Atlas Post Acute At Woodbury Country Club
ATLAS POST ACUTE AT WOODBURY COUNTRY CLUB in WOODBURY, NJ — inspection on November 26, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Complaint 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. A
Review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 08/19/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating the resident had a moderately impaired cognition.A Review of Resident #1's Care Plan (CP) revealed a focus of I have ( acute) pain r/t [related to] recent nasal bone fx's [fractures] and Arthritis initiated 08/14/2025 and an intervention of Administer analgesia as per orders.On 9/26/2025 a review of the Physicians Orders revealed Resident #1 had an order for Oxycodone 10 milligram (mg) give 1 tablet by mouth every 8 hours for severe pain, scheduled for 6:00 A.M., 2:00 P.M. and 10:00 P.M. beginning on 8/27/2025 and discontinued on 9/10/2025. A
Review of the Medication Admin Audit Report (MAAR) for 9/08/2025 revealed the 2:00 P.M. dose was administered at 3:53 P.M.
That is 1 hour and 53 minutes after the scheduled time. In an interview on 9/26/2025 at 12:45 P.M., with the Assistant Director of Nursing (ADON), the surveyor showed the MAAR for 9/8/2025 and the ADON said the medication was given late, the policy was not followed, and the physician should have been notified to clarify next steps for the medication. In an interview on 9/29/2025 at 11:32 P.M., with the Licensed Practical Nurse (LPN) the surveyor showed the MAAR for 9/8/2025 and the LPN explained the documentation showed the medication was given late. A review of the facility's policy titled Administering Medications with a revision date of April 2019 revealed under Policy Interpretation and Implementation that 4.
Medications are administered in accordance with prescriber orders. and 7.
Medications are administered within one (1) hour of their prescribed time.NJAC 8:39-11.2 (b), 29.2 (d)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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