Inspection Reports for Atlas Post Acute At Woodbury Country Club
467 Cooper Street, NJ, 08096
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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 details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 117
Deficiencies: 11
Apr 24, 2025
Visit Reason
A Recertification Survey was conducted from 4/16/25 to 4/24/25 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations.
Findings
The facility was found to have multiple deficiencies related to comprehensive care plans, ADL care, skin integrity, respiratory care, sufficient nursing staff, pharmacy services, drug regimen, food safety, infection control, and life safety code compliance. Deficiencies were identified for several residents and involved issues such as documentation, medication administration, staffing, and emergency preparedness.
Complaint Details
Complaint NJ #s: 170485, 171460, 171463, 175528, 176079, 182187, 182553, 184884, and 185001 were investigated during this survey.
Severity Breakdown
Level 3: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) - Comprehensive Care Plans not meeting professional standards of quality. | Level 3 |
| ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2) - Facility failed to ensure a resident was provided ADL care as scheduled. | Level 3 |
| Skin Integrity CFR(s): 483.25(b)(1)(i)(ii) - Facility failed to ensure comprehensive assessment and treatment of pressure ulcers. | Level 3 |
| Respiratory/Tracheostomy Care and Suctioning CFR(s): 483.25(i) - Facility failed to provide respiratory care consistent with professional standards. | Level 3 |
| Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2) - Facility failed to ensure sufficient nursing staff and timely response to call bells. | Level 3 |
| Pharmacy Services CFR(s): 483.45(a)(b)(1)-(3) - Facility failed to provide pharmaceutical services including consultation and medication administration. | Level 3 |
| Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6) - Facility failed to ensure residents were free from unnecessary drugs. | Level 3 |
| Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2) - Facility failed to properly label and store drugs and biologicals. | Level 3 |
| Food Procurement, Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2) - Facility failed to maintain food safety and sanitation standards. | Level 3 |
| Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) - Facility failed to establish and maintain an infection prevention and control program. | Level 3 |
| Life Safety Code - Emergency Lighting CFR(s): NFPA 101 - Facility failed to provide functioning emergency lighting for emergency generator transfer switch. | Level 3 |
Report Facts
Census: 117
Survey Dates: Survey conducted from 2025-04-16 to 2025-04-24.
Deficiency Completion Dates: Plans of correction completion dates range from 2025-05-14 to 2025-06-11.
Staffing Ratios: 13
Staffing Ratios: 11
Medication Administration Audit Times: 9
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 1
Apr 10, 2025
Visit Reason
The inspection was conducted based on complaints NJ182547 and NJ183498 to investigate staffing ratio compliance at the facility.
Findings
The facility was found not in compliance with New Jersey staffing ratio requirements, failing to meet minimum Certified Nurse Aide (CNA) staffing levels on 4 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint numbers NJ182547 and NJ183498 triggered the investigation. The facility was found deficient in CNA staffing on specific dates, but no residents were identified as immediately affected. The complaint was substantiated by the findings.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 4 of 14 day shifts reviewed, specifically CNA staffing shortages. |
Report Facts
Deficient CNA staffing days: 4
Census on 03/23/25: 120
Census on 03/29/25: 116
Census on 03/30/25: 115
Census on 04/05/25: 113
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 4
Dec 20, 2024
Visit Reason
A Complaint Survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers listed in the report.
Findings
The facility was found not in substantial compliance with federal requirements related to residents' rights regarding treatment and advance directives, documentation of physician orders, and proper handling of residents' end-of-life wishes. Immediate Jeopardy was identified but later downgraded to a level D and then level E for no actual harm with potential for more than minimal harm. The facility implemented a removal plan and corrective actions including staff education and audits.
Complaint Details
Complaint investigation based on multiple complaint numbers NJ00170972, NJ00171675, NJ00173566, NJ00175663, NJ00177015, NJ00178159, NJ00179724, NJ00179726, NJ00180017, and NJ00180066. Immediate Jeopardy was identified on 12/10/24 and was determined to exist on 02/27/24 at F678. The facility submitted a removal plan and the Immediate Jeopardy was removed by 12/20/24.
Severity Breakdown
Immediate Jeopardy (IJ): 1
Level D: 1
Level E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure physician's orders matched residents' documented wishes and proper documentation of residents' code status and end-of-life wishes. | Immediate Jeopardy (IJ) downgraded to Level D and then Level E |
| Failure to ensure staffing ratios met minimum state requirements for CNA staffing on multiple day shifts. | — |
| Failure to ensure accurate documentation and administration of controlled substance medications. | — |
| Failure to maintain an effective infection prevention and control program including proper use of PPE. | — |
Report Facts
Survey Census: 90
Sample Size: 28
Complaint Staffing Deficiency: 7
Minimum CNA Staffing Required: 13
Deficiency Counts: 4
Inspection Report
Complaint Investigation
Census: 115
Capacity: 124
Deficiencies: 14
Jan 9, 2024
Visit Reason
Complaint survey conducted by the New Jersey Department of Health due to multiple complaints alleging failure to ensure residents were free from abuse/neglect and failure to provide and maintain pharmaceutical services to meet residents' needs, constituting Immediate Jeopardy.
Findings
The facility was found not in substantial compliance with multiple federal requirements including failure to prevent abuse and neglect, failure to provide timely and appropriate pharmaceutical services, inadequate nursing staffing and competency, failure to maintain accurate and complete resident records, failure to provide adequate nutrition and palatable food, and failure to administer medications timely and accurately. Immediate Jeopardy was identified and later removed after the facility implemented an acceptable removal plan.
Complaint Details
Multiple complaints alleging failure to ensure residents were free from abuse/neglect and failure to provide and maintain pharmaceutical services to meet residents' needs, constituting Immediate Jeopardy at F600-L and F755-L. Immediate Jeopardy was removed after acceptable removal plans were implemented.
Severity Breakdown
Immediate Jeopardy: 2
Substandard Quality of Care: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from abuse and neglect, including an incident where adhesive paste was found inside a resident's stoma and failure to monitor a resident after an unwitnessed fall. | Immediate Jeopardy |
| Failure to provide and maintain pharmaceutical services to meet residents' needs, including delays and omissions in medication administration and failure to report and investigate medication issues. | Immediate Jeopardy |
| Failure to provide adequate nursing care and services, including inadequate staffing levels and failure to respond timely to call lights, assist with toileting, medication administration, meals, and hygiene. | Substandard Quality of Care |
| Failure to ensure residents received nutritional care and services to maintain adequate nutritional status, including lack of nutritional assessments and failure to monitor meal intake. | — |
| Failure to provide respiratory and tracheostomy care and suctioning consistent with professional standards and physician orders. | — |
| Failure to ensure agency nursing staff competency and orientation prior to working with residents. | — |
| Failure to ensure medication error rate was less than 5%, with multiple missed or late medication administrations. | — |
| Failure to provide residents with a nourishing, palatable, well-balanced diet that meets their preferences and dietary needs. | — |
| Failure to ensure menus were followed and residents received foods in accordance with their prescribed diets. | — |
| Failure to ensure food was palatable, attractive, and served at a safe and appetizing temperature. | — |
| Failure to administer medications timely and accurately, including failure to have a contract or position description for the Medical Director and failure of the Medical Director to be aware of serious resident care issues. | — |
| Failure to maintain complete, accurate, and accessible resident records, including documentation of assessments, care, and medication administration. | — |
| Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to identify and correct quality deficiencies and monitor adverse events. | — |
| Failure to administer medications as ordered, including failure to have medications available upon resident admission and failure to notify providers timely. | — |
Report Facts
Survey Census: 115
Total Capacity: 124
Medication Error Rate: 31.9
CNA Staffing Ratio: 37
CNA Staffing Ratio: 14
Medication Administration Delay: 25
Medication Doses Missing: 1
Medication Doses Missed: 5
Meal Intake Documentation: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse | Named in medication administration delay and failure to administer medications timely |
| RN4 | Registered Nurse | Named in failure to monitor resident after fall and failure to notify physician |
| NP2 | Nurse Practitioner | Named in assessment and hospital transfer of resident R37 |
| Director of Nursing | Director of Nursing | Named in multiple findings including failure to ensure medication administration, documentation, and staffing oversight |
| Administrator | Facility Administrator | Named in failure to identify and report abuse allegation and failure to ensure effective facility administration |
| Dietary Manager | Dietary Manager | Named in failure to provide palatable food and respond timely to resident food preferences |
| Consultant Pharmacist | Consultant Pharmacist | Named in medication administration and pharmacy service failures |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Nov 8, 2023
Visit Reason
The inspection was conducted in response to complaint NJ168570 to assess compliance with regulatory requirements.
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 #: NJ168570. The facility is in substantial compliance based on this complaint visit.
Report Facts
Sample size: 6
Inspection Report
Annual Inspection
Census: 103
Deficiencies: 5
Apr 14, 2023
Visit Reason
Annual recertification survey conducted to assess compliance with federal and state regulations for long term care facilities, including complaint investigations.
Findings
The facility was found not in substantial compliance with several regulatory requirements including medication self-administration assessments, timely resident assessment transmissions, quality of care related to post-fall monitoring, food safety temperature monitoring, and minimum staffing ratios. Deficiencies were cited and plans of correction were submitted. A follow-up revisit confirmed all cited deficiencies were corrected.
Complaint Details
Complaint intake numbers NJ153073, NJ153306, NJ154286, and NJ154537 were associated with the survey.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to assess one resident for clinically appropriate self-administration of medication. | SS=D |
| Failure to encode and transmit a discharge Minimum Data Set (MDS) assessment timely for one resident. | SS=D |
| Failure to provide care and treatment after a fall for one resident, including missed routine examinations and documentation. | SS=D |
| Failure to ensure staff consistently monitored refrigerator temperatures for safe food storage. | SS=F |
| Failure to meet minimum certified nursing assistant (CNA) staffing ratios on multiple day and evening shifts over several weeks. | — |
Report Facts
Census: 103
Sample size: 28
Deficiencies cited: 5
Staffing deficiencies: 7
Staffing deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #12 | Registered Nurse | Mentioned in medication self-administration observation and interview. |
| RN #13 | Registered Nurse | Interviewed regarding resident self-administration of medication. |
| Assistant Director of Nursing | ADON | Provided statements on medication administration and staffing. |
| Director of Nursing | DON | Provided statements on medication administration and staffing. |
| Administrator in Training | AIT | Provided statements on medication administration and staffing. |
| Staffing Coordinator | SC | Provided statements on staffing shortages and recruitment efforts. |
Inspection Report
Life Safety
Deficiencies: 0
Apr 14, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 04/13/2023 to 04/14/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
Atrium Post Acute Care of Woodbury was found to be in substantial compliance with the Emergency Preparedness requirements and in compliance with Life Safety Code requirements. The facility is a one-story Type II Protected building built in 2016 and divided into 10 smoke zones.
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 4
Jan 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ157969 and NJ160570 regarding compliance with professional standards and staffing ratios.
Findings
The facility was found not in substantial compliance with professional standards of care, specifically failing to document medications and treatments as ordered for 2 of 6 residents, and failing to consistently complete activities of daily living documentation for 1 of 6 residents. Additionally, the facility failed to maintain required staffing ratios on multiple shifts and failed to secure the facility front doors at night as required.
Complaint Details
The complaint investigation was triggered by complaints NJ157969 and NJ160570. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on failures in medication documentation, ADL documentation, staffing ratios, and physical security of the facility.
Severity Breakdown
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to follow standards of clinical practice and document medications and treatments as ordered by the Physician for 2 of 6 residents. | SS=E |
| Failure to consistently complete the Resident's Documentation Survey Report v2 for 1 of 6 residents reviewed for Activities of Daily Living. | SS=E |
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 24 of 28-day shifts and 1 of 28 evening shifts. | — |
| Failure to lock and secure the facility front doors at night and follow its policy titled 'Visitation.' | — |
Report Facts
Census: 113
Staffing Deficiencies: 24
Staffing Deficiencies: 1
Sample Size: 6
Dates of Deficient Staffing: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to findings on medication/treatment documentation and ADL documentation deficiencies. |
| Certified Nurses Assistant | CNA | Mentioned in interviews regarding ADL documentation and door security. |
| Licensed Practical Nurse | LPN | Interviewed regarding door locking procedures. |
| Regional Nurse | Regional Nurse | Interviewed regarding door locking and visitation policies. |
| Maintenance Assistant | Maintenance Assistant (MA) | Interviewed and demonstrated door locking procedures. |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding door key and locking procedures. |
| Administrator | Administrator | Interviewed regarding door locking policies and facility admission practices. |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Dec 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ147967, NJ149497, NJ150114, and NJ150402 to investigate compliance with New Jersey Administrative Code 8:39 for licensure of long-term care facilities.
Findings
The facility was found not in substantial compliance due to failure to meet minimum certified nursing assistant (CNA) staffing ratios on multiple day and evening shifts during the weeks of 08/22/2021 - 08/28/2021 and 11/28/2021 - 12/04/2021. Staffing deficiencies had the potential to affect all residents.
Complaint Details
Complaint Intake #NJ147967 was substantiated with findings of deficient CNA staffing ratios. The facility was deficient in CNA staffing for residents on multiple shifts during the specified weeks. The Administrator acknowledged staffing challenges due to census fluctuations and difficulty hiring agency staff.
Deficiencies (1)
| Description |
|---|
| Failure to ensure minimum CNA staffing ratios on 6 of 7 day shifts and 3 of 7 evening shifts during 08/22/2021 - 08/28/2021 and on 7 of 7 day shifts and 3 of 7 evening shifts during 11/28/2021 - 12/04/2021. |
Report Facts
Census: 74
Staffing Deficiencies: 6
Staffing Deficiencies: 3
Staffing Deficiencies: 7
Staffing Deficiencies: 3
Census: 42
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided statements regarding staffing challenges and census fluctuations. |
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 0
Oct 1, 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: 5
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 25, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey licensure procedures and standards, specifically regarding the failure to report a dishwasher failure to the New Jersey Department of Health.
Findings
The facility failed to report the dishwasher being non-operational from 8/20/2021 through 8/25/2021 as required. The dishwasher was down, and the facility used paper products and hand-washed equipment during this period. Interviews and documentation confirmed the issue and lack of reporting.
Deficiencies (1)
| Description |
|---|
| Failure to report dishwasher failure to the New Jersey Department of Health as required. |
Report Facts
Dates dishwasher was down: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dietary Services | Director of Dietary Services | Provided documentation and interview regarding dishwasher failure |
| Director of Nursing | Director of Nursing | Interviewed about knowledge and reporting of dishwasher failure |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Jul 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ 144625 and NJ 146319.
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 numbers NJ 144625 and NJ 146319 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 44
Deficiencies: 0
Apr 13, 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 related to COVID-19.
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
Annual Inspection
Census: 54
Deficiencies: 2
Mar 31, 2021
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 food safety practices including improper labeling and storage of food items, and infection prevention and control failures including improper use of PPE by staff and failure to disinfect equipment between residents.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to properly handle potentially hazardous food and maintain dry storage area in a safe and consistent manner to prevent food-borne illness, including unlabeled and expired food items and improperly stored plastic ware. | SS=D |
| Facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) when caring for newly admitted residents under observation and failed to clean and disinfect equipment between residents, increasing risk of infection transmission. | SS=E |
Report Facts
Sample Size: 22
N95 masks inventory: 280
N95 masks inventory: 100
Plastic spoons and knives: 2
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Director | Interviewed regarding food labeling and storage deficiencies | |
| Certified Nursing Assistant (CNA) | Observed wearing incorrect PPE in cohort room | |
| Licensed Practical Nurse (LPN) | Observed wearing incorrect PPE in cohort room | |
| Registered Nurse #1 (RN) | Observed wearing incorrect PPE and delivering lunch tray | |
| Occupational Therapist (OT) | Observed wearing PPE incorrectly in cohort room | |
| Registered Nurse/Unit Manager (RN/UM) | Observed wearing incorrect PPE and assisting resident | |
| Director of Nursing (DON)/Infection Preventionist | Provided interviews and education related to infection control and PPE use | |
| Administrator | Provided PPE inventory and facility information | |
| Central Supply Supervisor | Provided PPE inventory and supply information | |
| RN #2 | Registered Nurse | Observed failing to disinfect vital signs equipment between residents |
Inspection Report
Life Safety
Deficiencies: 0
Mar 31, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Routine
Census: 35
Deficiencies: 0
Jan 12, 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: 5
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