Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 & Healthcare At West Deptfor during CMS and state inspections, most recent first.
Failure to complete required pre-employment screening: the facility did not document a background check for one admission coordinator and did not document reference checks for 57 newly hired employees, including CNAs, NAs, LPNs, RNs, housekeepers, dietary staff, activities staff, a receptionist, and a nursing supervisor. The HRD stated that background checks and at least two reference checks were required for each new hire, and the LNHA acknowledged that these checks should be completed before hire and kept in the personnel file.
Dirty Shower Room Toilets: Surveyors observed strong urine odor, yellow staining, dirt, debris, and brown matter on training room toilets in two shower rooms. An LPN/UM, housekeeping staff, the ESD, and the IP all acknowledged the toilets were dirty and that the condition was an infection control concern before resident use.
MDS Incorrectly Coded Smoking Status: A resident with COPD and a pulmonary nodule was observed smoking in the designated smoking area, yet the comprehensive MDS coded the resident as not being a smoker. Records, including the care plan, smoking/nicotine assessments, and a social services note, identified the resident as a smoker, and staff interviews confirmed the resident routinely smoked and that the MDS was coded incorrectly.
A resident with multiple pressure ulcers, including a stage 4 sacral ulcer, was found on a low air loss mattress that was not set to the resident’s documented weight. The mattress pump was observed at 160 pounds and later at 200 pounds, while the resident weighed about 140.8 pounds. Staff stated the setting should match the resident’s weight and that nurses were responsible for checking the pump each shift.
BiPAP Mask Left Uncovered on Nightstand: A resident with sleep apnea, chronic respiratory failure with hypoxia, and COPD had a BiPAP machine in the room with the mask uncovered on the nightstand during survey observations. The resident also received oxygen via nasal cannula, and staff including an LPN, the IP, and the DON stated the BiPAP mask should be stored in a bag when not in use for infection control purposes, while the facility policy called for storage in an open bag or container.
The facility failed to keep kitchen equipment and nutrition room equipment clean and sanitary. In the kitchen, ovens, a 6-burner stove, and an attached oven had baked-on food debris and sticky buildup, and the FSD acknowledged the equipment was not cleaned per policy. In the East and 2nd floor nutrition rooms, cabinet drawers had crumb debris among resident snacks, refrigerators had damaged seals with black debris, freezers had ice buildup, and a microwave had splatters and debris; the LPNs and ESD acknowledged the areas were not clean per policy.
An LPN and another LPN failed to follow infection control practices during wound care for a resident with multiple pressure ulcers, chronic osteomyelitis, aphasia, and malnutrition. Observed lapses included placing supplies on the over-bed table before it dried, handling the trash can with gloved hands, failing to remove gloves and perform hand hygiene before opening dressing supplies and handling wound materials, reusing packing that fell onto the resident's brief, touching the resident with bare hands before hand hygiene, and returning uncleaned supplies to the treatment cart. Staff acknowledged the cross-contamination concerns during the observation.
A resident with quadriplegia and neurogenic bowel filed a grievance after wound care was provided but not documented in the medical record. Review of the TAR and Progress Notes showed no evidence that the wound vacuum dressing change and skin prep were completed as ordered, despite staff confirming the care was given. The LPN admitted to forgetting to document the treatment, resulting in an incomplete medical record.
A resident with multiple medical conditions, who was cognitively intact and dependent on staff for ADLs, filed a grievance about staff conduct. The facility failed to provide the required written summary of the grievance investigation and outcome, as confirmed by interviews with the resident, Administrator, and DON, in violation of facility policy.
The facility failed to maintain kitchen sanitation, with issues such as improper hair restraint, dented cans, wet nesting of pans, and a dishwasher operating below required temperatures. Spoiled food was found in the refrigerator, and temperature logs were incomplete. Unlabeled and undated food items were also discovered, indicating a failure to adhere to food safety practices.
A facility failed to obtain a physician order for a resident's Foley catheter use after reinsertion, despite the resident's diagnosis of Benign Prostatic Hyperplasia with Lower Urinary Symptoms. The absence of a physician order was confirmed by both the LPN and DON, and the facility's policy did not specify the need for such an order.
The facility failed to maintain accurate records of controlled medications, as none of the reviewed DEA 222 forms had the delivery amount and date entered. The DON, responsible for completing these forms, did not fill in the required sections, believing that keeping delivery slips was sufficient. Additionally, the facility lacked a policy for handling DEA 222 forms, contributing to the deficiency.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
The facility failed to implement its abuse policy by not completing required reference checks and background checks on employees before their start dates. The deficiency was identified during review of personnel files for 151 employees hired since the last standard survey, including one employee for whom no background check was found prior to employment and 57 employees for whom no reference check was found prior to employment. The surveyor requested the personnel files of all new employees hired since the prior standard survey, whether currently employed or terminated. Review of the files showed that Employee #30, an admission coordinator with a start date of 2/10/25, had no evidence of a background check prior to the start of employment. The same review also showed no evidence of a reference check prior to employment for Employees #1 through #57, including CNAs, NAs, LPNs, RNs, housekeepers, dietary staff, activities staff, a receptionist, a nursing supervisor, and an admission coordinator. During interviews, the HRD stated that a background check would be obtained on every newly hired employee and that a minimum of two reference checks would be obtained on every newly hired employee. The HRD stated that it was important to obtain these checks to confirm the employee was a good worker, had good attendance, and did not have abnormalities such as drug issues. The LNHA acknowledged that background checks should be done prior to hire and that two reference checks should be documented in the employee file. The facility policy titled Abuse, Neglect and Exploitation, revised 7/2024, stated that potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property and that background, reference, and credential checks would be conducted, with documentation maintained in the employee personnel file.
Dirty Shower Room Toilets
Penalty
Summary
The facility failed to maintain the training room toilets in a clean and homelike environment in 2 of 3 shower rooms inspected on the East and West nursing units. During observation of the East Wing Shower Room, a strong odor was noted around the toilet, and the toilet base had yellow staining with dirt and debris on the rear and sides. The unit manager stated it should have been cleaned that morning, and later confirmed that no residents had been showered yet that day. A housekeeping associate stated she had cleaned the area on 12/2/25 and that the yellow staining likely was urine and did not appear recent. She also observed brown matter below the toilet handle and stated it looked and smelled like someone had just had a bowel movement, with possible feces above the handle. In the [NAME] Unit Shower Room, the surveyor observed dark colored matter and debris on both sides of the base of the toilet. The concierge stated the toilet needed to be cleaned because it looked like a combination of dirt and staining on the base. The environmental services director stated the toilet looked dirty, like urine, and needed to be cleaned, and also said the brown matter above the handle was dirty and may have been touched by a dirty hand with feces on it. The infection preventionist stated it was an infection control issue if the toilets were not cleaned prior to resident usage and that hand hygiene would be required after usage to prevent the spread of infection.
MDS Incorrectly Coded Smoking Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected a resident’s smoking status. Resident #141 had diagnoses including chronic obstructive disease and a solitary pulmonary nodule, and the comprehensive MDS dated [DATE] included a BIMS score of 13 out of 15, indicating intact cognition. However, section J1300 of that MDS coded the resident as not being a smoker, even though the resident had a documented history of smoking and a care plan focus area dated 7/18/24 stating that the resident liked to smoke and had a history of smoking. Survey observation on 12/8/25 showed Resident #141 outside in the smoking area smoking two cigarettes. Facility records also included Smoking/Nicotine Devices assessments dated 6/17/25 and 9/15/25 stating that the resident used smoking/tobacco/nicotine products and did not require supervision while smoking, and a social services progress note dated 11/4/25 stating the resident was a smoker. Staff interviews confirmed the resident was a smoker: a CNA stated the resident had been a known smoker since February 2025, an LPN/UM stated the resident went out to smoke three times a day, and the MDSC confirmed the MDS was coded incorrectly and should reflect that the resident was a smoker. The DON stated the MDS should be accurate and that the MDSC should review records, progress notes, and residents to ensure accuracy.
Low Air Loss Mattress Set Incorrectly for Resident With Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident’s low air loss mattress was accurately set according to the resident’s weight. Resident #13 was admitted with diagnoses including a stage four sacral pressure ulcer, a pressure ulcer of the left hip unstageable, a pressure ulcer of the right buttock, chronic osteomyelitis, aphasia following cerebral infarct, and protein-calorie malnutrition. The resident’s quarterly MDS dated 11/26/25 showed a weight of 141 pounds and identified two stage three pressure ulcers and one stage four pressure ulcer present on admission. The care plan included a low air loss mattress for a draining sacral wound, and the physician’s order required checking the mattress placement and function every shift. During observation, the resident was seen lying in bed on an air mattress that was set at 160 pounds, and later the mattress pump was observed set at 200 pounds while the resident’s documented weight was 140.8 pounds. An LPN stated the pump should have been set at 140 pounds and adjusted it between 120 and 140 pounds to match the resident’s weight. The assigned nurse stated she had not yet checked the pump setting, and the unit manager and DON stated nurses were responsible for checking the low air loss mattress setting each shift and that it was set to the resident’s body weight to offload pressure.
BiPAP Mask Left Uncovered on Nightstand
Penalty
Summary
The facility failed to ensure respiratory equipment was stored appropriately to prevent the spread of infection for one resident receiving respiratory care. On 12/4/25, the surveyor observed the resident sitting on the bed with oxygen infusing at 3 liters via nasal cannula, and a BiPAP machine on the nightstand with the mask uncovered. The resident’s record showed diagnoses including sleep apnea, chronic respiratory failure with hypoxia, and COPD. The resident’s BIMS score was 11 out of 15, indicating moderately impaired cognition, and the care plan included interventions for sleep apnea and monitoring respiratory status. The physician ordered BiPAP at 17/13 with 3 liters of oxygen at bedtime and removal in the morning. The December 2025 TAR showed BiPAP use on two nights. On follow-up observation, the resident was again in bed with oxygen via nasal cannula, and the BiPAP mask remained uncovered and touching the nightstand surface. The LPN/UM observed the mask and stated it should be in a bag to prevent infection and cross contamination. The LPN/UM, the IP, and the DON each stated the BiPAP mask should be stored in a bag when not in use for infection control purposes, while the facility’s BiPAP and CPAP policy stated to store the mask in an open bag or container.
Kitchen and Nutrition Room Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean, safe, and sanitary manner. During observation in the kitchen with the Food Service Director present, two convention ovens had baked-on food debris on the glass doors and inside surfaces, the six-burner stove top had debris on all six burners and around the cooker hats, and the attached oven was dirty with a brown, sticky thick substance dripping from the cooktop area into the interior oven doorframe. The Food Service Director acknowledged that the equipment was not cleaned according to facility policy. The facility also failed to maintain nutrition room equipment in a clean, safe, and sanitary manner in the East and 2nd floor nutrition rooms. In both rooms, cabinet drawers contained multicolored crumb debris among resident snacks such as cookies and crackers. The East unit refrigerator had a cracked and ripped door seal with black debris in the seal track, and the frost-free freezer had sheets of ice present; the microwave had multicolored splatters and debris on the interior ceiling. On the 2nd floor, the refrigerator had a cracked and ripped door seal with black debris in the seal track, and the frost-free freezer had ice present on the back panel. The unit managers acknowledged the areas were not cleaned according to facility policy, and the Environmental Services Director stated housekeeping was to surface clean nutrition rooms daily and deep clean them weekly, while also acknowledging the surveyor concerns and that the areas were not clean according to policy.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards and procedures during wound treatments for a resident with multiple pressure ulcers and significant medical complexity, including a stage four sacral pressure ulcer, pressure ulcers of the left hip and right buttock, chronic osteomyelitis, aphasia following cerebral infarct, and protein-calorie malnutrition. The resident was observed lying in bed on an air mattress, and the record showed the wounds were present on admission. The care plan included enhanced barrier precautions because of an indwelling urinary catheter and wounds. During the wound treatment observation, two LPNs donned gowns and gloves before entering the room, but multiple infection control lapses were observed throughout the procedure. Supplies were placed on the over-bed table before the table had dried after being wiped, a trash can was handled with gloved hands and passed between staff, and gloves were not removed with hand hygiene performed before opening dressing supplies and removing soiled dressings. The nurse also failed to doff gloves and perform hand hygiene before pouring Dakin's solution into cups and soaking gauze for packing into the wounds. The observation further showed that when packing fell out of the sacral wound onto the resident's incontinence brief, an LPN picked it up with gloved hands and placed it back into the wound. The nurse also failed to perform hand hygiene before touching the resident with bare hands to reposition them, failed to clean the outside of reusable wound solution bottles before returning them to the treatment cart, and returned supplies to the cart after use. Facility staff interviewed during the observation acknowledged concerns for cross-contamination, contamination of the wound bed, and contamination of the treatment cart, and the facility's wound care and hand hygiene policies required hand hygiene, clean fields, no-touch technique, and wiping reusable supplies before return.
Failure to Document Wound Care Provided to Resident
Penalty
Summary
A deficiency was identified when the facility failed to maintain accurate and complete medical records for a resident with quadriplegia, neurogenic bowel, and neuromuscular bladder dysfunction. The resident, who was cognitively intact, filed a grievance indicating that a nurse had changed their wound dressing following a bowel movement. However, a review of the Treatment Administration Record (TAR) and Progress Notes for the relevant date showed no documentation that the wound vacuum dressing was changed or that skin prep was applied, as ordered. The facility's policy required all services provided to be documented in the resident's medical record. Interviews with the resident, an LPN shift supervisor, and the Director of Nursing confirmed that the wound care was provided, but the LPN admitted to forgetting to document the treatment due to a shift change. The DON also acknowledged that documentation should have been completed to reflect the care provided. The lack of documentation resulted in an incomplete medical record, contrary to facility policy and accepted professional standards.
Failure to Provide Written Grievance Investigation Summary to Resident
Penalty
Summary
A resident with diagnoses including iron deficiency anemia, orthopedic aftercare following surgical amputation, acquired absence of right leg below knee, and morbid obesity, who was cognitively intact and required assistance with activities of daily living, reported a grievance regarding the conduct of staff. The resident expressed dissatisfaction with the behavior of staff members, describing them as rude, and formally submitted a grievance to the facility. Despite the facility's policy requiring that residents be informed both verbally and in writing of the findings of any grievance investigation and the actions taken, the resident did not receive a written summary of the investigation or its outcome. Interviews with the resident, the Administrator, and the DON confirmed that no written response was provided to the resident regarding the grievance, which was in direct violation of the facility's established grievance policy.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner, leading to several deficiencies that could potentially result in foodborne illness. During an inspection, a dietary aide was observed with lengthy braids not fully contained within a hair net, exposing the hair to the kitchen environment. This lack of proper hair restraint is a violation of hygienic practices meant to prevent contamination of food from physical objects. In the dry storage room, a can of diced pears was found with a significant dent on the upper seam, which was not immediately removed from the storage area. Additionally, a stack of half pans was found wet and improperly stored, a condition known as wet nesting, which can promote the growth of microorganisms. The high-temperature dishwasher was also found to be operating below the required temperatures for effective cleaning and sanitization, with recorded temperatures significantly lower than the minimum standards. Despite the dishwasher's failure to meet these standards, it continued to be used until the issue was identified by the surveyor. Further inspection revealed issues with food storage in the walk-in refrigerator, where parsley and lettuce were found to be spoiled and slimy. Additionally, the temperature logs for the refrigerator and freezer were incomplete, with missing entries for specific dates. Unlabeled and undated food items were also found in the refrigerator, including sandwiches and a salad, which were not properly labeled or dated as per facility policy. These observations indicate a failure to adhere to food safety practices throughout the facility's food handling process.
Lack of Physician Order for Foley Catheter Use
Penalty
Summary
The facility failed to ensure that there was a physician order for the use of a Foley catheter for a resident who was reviewed for catheter use. The resident, who had a diagnosis of Benign Prostatic Hyperplasia with Lower Urinary Symptoms, was admitted to the facility and had a Foley catheter reinserted after a failed voiding trial. Despite the reinsertion of the catheter, there were no physician orders documented for the use and care of the Foley catheter after the previous orders were discontinued. The deficiency was identified through observations, interviews, and a review of medical records and facility documentation. The Licensed Practical Nurse/Unit Manager and the Director of Nursing both confirmed the absence of a physician order for the Foley catheter, which is required for the care of residents. The facility's policy on catheter care did not specify the need for a physician order for the use of a Foley catheter, contributing to the oversight.
Incomplete Documentation of Controlled Medications
Penalty
Summary
The facility failed to maintain a detailed record of receipts and accurate reconciliation of controlled medications, as evidenced by incomplete DEA 222 forms. The surveyor reviewed seven DEA 222 forms from the past six months and found that none of them had the delivery amount and date entered. Additionally, two of the forms did not have the number of packages completed and accurately documented. The Director of Nursing (DON) was responsible for completing these forms and admitted to not filling in Part 5, which requires the number of packages received and the date received, as she believed keeping copies of delivery slips was sufficient. During the survey, it was revealed that the facility did not have a policy for handling DEA 222 forms. The Licensed Nursing Home Administrator (LNHA) confirmed the absence of such a policy. The printed instructions on the DEA 222 form clearly indicated that Part 5 should be filled in by the purchaser, which was not done in this case. This lack of documentation and policy adherence led to the deficiency noted by the surveyor.
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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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Nursing homes near West Deptford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shady Lane Gloucester Co Home | 2.2 mi | ★★★★★ | 13 | 0 |
| Atlas Post Acute At Woodbury Country Club | 5.1 mi | ★★★★★ | 1 | 0 |
| Aventura At Prospect | 5.3 mi | ★★★★★ | 16 | 0 |
| Advanced Subacute Rehabilitation Center At Sewell | 6.3 mi | ★★★★★ | 2 | 0 |
| Little Flower Manor | 6.5 mi | ★★★★★ | 1 | 0 |
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