Inspection Reports for Atlas Rehabilitation & Healthcare At West Deptfor
550 Jessup Road, NJ, 8066
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 2
Jun 16, 2025
Visit Reason
The inspection was conducted due to a complaint (Complaint #: NJ186633) regarding grievances and staffing issues at the facility.
Findings
The facility was found not in substantial compliance with federal and state requirements related to resident grievances and staffing ratios. The facility failed to provide a written summary of grievance investigations to residents and did not meet minimum staffing requirements for Certified Nurse Aides (CNAs) on several shifts.
Complaint Details
Complaint #: NJ186633 was substantiated. The facility failed to provide a resident (Resident #2) with a written summary of a grievance investigation and failed to meet minimum CNA staffing requirements on multiple days. The grievance policy was reviewed and revised with corrective actions planned and implemented.
Severity Breakdown
Level B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide a resident with a written summary of grievance investigation in accordance with the facility's Grievance Policy. | Level B |
| Failure to ensure staffing ratios were met for 3 of 14-day shifts reviewed, deficient CNA staffing. | Level B |
Report Facts
Census: 150
Sample Size: 3
Deficiencies cited: 2
Staffing counts: 15
Staffing counts: 17
Staffing counts: 18
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 1
Feb 21, 2025
Visit Reason
The inspection was conducted based on complaints NJ183158, NJ183469, and NJ183516 to investigate staffing ratio deficiencies at the facility.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding mandatory access to care due to failure to meet required staffing ratios on 3 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint numbers NJ183158, NJ183469, NJ183516 triggered the investigation. The facility was found deficient in staffing ratios but no negative outcomes to residents were reported.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 3 of 14-day shifts reviewed, specifically deficient in Certified Nurse Aide (CNA) staffing on 02/02/25, 02/07/25, and 02/15/25. |
Report Facts
Census: 149
Deficient shifts: 3
CNA staffing on 02/02/25: 16
Residents on 02/02/25: 148
CNA staffing on 02/07/25: 17
Residents on 02/07/25: 146
CNA staffing on 02/15/25: 18
Residents on 02/15/25: 149
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 0
Aug 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ175746.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities, and in compliance with New Jersey Administrative Code standards for licensure of long term care facilities.
Complaint Details
Complaint number NJ175746 was investigated and the facility was found to be in substantial compliance with regulatory requirements.
Report Facts
Sample Size: 4
Inspection Report
Annual Inspection
Census: 125
Capacity: 156
Deficiencies: 15
Jul 9, 2024
Visit Reason
Annual Life Safety Code and regulatory compliance survey including complaint investigation and standard survey of Atlas Rehabilitation & Healthcare at West Deptford.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including staffing ratios, fire safety, emergency preparedness, medication and pharmacy services, kitchen sanitation, and maintenance of physical plant systems. Deficiencies were cited in areas such as physician orders, medication administration, kitchen sanitation, fire safety inspections, emergency lighting, sprinkler system maintenance, corridor and smoke barrier doors, HVAC exhaust fans, and oxygen tank storage.
Complaint Details
The inspection included a complaint investigation related to staffing and other regulatory concerns.
Severity Breakdown
SS=F: 9
SS=E: 4
SS=D: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure physician orders for Foley catheter use were obtained and documented for Resident #115. | SS=D |
| Failed to maintain accurate and complete DEA 222 forms for controlled substances including missing delivery amounts and dates. | — |
| Failed to maintain kitchen sanitation including hair containment, dented cans, wet nesting of pans, dishwasher temperature monitoring, and food storage. | SS=F |
| Failed to maintain required minimum direct care staff to resident ratios for multiple weeks during complaint investigations and prior to survey. | SS=F |
| Failed to ensure quarterly local fire inspections were performed as required by the New Jersey Uniform Fire Safety Code. | SS=F |
| Front main entrance exit doors had a manually operated latch that could lock doors together preventing egress without operating the lock. | SS=F |
| Two stairwell exit doors failed to close properly into their door frames when opened to 90 degrees and released. | SS=F |
| Battery powered emergency light was not present at the emergency power generator transfer switch. | SS=E |
| Semiannual kitchen hood and cooking line fire suppression system inspection was not performed timely. | SS=F |
| Automatic fire sprinkler system inspections and maintenance were not performed or documented as required, including corrosion repairs and trip tests. | SS=F |
| Corridor doors to rooms 227 and 104 did not close and latch properly into their frames and resisted passage of smoke. | SS=E |
| Smoke barrier doors failed to resist transfer of smoke and had excessive clearance at the bottom of the door. | SS=F |
| Six bathroom exhaust fans were not operational. | SS=E |
| Emergency power generator weekly inspections and monthly load tests were not performed or documented for multiple months. | SS=F |
| Compressed oxygen tanks were not secured against tipping and rupture and the ventilation fan in the oxygen storage room was not operational. | SS=E |
Report Facts
Census: 125
Total Capacity: 156
Deficiency counts: 14
Staffing ratios: 8
Staffing shifts deficient: 14
Semiannual inspection delay: 12
Emergency generator weekly inspections missing: 30
Emergency generator monthly load tests missing: 7
Bathroom exhaust fans non-operational: 6
Oxygen tanks unsecured: 4
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 1
Jun 9, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to complaints NJ00162610, NJ00163462, and NJ00163983 between 06/07/23 and 06/09/23.
Findings
The facility was found to be in substantial compliance with federal long term care requirements but was not in compliance with New Jersey state staffing ratio standards, failing to meet minimum certified nursing assistant (CNA) staffing ratios on 8 of 14 day shifts reviewed from 05/21/2023 to 06/03/2023.
Complaint Details
Complaint survey based on complaints NJ00162610, NJ00163462, and NJ00163983. The facility was found not in compliance with New Jersey Administrative Code Chapter 8:39 for licensure of long term care facilities due to staffing deficiencies. The facility was required to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum direct care staff to resident ratios as mandated by the state of New Jersey for 8 of 14 day shifts reviewed. |
Report Facts
Survey Census: 128
Sample Size: 7
Deficient CNA staffing shifts: 8
CNA staffing counts: 15
CNA staffing counts: 15
CNA staffing counts: 14
CNA staffing counts: 15
CNA staffing counts: 15
CNA staffing counts: 13
CNA staffing counts: 15
CNA staffing counts: 14
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 1
Mar 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint#: NJ161692) to determine compliance with staffing ratio requirements.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements, failing to meet minimum Certified Nurse Aide (CNA) staffing ratios on 14 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint#: NJ161692. The facility was found deficient in meeting minimum staffing ratios as required by New Jersey statutes, with no residents directly affected but potential risk to current residents.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 14 of 14 day shifts reviewed, deficient in CNA staffing. |
Report Facts
Census: 131
Day shifts deficient in CNA staffing: 14
CNA staffing counts and requirements: 10
CNA staffing counts and requirements: 15
CNA staffing counts and requirements: 11
CNA staffing counts and requirements: 15
CNA staffing counts and requirements: 13
CNA staffing counts and requirements: 15
CNA staffing counts and requirements: 13
CNA staffing counts and requirements: 15
CNA staffing counts and requirements: 12
CNA staffing counts and requirements: 15
CNA staffing counts and requirements: 12
CNA staffing counts and requirements: 16
CNA staffing counts and requirements: 10
CNA staffing counts and requirements: 16
CNA staffing counts and requirements: 11
CNA staffing counts and requirements: 16
CNA staffing counts and requirements: 12
CNA staffing counts and requirements: 16
CNA staffing counts and requirements: 13
CNA staffing counts and requirements: 16
CNA staffing counts and requirements: 13
CNA staffing counts and requirements: 17
CNA staffing counts and requirements: 13
CNA staffing counts and requirements: 17
CNA staffing counts and requirements: 14
CNA staffing counts and requirements: 17
CNA staffing counts and requirements: 13
CNA staffing counts and requirements: 16
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 0
Jan 4, 2023
Visit Reason
The inspection was conducted in response to a complaint identified as NJ157981.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #: NJ157981. The facility is in substantial compliance based on this complaint visit.
Report Facts
Sample size: 4
Inspection Report
Annual Inspection
Census: 129
Deficiencies: 9
Nov 1, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to facility environment maintenance, accuracy of resident assessments, accident hazards, bowel/bladder care, dialysis medication coordination, pharmacy services, medication labeling and storage, and food safety practices.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to maintain an orderly environment with peeling wallpaper, closet off hinges, and dried stains in 5 resident rooms. | SS=D |
| Facility failed to complete resident assessment accurately reflecting resident's status/behaviors for 1 of 31 residents. | SS=D |
| Facility failed to provide a safe environment in shower room with unsecured sharps container containing razors and nail clipper accessible to residents. | SS=D |
| Facility failed to secure catheter securement device properly for 1 of 3 residents. | SS=D |
| Facility failed to adjust medication times to accommodate dialysis schedule for 1 of 2 residents. | SS=D |
| Facility failed to supervise medication administration; nurse left nasal spray at resident bedside unattended. | SS=D |
| Facility failed to label and store drugs and biologicals properly; expired opened medication found in active inventory. | SS=D |
| Facility failed to maintain kitchen sanitation; cook did not perform hand washing prior to donning gloves. | SS=E |
| Facility failed to maintain required minimum direct care staff-to-resident ratios for day shifts; deficient CNA staffing on 14 of 14 day shifts. | — |
Report Facts
CNA staffing deficiency: 14
Census: 129
Medication administration times: 6
Sharps count: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Interviewed regarding wallpaper maintenance and staffing ratios | |
| Maintenance Director | Confirmed findings of unsecured sharps container | |
| LPN #1 | Licensed Practical Nurse | Left nasal spray at resident bedside unattended |
| Unit Manager Registered Nurse #1 | Unit Manager RN | Interviewed about catheter securement device |
| Unit Manager Registered Nurse #2 | Unit Manager RN | Interviewed about dialysis medication timing |
| Director of Nursing | Director of Nursing | Interviewed about catheter securement, dialysis medication timing, and medication administration |
| Staff Development Coordinator | Staff Development Coordinator | Responsible for re-education of nursing staff on various deficiencies |
| Food Service Director | Food Service Director | Observed kitchen sanitation practices |
Inspection Report
Life Safety
Deficiencies: 6
Nov 1, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 10/31/2022 and 11/01/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found noncompliant with several Life Safety Code requirements including emergency lighting, vertical openings enclosure, sprinkler system maintenance, smoke barrier doors, HVAC ventilation, and essential electrical system maintenance. Deficiencies included missing battery backup emergency lighting, fire doors not latching properly, missing ceiling tiles affecting sprinkler activation, smoke barrier door gaps exceeding limits, nonfunctional bathroom exhausts, and lack of remote emergency generator shutoff.
Severity Breakdown
SS=E: 5
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide a battery backup emergency light above the emergency generator transfer switch. | SS=E |
| Laundry chute door and exit access stairwell door did not close and positive latch to maintain fire rated construction. | SS=E |
| Ceiling tiles missing in kitchen HVAC and boiler rooms, and dust covering sprinkler head in laundry room delaying sprinkler activation. | SS=E |
| Smoke barrier corridor doors failed to maintain smoke resistance with gaps larger than 3/4 inch. | SS=E |
| Four of ten resident bathroom exhaust systems were not functional. | SS=D |
| No remote manual stop station for emergency generator was installed. | SS=E |
Report Facts
Deficiencies cited: 6
Resident bathrooms with nonfunctional exhaust: 4
Smoke barrier door gap measurement: 1.25
Smoke barrier door gap measurement: 1.125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed multiple findings including emergency lighting, fire doors, sprinkler system, smoke barrier doors, bathroom exhausts, and emergency generator issues. | |
| Nursing Home Administrator | Informed of findings during exit conference and responsible for educating Maintenance Director and overseeing corrective actions. | |
| Corporate Regional Maintenance (CRM) | Participated in building tours and confirmed observations related to fire doors, sprinkler system, and smoke barrier doors. |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
May 25, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaints #NJ 151353, NJ 154313, and 154823.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint investigation for complaints #NJ 151353, NJ 154313, and 154823. The facility was found to be in substantial compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Nov 23, 2021
Visit Reason
The inspection visit was conducted in response to complaint NJ149548 to assess compliance with long term care facility regulations.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Complaint Details
Complaint number NJ149548 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Oct 5, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ 147393.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities. A COVID-19 Focused Infection Control Survey found the facility in compliance with infection control regulations related to CMS and CDC recommended practices.
Complaint Details
Complaint # NJ 147393 was investigated and the facility was found to be in substantial compliance.
Report Facts
COVID-19 positive residents in house: 14
Sample size: 8
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Jun 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint#: NJ142821) to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to maintain accurate medical records documentation for 1 of 3 residents reviewed. Specifically, documentation in the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) was incomplete, with missing initials for medication and treatment administration as ordered by the physician.
Complaint Details
Complaint#: NJ142821. The facility was found not in substantial compliance based on this complaint visit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain accurate medical records documentation, including incomplete documentation of medication and treatment administration in EMAR/ETAR. | SS=D |
Report Facts
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed and stated that blank spaces on EMAR/ETAR indicated documentation was not completed. |
Inspection Report
Routine
Census: 108
Deficiencies: 0
Feb 22, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
Inspection Report
Routine
Census: 92
Deficiencies: 0
Nov 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
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