Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atlas Rehabilitation And Healthcare At Washington during CMS and state inspections, most recent first.
The facility failed to maintain proper food handling and sanitation practices. The AFSD demonstrated inadequate handwashing, and kitchen equipment was not properly cleaned. Food items in the refrigerator and freezer were improperly labeled and stored beyond use-by dates. During tray line service, utensils were mishandled, and handwashing practices were insufficient. The FSD acknowledged the lack of a cleaning schedule and proper food labeling, contributing to the deficiencies.
A facility failed to develop a comprehensive baseline care plan within 48 hours for a resident with multiple diagnoses, including atrial fibrillation and anemia. The care plan only addressed malnutrition risk, omitting other critical areas like falls and pain management. The DON acknowledged the oversight, which violated the facility's policy requiring a complete care plan to meet immediate health needs.
A facility failed to provide a resident with a discharge summary and post-discharge instructions, leading to a deficiency. The resident, with multiple medical conditions and moderate cognitive impairment, was discharged without documented evidence of receiving necessary care instructions. Interviews with staff revealed inconsistencies in the discharge process, and records showed missing prescriptions and signatures. This lack of documentation and communication resulted in an incomplete discharge plan.
A resident with a history of atrial fibrillation and other conditions experienced a change in condition with low oxygen saturation. The facility failed to document physician notification, obtain orders for oxygen and hospital transfer, and document RN assessments. Staff interviews revealed inconsistencies in documentation and communication, and facility policies were not followed.
A resident with a sacral pressure ulcer did not receive timely collagen treatment as recommended by the Wound Care Consultant (WCC). Despite weekly visits and recommendations from the WCC, the Treatment Administration Record lacked a collagen treatment order for a period in September. Interviews with staff revealed communication failures and a lack of adherence to the WCC's recommendations, contributing to the deficiency.
A facility failed to adjust a resident's medication times to accommodate their dialysis schedule, leading to incorrect timing of blood sugar checks and insulin administration. The resident, with chronic kidney disease and dependent on dialysis, had physician orders requiring medication timing adjustments, which were not reflected in the MAR. The Unit Manager and DON acknowledged the errors, which violated the facility's medication administration policy.
A facility failed to ensure proper infection control during medication administration. An LPN did not perform hand hygiene after handling a resident's used cups and did not wear PPE for a resident on contact isolation due to MRSA and MDRGN. There was no signage indicating the need for contact isolation, contrary to facility policy.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation, as observed by the surveyor. The Assistant Food Service Director (AFSD) demonstrated improper handwashing techniques, washing hands for too short a time. The kitchen equipment, including the oven, mixer, deli slicer, and can opener, were not properly cleaned or maintained. The oven was heavily soiled, and the cleaning schedule was missing. The mixer and deli slicer were not covered as required, and the can opener had debris on the blade, which the AFSD did not recognize as a potential contamination risk. In the walk-in refrigerator, several food items were improperly labeled and stored. Opened containers of applesauce, chopped chicken, baked chicken, cottage cheese, and sliced turkey deli meat lacked use-by dates, and some were past the recommended consumption period. In the walk-in freezer, pulled pork and pepperoni were stored beyond their use-by dates. The AFSD acknowledged that weekly walkthroughs were supposed to ensure food was within date, but this was not effectively implemented. During tray line service, improper handling of utensils was observed, with a ladle and scoop placed directly on the prep counter and then used to serve food. Handwashing practices were again noted to be inadequate, with a Dietary Aide washing hands for only 10 seconds. The Food Service Director (FSD) admitted to the lack of a cleaning schedule and acknowledged the need for proper labeling and dating of food items. The facility's policies on date marking, oven cleaning, and hand hygiene were not adhered to, contributing to the deficiencies observed.
Failure to Implement Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive baseline care plan within 48 hours of admission for a resident, as required by their policy. This deficiency was identified during a review of the medical records and interviews conducted by the surveyor. The resident in question was admitted with multiple diagnoses, including paroxysmal atrial fibrillation, pseudocyst of the pancreas, cognitive communication deficit, anemia, dizziness, and a need for assistance with personal care. Despite these complex medical needs, the baseline care plan provided by the facility was incomplete, consisting of only a single focus on the risk of malnutrition related to chronic disease and recent hospitalization, without addressing other critical areas such as falls, skin integrity, activities of daily living, or pain management. The Director of Nursing (DON) acknowledged the deficiency during an interview, stating that the baseline care plan should have been completed by the nurse or unit manager upon the resident's admission. The facility's policy, revised in March 2022, mandates that a baseline care plan be developed within 48 hours to address the resident's immediate health and safety needs, including initial goals based on admission orders and discussions with the resident or their representative. However, the care plan for this resident was not comprehensive, lacking necessary instructions and interventions to provide effective, person-centered care. The failure to adhere to this policy resulted in an incomplete care plan that did not meet professional standards of quality care.
Failure to Provide Discharge Instructions and Summary
Penalty
Summary
The facility failed to ensure that a resident was provided with a discharge summary and post-discharge instructions, which are essential for a safe and effective transition of care. This deficiency was identified during a review of Resident #155's closed records. The resident, who was moderately cognitively impaired, had multiple medical conditions including surgical aftercare following digestive system surgery, acute cholecystitis, and a need for assistance with personal care. Despite the complexity of the resident's medical needs, there was no documented evidence that the resident or their family received the necessary discharge instructions or education on managing the resident's care at home. Interviews with facility staff revealed inconsistencies and gaps in the discharge process. The Licensed Practical Nurse (LPN) and Unit Manager (UM) indicated that discharge instructions should have been provided and signed by the resident or their family, but there was no documentation to confirm this occurred. The Director of Nursing (DON) and Director of Social Services (DSS) also acknowledged that training and education should have been documented, but it was not. The DSS admitted to scrambling to arrange the discharge without a formal care conference, relying on phone calls with the resident's family. Further review of the resident's records showed that prescriptions for the care of the cholecystectomy drainage tube were not provided, and there was no evidence of a resident signature on the discharge instructions. The LPN/UM's handwritten note on the discharge instructions lacked a date and time, and there was no progress note to confirm that the resident received the instructions. This lack of documentation and communication among the staff contributed to the failure to provide a comprehensive discharge plan, as required by the facility's policy.
Failure to Document and Obtain Orders for Resident's Change in Condition
Penalty
Summary
The facility failed to document a physician notification in response to a resident's change of condition, obtain an order for supplemental oxygen use, obtain an order to send the resident to the hospital, document a Registered Nurse (RN) assessment, and document a resident's clinical status after the resident was sent to the hospital. This deficiency was identified for one resident who was reviewed for a change in condition. The resident, who had a history of paroxysmal atrial fibrillation, pseudocyst of the pancreas, cognitive communication deficit, anemia, dizziness, and a need for assistance with personal care, experienced a change in condition that was not properly documented or managed according to professional standards. The resident's health status note indicated that the resident was found with an oxygen saturation level of 87%, which is below normal parameters. Despite this, there was no documented order for oxygen or for sending the resident to the hospital. The Licensed Practical Nurse (LPN) involved stated that they typically called the doctor for a prn order for oxygen but might have forgotten to document it. Additionally, the Registered Nurse/Infection Preventionist (RN/IP) did not document her assessment findings, and there was no follow-up note regarding the resident's status after being sent to the hospital. Interviews with facility staff revealed inconsistencies in the documentation and communication processes. The LPN/Unit Manager (UM) and the Director of Nursing (DON) acknowledged that vital signs should have been documented every shift and that an order should have been obtained to send the resident to the hospital. The facility's policies on resident examination, vital signs, and change in condition were not adhered to, leading to a lack of proper documentation and communication regarding the resident's care and condition.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to address the recommendations from the Wound Care Consultant (WCC) in a timely manner for a resident with a sacral pressure ulcer. The resident, who had diagnoses including pressure ulcer of the sacral region, diabetes mellitus type 2, paraplegia, and morbid obesity, was observed by the surveyor and confirmed to have a wound. The resident's Minimum Data Set indicated intact cognition and a pressure ulcer present upon admission. The care plan included interventions for treatments as ordered and consultation with the WCC. The WCC reports from late August to early September recommended a collagen treatment for the resident's sacral pressure ulcer, which showed no improvement over time. However, the Treatment Administration Record (TAR) did not include a collagen treatment order for the period from September 6 to September 16. Additionally, the progress notes lacked documentation related to the WCC recommendations, wound treatment re-evaluation, or physician notification for new treatment orders. Interviews with the LPN, RN/UM, and DON revealed a breakdown in communication and follow-through on the WCC's recommendations. The WCC stated that recommendations were discussed with the DON and UM during exit meetings, and she expected to be notified if her recommendations were not followed. The facility's policies did not include specific procedures for addressing WCC recommendations or re-evaluating wound treatments with a duration. This lack of adherence to the WCC's recommendations and the absence of a treatment order for the resident's sacral wound led to the deficiency identified by the surveyor.
Failure to Adjust Medication Timing for Dialysis Schedule
Penalty
Summary
The facility failed to adjust a resident's medication times to accommodate their dialysis schedule, resulting in a deficiency. The resident, who has acute kidney failure, chronic kidney disease, and is dependent on renal dialysis, was observed with moderately impaired cognition. The resident's physician orders specified dialysis treatment three times a week and required medication and treatment timing adjustments to align with the dialysis schedule. However, the Medication Administration Record (MAR) did not reflect these necessary adjustments, leading to incorrect timing of blood sugar checks and insulin administration. The Unit Manager Registered Nurse confirmed that blood sugar checks were conducted at incorrect times on several days when the resident was not scheduled for dialysis. The Director of Nursing acknowledged that medication administration should be coordinated with the resident's presence in the facility and dialysis schedule. The facility's policy on administering medications mandates adherence to prescriber orders, including timing, which was not followed in this case.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during a medication administration observation. An LPN was observed entering a resident's room to administer medication without performing hand hygiene afterward. The LPN handled the resident's used medicine and drinking cups with bare hands and did not sanitize her hands before returning to the medication cart. This lapse in hand hygiene occurred despite the resident having a diagnosis of parainfluenza virus pneumonia, chronic obstructive pulmonary disease with acute exacerbation, and acute respiratory failure with hypoxia. Additionally, the facility did not adhere to transmission-based precautions for a resident on contact isolation due to MRSA and MDRGN. There was no signage outside the resident's room indicating the need for contact isolation, and the LPN did not wear any PPE while administering medication. The facility's policy required clear identification of the type of precautions and the necessary PPE, as well as signage to inform staff and visitors. The failure to follow these protocols was confirmed by the LPN/Unit Manager and the Infection Preventionist during interviews.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sewell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Center For Rehab & Nursing Washington Township | 1.6 mi | ★★★★★ | 18 | 1 |
| United Methodist Communities At Pitman | 4.8 mi | ★★★★★ | 4 | 0 |
| Elmwood Hills Healthcare Center Llc | 5.3 mi | ★★★★★ | 1 | 1 |
| Cedar Grove Respiratory And Nursing Center | 5.3 mi | ★★★★★ | 0 | 0 |
| Advanced Subacute Rehabilitation Center At Sewell | 6.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.