Atlas Rehabilitation & Healthcare at West Deptfor

In the surveyor’s words

From the most serious findings on record at Atlas Rehabilitation & Healthcare at West Deptfor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 9, 2024

  Based 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 [DATE] 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. […]

• No harm, potential for more than minimal, patternF607Dec 10, 2025

  Based 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. The deficient practice was identified for 1 of 151 employees reviewed for background checks (Employee #30) and 57 of 151 employees reviewed for reference checks (Employee #1, Employee #2, Employee#3, Employee #4, Employee #5, Employee #6, Employee #7, Employee #8, Employee #9, Employee #10, Employee #11, Employee #12, Employee #13, Employee #14, Employee #15, Employee #16, Employee #17, Employee #18, Employee #19, Employee #20, Employee #21, Employee #22, Employee #23, Employee #24, Employee #25, Employee #26, Employee #27, Employee #28,… […]

• No harm, potential for more than minimal, patternF812Nov 1, 2022

  FACILITY 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. […]

• No harm, potential for more than minimal, isolatedF627Aug 18, 2026

  COMPLAINT # 2800691 Based on interview, medical record review, and review of pertinent facility documentation on 8/17/26 and 8/18/26, the facility failed to complete a thorough and accurate discharge summary for Resident #3 when it did not include a post-discharge appointment. The deficient practice was identified for one of two residents (Resident #3) reviewed for discharge and was evidenced by the following:A review of Resident #3's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: displaced intertrochanteric fracture of the left femur (a break in the upper part of the thigh bone between the hip joint and the main shaft), vascular dementia, and chronic diastolic (congestive) heart… […]

• No harm, potential for more than minimal, isolatedF584Dec 10, 2025

  Based 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. […]