Inspection Reports for
Atlas Post Acute At Woodbury Country Club

Complaint 2616856 was substantiated based on interviews, record review, and policy review conducted on 9/26/2025 and 9/29/2025, confirming late medication administration and failure to follow policy.

The facility failed to administer a scheduled pain medication on time to Resident #1, resulting in potential unrelieved pain and discomfort. The medication was given 1 hour and 53 minutes late, and the facility did not follow its policy requiring medications to be administered within one hour of the prescribed time.

Complaint NJ #s: 170485, 171460, 171463, 175528, 176079, 182187, 182553, 184884, and 185001 were investigated during this survey.

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 investigations NJ184884, NJ170485, NJ176079, NJ182553, NJ171463, NJ171460.

The facility was found deficient in multiple areas including inaccurate medication administration and documentation, failure to complete skin assessments as ordered, insufficient nursing staff and delayed call bell responses, improper medication storage, inaccurate dietary tray contents, improper infection control hand hygiene practices, and unsafe food handling and storage.

Complaint numbers NJ184884, NJ170485, NJ176079, NJ182553, and NJ171463 were investigated. The complaints involved medication administration errors, inadequate skin assessments, missed showers, and insufficient nurse staffing with delayed call bell responses. The complaint investigations found substantiated deficiencies in these areas.

The facility failed to maintain accurate accountability and documentation for the administration of Milrinone intravenous infusion, failed to complete accurate skin assessments upon admission and when new skin conditions were identified, failed to provide scheduled showers to a resident, and failed to ensure sufficient nursing staff and timely call bell responses.

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.

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 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.

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 NJ00173566 involved allegations that the facility failed to honor residents' end-of-life wishes, resulting in CPR on a DNR resident, and failures in medication documentation and infection control practices.

The facility failed to ensure residents' code status was properly documented and honored, resulting in an Immediate Jeopardy situation where CPR was performed on a resident with a documented DNR. Additionally, the facility failed to accurately document controlled substance medication administration times and failed to ensure proper PPE use for residents on COVID-19 isolation precautions.

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.

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.

Multiple complaints were investigated including issues with medication administration, staffing, nutrition, abuse, neglect, and resident property misappropriation.

The facility was found deficient in multiple areas including inadequate linen supply, failure to address grievances, abuse and neglect allegations, medication administration errors, insufficient staffing, poor nutritional services, inadequate respiratory care, incomplete medical records, and ineffective facility administration and quality assurance.

Complaint intake numbers NJ153073, NJ153306, NJ154286, and NJ154537 were associated with the survey.

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.

The facility was found deficient in several areas including failure to assess a resident for safe self-administration of medication, failure to timely encode and transmit a discharge Minimum Data Set (MDS) assessment, failure to conduct required neurological checks after a resident fall, and failure to consistently monitor refrigerator temperatures for food safety.

The complaint investigation found that the facility failed to conduct neuro checks as required after an unwitnessed fall of Resident #281 on 04/10/2022. The deficiency was substantiated based on record review and staff interviews.

The facility failed to conduct and document neuro checks for Resident #281 as required after an unwitnessed fall on 2022-04-10. Interviews with nursing staff and administration confirmed expectations to follow the neuro check flowsheet, but documentation was missing for neuro checks at 7:40 PM and 8:40 PM on the day of the fall.

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.

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 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.

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.

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 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.

The facility was found deficient in properly labeling and storing food items, failing to ensure staff consistently used appropriate PPE when caring for residents under COVID-19 observation, and not disinfecting shared equipment between residents. These deficiencies posed minimal harm or potential for actual harm to a few or some residents.