Inspection Reports for
Atlas Rehabilitation & Healthcare At West Deptfor

Complaint NJ00187516 / 402411 was substantiated based on review of medical records and interviews confirming failure to document wound care treatment for Resident #2 on 4/30/25.

The facility failed to document wound care treatments for Resident #2 on 4/30/25 despite the care being provided, resulting in incomplete medical records and a grievance filed by the resident. Interviews with staff confirmed the treatment was done but not documented.

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.

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 #: NJ186633. The complaint was substantiated based on interviews, medical record review, and facility documentation indicating the facility did not provide a written response to the resident's grievance dated 12/30/24.

The facility failed to provide Resident #2, who voiced a grievance, with a written summary of the investigation as required by the facility's grievance policy. Interviews with the resident, administrator, and Director of Nursing confirmed the absence of a written response.

Complaint numbers NJ183158, NJ183469, NJ183516 triggered the investigation. The facility was found deficient in staffing ratios but no negative outcomes to residents were reported.

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.

The inspection included a complaint investigation related to staffing and other regulatory concerns.

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.

The facility was found deficient in ensuring a physician order for Foley catheter use for one resident, maintaining accurate records and reconciliation of controlled medications, and maintaining kitchen sanitation and food safety standards including dishwasher temperature compliance and proper food storage.

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.

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#: 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.

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.

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.

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.

The facility was found deficient in multiple areas including failure to maintain a safe and clean environment, inaccurate resident assessments, unsafe storage of sharps, improper catheter securement, failure to adjust medication timing for dialysis patients, unsupervised medication administration, failure to remove expired medications, and inadequate kitchen sanitation practices.

Complaint#: NJ142821. The facility was found not in substantial compliance based on this complaint visit.

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.

The facility was found deficient in multiple areas including failure to notify residents or their representatives in writing about the bed hold policy upon hospital transfer, inadequate incontinence care for a resident, lack of mandatory in-service training for most CNAs, failure to maintain narcotic medication count logs properly, and poor kitchen sanitation practices including exposed food, dented cans, and inadequate hair restraints.