Atlas Post Acute at Woodbury Country Club

Inspectors wroteComplaint 2616856Based on interview, record review, and policy review on 9/26/2025 and 9/29/2025, it was determined that the facility failed a. to ensure medications were administered to a resident according to standards of practice and b. to follow their own policy for medication administration. This deficient practice resulted in Resident #1 receiving a scheduled pain medication late, with the potential for unrelieved pain and discomfort. This deficient practice was identified for 1 of 8 sampled residents (Resident #1) and was evidenced by the following:According to Resident #1's admission Record (AR), the resident was admitted to the facility with diagnoses that included but were not limited to: fracture of the nasal bones. [...]

Inspectors wroteBased on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 4/16/25 from 9:37 AM to 10:33AM, the surveyor observed the following in the presence of the Food Service Director (FSD #1): The Dry Storage Room 1. Plastic portion cup lids spilling out of the plastic bag, not covered. The FSD #1 stated that the lids should be covered and in the plastic bag. 2. A box of white plastic fork utensils spilling out of the plastic bag, not covered. FSD #1 stated that that the plastic forks should be covered and stored in the plastic bag. Reach in Refrigerator 1. A half empty blue sports drink bottle not dated or labeled. [...]

Inspectors wroteComplaint: #NJ184884 #NJ 170485 Based on interview, record review, and review of facility documents, it was determined that the facility failed to: a.) maintain an accurate accountability for the management and administration of a Milrinone (a medication primarily used to treat life-threatening heart failure) intravenous infusion b.) ensure skin assessments were completed accurately upon admission, per physician's order, and according to the facility policy when a new skin condition was identified. This deficient practice was identified for 1 of 3 residents (Resident #179) reviewed for a change in condition and for 1of 5 residents (Resident # 178) reviewed for pressure ulcers and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteComplaint # NJ176079, #NJ182553 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a resident was provided a shower as scheduled. This deficient practice was identified for 1of 5 residents (Resident #122) reviewed for Activities of Daily Living (ADLs) and was evidenced by the following: On 4/17/25 at 10:00 AM, a resident council meeting was conducted with six (6) alert and oriented residents (Residents #19, #33, #39, #52 and #122), Resident # 122 stated that he/she was supposed to receive a shower the day before (4/16/25) and was not offered a shower. Resident #122 further stated that their shower days were Wednesdays and Saturdays and stated, My hair gets greasy. On 4/17/25 at 11:33 AM, the surveyor observed Resident #122 awake and alert sitting in their room, hair appeared slick. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 1 of 5 residents (Resident #32) reviewed for pressure ulcers and was evidenced by the following: On 4/17/25 at 9:53 AM, the surveyor observed Resident #32 lying in bed awake on an air mattress. The air mattress pump was noted on the foot of the bed and it was set at 350 pounds (lbs). When interviewed, the resident stated that they weighed 260 lbs. The resident stated that they had a wound on their left heel that resulted prior to admission after two hip surgeries. The resident stated that he/she wore a boot on the right foot. On 4/22/25 at 12:32 PM, the surveyor observed Resident #32 lying in bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) label, date, and store respiratory equipment in a sanitary manner and b.) clarify a physician's order. This deficient practice was identified for 1 of 1 resident (Resident #88) reviewed for respiratory care and was evidenced by the following: On 4/16/2025 at 10:10 AM, the surveyor observed resident #88 resting in bed, alert and awake. The nasal cannula (N/C - a medical device used to deliver supplemental oxygen or air to a patient through the nostrils) was draped over the resident's nightstand, open to air, and unused. At that time, the resident stated that he/she last used the oxygen yesterday (4/14/2025) and the doctor was trying to wean them off the oxygen. [...]

Inspectors wroteComplaint NJ #'s: 171463, 176079, and 182553 Based on interview, record review, and review of pertinent facility documentation, it was determined the facility failed to ensure sufficient nursing staff and call bells were answered timely without waiting a long period of time for 1 of 3 residents (Residents #182) reviewed for sufficient nurse staffing. This deficient practice was evidenced by the following: The surveyor reviewed the Call bell Audit Report for Resident #182 from 7/5/24 to 8/11/24. The section under Response reflected the following dates and response times greater than (>)15 minutes): [...]

Inspectors wroteComplaint NJ #171463 Based on observation, interview, record review and review of facility documentation, it was determined that the facility failed to a.) administer medications in accordance to the physician's orders for Resident #177), b.) ensure that the declining controlled substance count was signed for two (2) residents (Resident #20 and #58) on one (1) of three (3) medication carts (cart #3) checked during the medication storage task, and c.) ensure that the narcotic shift to shift was not presigned on one (1) of three (3) medication carts checked during the Medication storage task. This deficient practice was evidenced by the following: 1.) On 4/23/25 at 2:00 PM, the surveyor reviewed the medical record for Resident #177. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to appropriately administer pain medications in accordance with physician orders. This deficient practice was identified for one (1) of five (5) residents (Resident #20) reviewed for unnecessary medications and was evidenced by the following: On 4/23/25 at 10:12 AM, the surveyor observed Resident #20 in bed with their eyes closed. On 4/23/25 at 10:19 AM, the surveyor reviewed the medical records for Resident #20. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, generalized anxiety disorder. [...]

Inspectors wroteComplaint NJ#: 171460 Based on observation, interview, and review of facility documents, it was determined that the facility failed to store medications properly. This deficient practice was identified on one (1) of two (2) units (200 Unit) and evidenced as follows: On 4/16/25 at 11:05 AM, during the initial tour, the surveyor entered Resident #10's room and observed a fluticasone-salmeterol 500 - 50 microgram/actuation (mcg/act) inhaler (used to treat chronic obstructive pulmonary disease, a progressive lung disease that makes it difficult to breathe) on the resident's overbed table. At 11:11 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #7, who stated that medications were stored in the medication cart and should never be left in the resident's room at the bedside. At that time, LPN #7 was informed that the fluticasone-salmeterol was in the resident's room. [...]

Inspectors wroteComplaint NJ #171463 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were accurately implemented for 1 of 1 resident (Resident #20) reviewed for dining and was evidenced by the following: On 4/22/25 at 8:50 AM, the surveyor observed Resident #20 sitting upright in their bed with a breakfast tray on the overbed table. The resident's diet slip indicated a Western omelette, home-fried potatoes, margarine, two cold cereals, yogurt, coffee with cream and sugar. Instead of an omelet, the resident's breakfast tray included scrambled eggs, one cold cereal, and no yogurt. At that time, the surveyor interviewed the resident, who stated that occasionally the facility ran out of yogurt, and would not receive any. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to prevent the spread of infection. This deficient practice was identified for 2 of 2 Licensed Practical Nurses (LPN #6, and #7) observed during the medication observation task and was evidenced by the following: On 4/17/2025 at 8:49 AM, the surveyor observed Licensed Practical Nurse (LPN #6) administer the medication to Resident #112. After administering the medication and performing hand hygiene, she went into an unsampled resident's room to assist the resident. She touched the resident's mattress, then proceeded to wash her hands. After washing her hands, she turned off the faucet with her bare hand. [...]

Inspectors wroteComplaint#: NJ00173566 Based on interviews, record reviews, and a review of the facility's policy, it was determined that the facility failed to ensure residents code status was documented in the medical records, the Physician's Order for Life-Sustaining Treatment (POLST) reflected the residents' end of life wishes and the proper documentation was completed so that those end of life wishes were honored in the facility and/or during transport. The facility also failed to follow its policies titled Residents' Rights Regarding Treatment and Advance Directives and the Social Services Director Job Description for 8 of 28 residents (Resident (R)2, R10, R13, R17, R24, R25, R26, and R28) reviewed for code status. R17 was admitted to the facility from the hospital with documented evidence that he/she had chosen a Do Not Resuscitate (DNR) code status; [...]

Inspectors wroteComplaint#: NJ00173566 Based on interviews, record reviews, and a review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, it was determined that the facility failed to ensure the physician's orders matched the resident's documented end-of-life wishes, which resulted in cardiopulmonary resuscitation (CPR) being done on a resident (Resident (R) 17) reviewed for code status out of a total sample of 22 residents. While in the hospital, R17 chose to be a do-not-resuscitate (DNR). However, the facility was unable to provide evidence that they implemented their policy for R17 for Advance Directives upon R17 admission to the facility. On [DATE], when R17 was found unresponsive, the facility performed approximately five rounds of chest compressions on the resident before the emergency medical services (EMS) arrived. [...]

Inspectors wroteC#'s: NJ00177015 and NJ00180017. Based on interviews, record review, and review of the facility's policy, the facility failed to ensure documentation of controlled substance medications accurately reflected disposition and administration times in 3 of 28 residents (Resident (R)4, R23, and R24). The facility's failure placed residents who were ordered and administered controlled medications at risk of their controlled medications being misappropriated/diverted. This provided inaccurate documented evidence during the investigation of misappropriation/diversion events and/or allegations.

Inspectors wroteC#'s: NJ00177015 and NJ00180017. Based on observations, interviews, and record review, it was determined that the facility failed to utilize the proper personal protective equipment (PPE) for residents on special droplet/contact precautions for 4 of 22 residents (Residents (R) 10, R11, R12, and R13) reviewed for COVID-19 out of a sample of 22 residents. The facility also failed to follow its COVID-19 Prevention, Response, and Reporting policy. This created the potential for the transmission of infection to staff and other residents.

Inspectors wroteComplaints: NJ00158123, NJ00158489, NJ00158677, NJ00159247, NJ00159800, NJ00167295, NJ00168400, NJ00168603, NJ00169368, NJ00169776 Based on observations, interviews, record reviews, and review of the facility's policies, the facility systemically failed to provide and maintain pharmaceutical services to acquire, receive, dispense, administer, and reconcile medications for 6 residents reviewed for medications (Resident R 60, R14, R64, R32, R63, and R9) out of a total sample of 65 residents. This systemic failure affected and/or had the likelihood to affect all residents of the facility, and any future admissions to the facility. The facility's systemic failure to ensure pharmaceutical services were provided to meet the needs of each resident had caused or was likely to cause serious injury, harm, impairment, or death to a resident. [...]

Inspectors wroteBased on interviews, record review, and review of the facility Administrator's Job Description, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure had the likelihood to affect all 115 residents of the facility. 1. The facility's administration failed to ensure residents remained free from neglect and abuse when R37 and R57 sustained actual harm from being deprived of treatment; and R38's family reported that ostomy paste adhesive was found directly in the center of R38's stoma, obstructing the waste from emptying into his ileostomy bag. [...]

Inspectors wroteComplaints: NJ00157215, NJ00161186, NJ00161762, NJ00162457, NJ00162827, NJ00167295, NJ00168400, NJ00168545, NJ00168603, NJ00169368 Based on observation, interview, record review, and facility policy review, the facility failed to protect one resident's (Resident (R) 38) right to be free from physical abuse by staff and failed to protect two residents' (R37 and R57) right to be free from neglect out of a total sample of 65 residents. An allegation was reported that R38 was found with adhesive paste inside his ileostomy stoma. It was reported the stoma adhesive paste was in an amount sufficient to obstruct R38's stoma. The facility failed to identify the alleged incident as an allegation of abuse, failed to report the allegation to the state agency, failed to conduct a thorough investigation, and failed to protect residents during the investigation. [...]

Inspectors wroteComplaints: NJ00151851, NJ00153272, NJ00153799, NJ00156210, NJ00157166, NJ00157827 Based on interview and record review, the facility failed to ensure agency staff were competent in their duties before allowing them to work with residents. This had the potential to affect 115 of 115 residents who resided at the facility.

Inspectors wroteBased on interviews, record review, and review of the facility's Medical Director's Responsibilities policy, the facility failed to ensure the Medical Director was aware of serious occurrences in Freedom from Abuse, Neglect, and Exploitation, Quality of Care, and Pharmacy Services that resulted in actual harm and/or the likelihood for serious harm or death. The facility's failure had the potential to affect all 115 residents who resided at the facility.

Inspectors wroteComplaints: NJ00158123, NJ00158489, NJ00159800 Based on observations, interviews, record reviews, and review of the facility's policy, the facility failed to ensure resident records were complete and accurate for six residents (Resident (R) 64, R14, R63, R57, R58, and R15) of a total sample of 65 residents. The facility's failure to ensure nursing staff completely and accurately documented each residents clinical status placed all 115 residents of the facility at risk for serious unmet care needs.

Inspectors wroteBased on interview and facility policy review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that identified quality concerns, developed corrective actions, and monitored for adverse events related to pharmacy services, documentation, and call light response times. This had the potential to affect 115 of 115 residents who resided at the facility.

Inspectors wroteComplaints: NJ00156380, NJ00156776, NJ00157166, NJ00157827, NJ00159247, NJ00159405, NJ00161524, NJ00168545, NJ00168603 Based on observations, interview, and policy review, it was determined the facility failed to ensure a clean comfortable and homelike environment, this was evidenced by the facility failing to have an adequate supply of clean linens (towels, washcloths, flat sheets, fitted sheets, and gowns) available for resident use.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure grievances were addressed for two of 65 sampled residents (Resident (R) 62 and R21). The facility failed to document significant concerns as grievances; failed to address the concerns; failed to communicate resolution; and failed to assess resident/family satisfaction upon the conclusion of the grievance.

Inspectors wroteComplaint: NJ00158720, NJ00159247, NJ00159405, NJ00161186 Based on interview, record review, and policy review, the facility failed to ensure three of 65 sampled residents (Residents (R)15, R3, and R4) reviewed for nutrition received nutritional care and services to maintain adequate parameters of nutritional status. R15 was not weighed, and a nutritional assessment was not completed; and for R15, R3, and R4 meal intake was not recorded or monitored. These failures placed residents at risk for undetected weight loss and dehydration.

Inspectors wroteComplaints: NJ00151851, NJ00153272, NJ00153799, NJ00156210, NJ00157166, NJ00157827, NJ00158123, NJ00158489, NJ00158720, NJ00158677, NJ00159247, NJ00159405, NJ00159679, NJ00159800, NJ00160123, NJ00161147, NJ00161524, NJ00162457, NJ00162827, NJ00162977, NJ00168603, NJ00169368 Based on observation, interview, record review, and policy review, the facility failed to ensure nursing department staffing was adequate in numbers and responsiveness to meet the needs of 17 out 65 sampled residents (Residents (R)59, R34, R35, R36, R14, R16, R18, R21, R20, R15, R62, R57, R42, R40, R44, R41, and R4). Staffing was inadequate to ensure residents' call lights were answered timely, residents were toileted timely, received medications timely, received meals timely, and were gotten up, dressed, and provided hygiene timely. [...]

Inspectors wroteComplaints: NJ00158123, NJ00158489, NJ00158677, NJ00159247, NJ00159800 Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Fifteen errors were made with a total of 47 opportunities for error, resulting in a 31.9% error rate. The errors involved two residents of five residents (Resident (R) R58 and R65) reviewed for medication administration out of a total sample of 65 residents. Fourteen medications, including insulin, were not administered to R58 within one hour of the scheduled time. Stiolto, a respiratory combination inhaler, was not administered to R65 due to the medication not being available. 1. [...]

Inspectors wroteComplaints: NJ00157166, NJ00162457 Based on observation, interview, and record review, the facility failed to ensure 15 residents, including seven sampled residents (Resident (R)18, R53, R47, R55, R49, R50, R51) and eight of 13 residents attending the group interview (R6, R42, R43, R40, R44, R57, R4, R41), were served a well-balanced diet taking into consideration the preferences of each resident. Residents' preferences were not served in accordance with their meal tickets. When residents contacted the dietary department for alternate selections staff did not consistently answer the phone, the selections were not consistently available, or the selections were not served. This created the potential for resident dissatisfaction and weight loss.

Inspectors wroteComplaints: NJ00153272, NJ00160123, NJ00161147, NJ00169368 Based on observation, interview, record review, and facility policy review, the facility failed to ensure the menus were followed for five residents (Resident (R) 46, R47, R51, R52, R54). Foods were not served in accordance with the menu for residents on renal, mechanical soft and pureed diets.

Inspectors wroteComplaints: NJ00157166, NJ00160123, NJ00162177, NJ00162457, NJ00162977 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure food was palatable for ten residents including two sampled residents (Resident (R) 20 and R18) and eight of 13 residents attending the group interview (R44, R43, R41, R42, R57, R14, R40, R4) out of a total sample of 65 residents. Specifically, the food did not taste good, was not appetizing in appearance, and was not at a palatable temperature when residents received their meals. This created the potential for dissatisfaction and weight loss.

Inspectors wroteComplaint: NJ000168256 Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents' property was safeguarded from misappropriation for one of two residents (Resident (R) 30) reviewed for misappropriation of property out of a total sample of 65 residents. R30 returned to the facility to retrieve her personal belongings after she was emergently transferred to an acute care hospital; however, the facility could not locate the resident's belongings.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an allegation of abuse to the required agencies within two hours for one resident (Resident (R) 38) and failed to report timely an allegation of misappropriation of resident property for one resident (R30) out of a total sample of 65 residents. The failure presented a potential for continued abuse and misappropriation of property for R38 and R30, respectively.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse for one resident (Resident (R) 38) and an allegation of misappropriation of property for one resident (R30) out of a total sample of 65 residents. These failures increased the potential for additional allegations of abuse to go uninvestigated in a timely manner.

Inspectors wroteComplaint: NJ00157215, NJ00157739, NJ00157827, NJ00158677, NJ00161186, NJ00161524, NJ00162977, NJ00167295, NJ00168545 Based on interview and record review, the facility failed to flush gastrostomy tube and provide oral nutrition supplements as ordered for resident (R16) out of a total sample of 65 residents.

Inspectors wroteComplaint : NJ00167295 Based on interview, record review, and policy review, the facility failed to ensure one out of one sampled residents reviewed for tracheostomy care and services (Resident (R)16) received consistent care and services as prescribed by the physician to address his tracheostomy and respiratory needs.

Inspectors wroteBased on document review, interview, and facility policy review, it was determined that the facility failed to ensure staff consistently monitored the refrigerator temperature for safe temperature ranges. This had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to assess 1 (Resident #62) of 5 residents reviewed for self-administration of medication.

Inspectors wroteBased on record review, interviews, facility policy review, and the Centers or Medicare & Medicaid [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, it was determined the facility failed to encode and transmit a discharge Minimum Data Set (MDS) assessment for 1 (Resident #43) of 28 residents reviewed for MDS requirements.

Inspectors wroteBased on record review, interviews, and facility policy review, it was determined that the facility failed to provide care and treatment after a fall for 1 (Resident #281) of 3 residents. Specifically, the facility failed to conduct routine neurological examinations (neuro checks) for Resident #281 after a fall on 04/10/2022.

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) ensure that staff used the appropriate Personal Protective Equipment (PPE) when caring for newly admitted residents who were under observation for sign/symptoms of COVID-19 for 5 of 8 staff members observed for infection control practices on 2 of 2 units (100 Unit and 200 Unit); and, b.) clean and disinfected the equipment between residents and minimize the potential spread of infection to residents for 1 of 2 nurses observed during medication pass on 1 of 2 units (100 Unit). This deficient practice was evidenced by the following: 1. On 3/24/21 at 12:20 PM, the surveyor observed Resident #288's room with signage posted on the door frame indicating that the room was a COHORT 4 / Admit or Readmit room with a handwritten date of 3/26/2021. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly handle potentially hazardous food and maintain the dry storage area in a safe and consistent manner to prevent food-borne illness. This deficient practice was evidenced by the following: On 03/24/21 from 9:01 AM until 9:59 AM, the surveyor, accompanied by the Dietary Director (DD), observed the following in the kitchen: 1. In the reach-in refrigerator, on the second shelf, a container of French vanilla creamer was not labeled or dated. The DD stated, There is a sticker, but no date. 2. In the dry storage area, there was a Rubbermaid bin with a dry bread-like substance with no label or date. The DD stated, I just put this stuff in there; and it should be labeled and dated. 3. [...]