Atlas Rehabilitation & Healthcare at West Deptfor

Inspectors wroteBased on interview, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete reference checks and background checks on employees before their start date. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain the training room toilets in the resident shower rooms in a clean and homelike environment. This deficient practice was identified for 2 of 3 shower rooms inspected on 2 of 3 nursing units (East and West) and was evidenced by the following:On 12/5/25 at 10:57 AM, the surveyor observed the East Wing Shower Room in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) #2. When the surveyor entered the training toilet bathroom, there was a strong odor noted around the toilet. When the surveyor asked LPN/UM #2 if the area smelled of urine, the LPN/UM stated, a little bit. LPN/UM #2 then stated it should have been cleaned that morning. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that the Minimum Data Set (MDS), an assessment tool, accurately reflected the resident's smoking status. This deficient practice was identified for 1 of 30 sampled residents (Resident #141), and was evidenced by the following: On 12/8/25 at 1:03 PM, the surveyor, accompanied by the Certified Nursing Assistant (CNA) #1, observed Resident #141 go outside in the smoking area and smoke two cigarettes. On 12/8/25 at 1:30 PM, the surveyor reviewed the medical record for Resident #141. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observations, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 1 of 1 resident, (Resident #13) reviewed for pressure ulcers and was evidenced by the following:On 12/5/25 at 10:43 AM, the surveyor observed Resident #13 lying in bed awake with the head of the bed elevated. At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 presented to the room and attempted to offer the resident a drink of water. The resident did not respond verbally when they were spoken to. The resident was on an air mattress that was set at 160 pounds (lbs). On 12/5/25, the surveyor reviewed the medical record of Resident #13. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection, for 1 of 4 residents (Resident #162) reviewed for respiratory care. This deficient practice was evidenced by the following:On 12/4/25 at 10:01 AM, the surveyor observed Resident #162 in their room sitting on the bed with oxygen infusing at three liters via a nasal canula (tubing used to deliver oxygen). The surveyor also observed a Bilevel Positive Airway Pressure (BiPAP) machine (a non-invasive breathing device used to treat sleep apnea by delivering pressurized air through a mask) on the resident's nightstand. The mask was uncovered on the nightstand. On 12/4/25 at 1:33 PM, the surveyor reviewed the resident's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) maintain kitchen equipment in a clean, safe, and sanitary manner and b.) maintain nutrition room equipment in 2 of 3 units (East and 2nd) in a clean, safe and sanitary manner as evidenced by the following:On 12/4/25 at 11:02 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following in the kitchen:1. Two (2) of two (2) convention ovens (1-upper and 1-lower unit), had baked on food debris on the two glass doors and on the inside surfaces. The FSD acknowledged that it was not cleaned according to facility policy. 2. One (6 burner) stove top, had all 6 burners with debris on the grates and around the cooker hats. The FSD acknowledged that it was not cleaned according to facility policy. 3. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to adhere to infection control standards and procedures during the provision of wound treatments. This deficient practice was identified for 1 of 1 resident (Resident #13) reviewed for pressure ulcers and was evidenced by the following:On 12/5/25 at 10:43 AM, the surveyor observed Resident #13 lying in bed awake with the head of the bed elevated. The resident did not respond verbally when they were spoken to and was lying on an air mattress. On 12/5/25, the surveyor reviewed the medical record of Resident #13. A review of the 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#: NJ00187516 / 402411Based on interview and review of medical records and other pertinent facility documents it was determined that the facility failed to maintain an accurately documented and complete medical records in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and was evidenced by the following: A review of Resident #2's admission Record revealed that that the resident was admitted to the facility with diagnoses that included but were not limited to: quadriplegia, neurogenic bowel (a condition where the nerves that control bowel function are impaired, leading to abnormal bowel movements), and neuromuscular dysfunction of bladder. [...]

Inspectors wroteComplaint #: NJ186633 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 5/28/25 and 5/30/25, it was determined that the facility failed to provide a resident (Resident #2), who voiced a grievance, a written summary of the investigation in accordance with the facility's Grievance Policy. The deficient practice was identified for 1 of 3 residents, Resident #2, and evidenced by the following: According to the Admitting Face Sheet, Resident #2 had diagnoses which included but were not limited to: Iron Deficiency Anemia, Unspecified, Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of Right Leg Below Knee, and Morbid (Severe) Obesity Due to Excess Calories. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 6/26/2024 from 9:17 to 9:56 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the kitchen a dietary aide (DA) was observed to have lengthy braids extending to the shoulder area. The braids on either side of the head were not contained in the hair net and were exposed. 2. In the dry storage room on an upper shelf a can of Pear Diced had a significant dent on the upper seam of the can. The FSD removed the dented can to the designated dented/damaged can area on a lower shelf of the room. 3. [...]

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 that there was a physician order for the use of a Foley catheter for 1 of 2 residents reviewed for catheter use (Resident #115). This deficient practice was evidenced by the following: On 06/26/2024 at 09:49 AM the Licensed Practical Nurse/Unit Manager (LPN/UM) told the surveyor that we tried a voiding trial and the resident failed and then the Foley catheter was reinserted. The LPN/UM then told the surveyor Resident #115 was scheduled for a surgical procedure in July. On 06/26/2024 at 12:15 PM, Resident # 115 was observed self-propelling in their wheelchair in the hallway. The catheter bag was noted inside a privacy bag. [...]

Inspectors wroteBased on interview and review of other facility documents, it was determined that the facility failed to maintain a detailed record of receipts and accurate reconciliation of controlled medications. This deficient practice was evidenced by the following: On 06/27/2024 at 01:38 PM, the surveyor requested and reviewed all the Drug Enforcement Administration (DEA) 222 forms (a form used for ordering controlled substances) for the last 6 months from the Director of Nursing (DON) for the past 6 months. At that time the surveyor also requested copies of those seven forms. The DON provided the surveyor with seven (7) DEA 222 forms. A review of the DEA 222 forms showed there was no entered delivery amount and date for 7 of 7 DEA 222 forms and 2 of 7 NO. (number) of packages were not completed and accurately documented as follows: 1. [...]

Inspectors wroteFACILITY Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/31/2022 from 11:24 to 11:50 AM the surveyors, accompanied by the Food Service Director (FSD) observed the following in the kitchen: 1. The surveyors were in the kitchen to assess food temperatures prior to start of the lunch meal. The surveyor observed the cook behind the steam table. The cook proceeded to walk down to the end of the steam table and removed a pair of disposable gloves from a box. The cook was not observed to perform hand washing prior to entering the steam table area. The cook proceeded to don the disposable gloves and grab the thermometer and alcohol wipes that were on the counter. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to maintain an orderly environment when wallpaper was observed peeling from the wall, a closet was off the hinges, and various dried, liquid stains were observed on the floor. The observations were made in 5 resident rooms. On 10/26/22 at 08:51 AM, inside room [ROOM NUMBER], surveyor #1 observed the wall paper peeling at the seams in at least five different areas. The surveyor further observed dried brown liquid on the floor. On the same date at 09:17 AM inside room [ROOM NUMBER], surveyor #1 observed wallpaper peeling from the wall. The area peeling was approximately 48 inches long. On the same date at 09:20 AM inside room [ROOM NUMBER], surveyor #1 observed wallpaper peeling from the wall in three areas. Each peeling area was approximately 24 inches long. [...]

Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to complete a resident assessment that accurately reflected the resident's status/behaviors. This was identified during a review of the Minimum Data Set (MDS), an assessment tool, for 1 of 31 residents reviewed (Resident #51). This deficient practice was evidenced by the following: On 10/24/2022 at 10:29 a.m. the surveyor reviewed an admission MDS Assessment that had a reference date of 8/25/2022. According to Section C0500 Resident #51 scored a 3 on a Brief Interview for Mental Status which indicated that the resident was severely cognitively impaired. Review of Section E0200 revealed that the resident had not displayed any physical, verbal, or other behavioral symptoms. Review of section E0800 revealed that Resident#51 did not reject care and section E0900 revealed that resident had not wandered. [...]

Inspectors wroteBased on observations on 10/31/2022 in the presence of facility management, it was determined the facility failed to provide a safe environment for the residents. This deficient practice was indentified for 1 of 3 shower rooms, 2nd floor. This deficient practice was evidenced by the following: During the tour of the facility in the presence of the facility's Maintenance Director (MD) at 10:56 AM,an inspection inside the second floor Resident shower room was performed. The corridor door had a passage (no means to lock) door knob installed on the door. The surveyor observed inside the shower room a sharps container cabinet that was mounted to a wall with no evidence of the inner puncture proof sharps container with a one way drop down tray. Further inspection identified that the cabinet door was unlocked and the cabinet contained approximately 35 razors and a nail clipper. [...]

Inspectors wroteBased on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to provide the appropriate care and services to prevent potential injury to a resident with an indwelling, suprapubic catheter (tube inserted into the bladder to facilitate the flow of urine) by not securing the tube properly to the securement device (plastic device used to secure the tube to prevent the catheter from being pulled). The deficient practice was observed for 1 of 3 residents (Resident #1) investigated for Catheter and was evidenced by the following: On 10/24/2022 at 10:26 AM, the surveyor obtained permission from Resident #1 to observe the catheter securement device applied to the upper, left thigh. At this time, the surveyor observed that the tube was not secured properly and could move freely within the securement device. [...]

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 2 residents (Resident #38) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/24/2022 at 9:41 AM, Resident #38 was observed lying in bed. Resident #38 said he/she goes to dialysis on Tuesday, Thursday, and Saturday in the AM. A review of the Electronic Medical Record revealed Resident #38 was admitted to the facility with diagnoses including but not limited to, End Stage Renal Disease, Dependence on dialysis and Hypertension. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to supervise the administration of medication for 1 of 31 sampled residents, (Resident #34). This deficient practice was evidenced by the following: Upon entering Resident #34's room on 10/24/2022 at 9:18 AM, the surveyor, in the presence of another surveyor, observed an inhaler and nasal spray sitting on the bedside table. There was no nurse observed in the room. The surveyor questioned Resident #34 if he/she keeps the medications at their bedside. Resident #34 said, No, the nurse brought them and leaves them. Resident #34 said, Most nurses leave the inhaler and nasal spray. The nurse watched me take my pills and I do these (motioning to the inhaler and nasal spray) and then they pick them up. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to detect and remove opened expired medication from active inventory in 1 of 2 medication storage areas reviewed. This deficient practice was evidenced by the following: On [DATE] 09:13 AM the surveyors reviewed the first-floor medication storage room and observed a used vial of tuberculin purified protein solution (PPD solution) in the opened manufacturer's box. The surveyor observed the box dated [DATE] in blue pen. The vial and the box reflected to discard opened product after 30 days. During an interview with the surveyor on [DATE] at 9:13 AM, the Licensed Practical Nurse #2 stated the PPD solution should have been discarded on the 16th or 17th of October. [...]