance with professional standards. This deficient practice was identified for 1 of 2 residents (Resident #154) reviewed for change in condition. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to address recommendations from the Wound Care Consultant in a timely manner for 1 of 1 resident (Resident #74) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 09/15/24 at 9:54 AM, the surveyor observed Resident #74 lying in bed. The resident stated he/she had a wound. According to the admission Record, Resident #74 had diagnoses which included, but were not limited to, pressure ulcer of sacral region, diabetes mellitus type 2, paraplegia, and morbid obesity. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/23/24, included the resident had a Brief Interview for Mental Status score of 15, which indicated the resident's cognition was intact. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 1 resident (Resident #57) reviewed for dialysis. This deficient practice was evidenced by the following: On 09/15/2024 at 9:54 AM, Resident #57 was observed sitting in his wheelchair with his eyes closed. A review of the Electronic Medical Record revealed Resident #57 was admitted to the facility with diagnoses including but not limited to, Acute Kidney Failure, Chronic Kidney Disease, Dependence on Renal Dialysis. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) ensure hand hygiene was performed following medication administration, and b.) follow transmission-based precautions (TBP) to prevent the potential spread of infection by not utilizing personal protective equipment (PPE) for a resident on contact precautions for 1 of 2 residents (Resident #255) being observed during a medication observation. This deficient practice was evidenced by the following: On 09/16/24 at 8:12 AM, during a medication administration observation, the surveyor observed Licensed Practical Nurse (LPN) #3 enter Resident #255's room to administer medications. After the resident took their medication, LPN #3 took the empty medicine cup and drinking cup from the resident using her bare hands, discarded the cups, and exited the resident's room. [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, it was determined that the facility failed to ensure resident safety related to lights over headboard are smoking when turned on for (Resident (R)73 and R51). The lights were found to be smoking by staff on 8/31/2023 and not repaired until 9/28/2023. This failure placed R73 and R51, as well as all residents, at risk of an electrical fire and in an Immediate Jeopardy situation. Additionally, the facility failed to provide a safe smoking environment for 10 residents (Resident (R) 17, R24, R48, R52, R55, R60, R65, R72, R159, and R160) of the facility identified as smokers. The facility's Administrator was informed on 09/28/23 at 6:54 PM that Immediate Jeopardy existed related to the failure to ensure overhead lights were not smoking when turned on for R73 and R51 resulting in the potential for an electrical fire. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that menus were being followed, that the menus reflected input received from residents and resident council, and were reviewed by the facility's dietitian for nutritional adequacy for 107 out of 107 residents residing in the facility who receive meals from the kitchen. Specifically, menu items were substituted without notifying the residents, incorrect serving utensils were being utilized on the tray line leading to smaller portion sizes being served, standardized recipes were not being utilized, and current menus had not been reviewed by the dietitian. This had the potential to lead to nutrient deficiencies for all 107 residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure palatable food was served to 11 (Resident (R) 96, R160, R95, R77, R10, R51, R54, R90, R60, R1 and R53) of 107 total residents. Specifically, the food did not look appetizing, lacked flavor and was not at an appropriate temperature. Failure to provide palatable food to residents has the potential to affect nutritional status and quality of life.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure cold and dry storage food items were labeled properly and not expired and did not contain stagnant rainwater. This had the potential to affect 107 of 107 residents who received food from the kitchen.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure a resident's right to formulate or refuse an Advance Directive upon admission relating to healthcare in the event that the resident becomes incapacitated for one of two residents (Resident (R) R35) reviewed for Advanced Directives. The facility failed to follow up with R35's responsible party to obtain copies of R35's Advance Directives.

Inspectors wroteBased on observations, record reviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two (Resident (R)22 and R257) out of 28 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements, inaccurate assessment, and inaccurate care planning of the resident.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was in place for the diagnosis of dementia for one (Resident(R)102) of 28 sample residents reviewed for care plans. This had the potential for the resident to have unmet care needs.

Inspectors wroteBased on observation, interview, record review, and facility contract review, the facility failed to provide timely transportation of residents to the dialysis center for one of two (Residents (R)1) reviewed for dialysis. This had the potential to cause disruption of R1's treatment and pose a significant health risk.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to follow the prescribed diet and honor preferences, food allergies, and intolerances for three (Residents (R)1, R90, and R161) of 10 residents sampled for food preferences, out of 28 sample residents. This had the potential for the residents having negative health consequences.