Atlas Post Acute At Woodbury Country Club
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
ATLAS POST ACUTE AT WOODBURY COUNTRY CLUB in WOODBURY, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WOODBURY, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ATLAS POST ACUTE AT WOODBURY COUNTRY CLUB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.