Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Old Bridge during CMS and state inspections, most recent first.
Improper food storage, labeling, and dating were observed in the kitchen and an A-wing pantry. Surveyors found rotten bananas, unlabeled cups of pudding and ground pears, and sandwiches that were either past their use-by date or missing labels. An RFSD and an LPN acknowledged the items should have been labeled individually and could not verify when some foods were prepared or should have been used by.
Respiratory care was not maintained for residents receiving O2, and one resident received O2 without an active physician order. Surveyors observed trach and nasal cannula tubing that was not dated or labeled, oxygen supplies left exposed instead of stored properly, no O2-in-use sign at a resident’s door, and an empty O2 tank still connected while the resident was using it. Staff acknowledged that O2 tubing and related supplies should be dated and changed routinely for infection control, and that O2 should not be given without an order.
Routine medications were not obtained in time or administered as prescribed for two residents. One resident with intact cognition reported repeated missed doses of medications such as Rifaximin, Zoloft, and BP meds, and the EMAR showed several doses coded as not given with no physician notification documented. Another resident was observed during med pass when an LPN could not find Lactulose and Flonase in the cart, and the DON confirmed the routine meds had not been ordered in time to be available.
A resident’s room on B Wing had visible wall damage, including large white patched areas and a hole in the wall, with the resident stating the condition had been present since admission and was “not pretty.” The DM acknowledged the spackle from prior repairs and said the walls had not been repainted for about 2 months, while the LNHA stated the walls should have been painted once the spackle was dry to support a homelike environment.
Failure to Protect Resident Income: The facility failed to ensure a resident was free from exploitation and misappropriation of income. The resident had major depressive disorder, altered mental status, and moderate cognitive impairment. The BO filed to become representative payee for the resident’s Social Security benefits, while the resident’s financial POA had concerns about the income going directly to the facility. The facility could not provide proof of approval, notification to the POA, or a policy authorizing the application.
Incomplete Care Plans for Anticoagulant Use and Suprapubic Catheter: Two residents had missing focused care plan items for identified needs. One resident with paroxysmal A-fib was receiving apixaban with orders to monitor for bleeding, bruising, and black tarry stools, but the care plan did not address A-fib or anticoagulant use. Another resident had a suprapubic catheter with orders for SPC care and output monitoring, but the care plan did not include the catheter. Staff acknowledged both conditions should have been care planned.
A facility failed to ensure that alternating air pressure mattresses were functioning properly and set according to resident weight and physician orders for two residents with skin integrity concerns. One resident had severe cognitive impairment, malnutrition, and a history of wound care, while the other had moderately impaired cognition, malnutrition, and a stage 4 pressure ulcer. Surveyors repeatedly observed the mattress pumps set far above each resident’s recorded weight, and the DON later confirmed the incorrect settings and adjusted them during the survey.
Missing Dialysis Progress Notes: The facility failed to consistently document required pre- and post-HD Progress Notes for two residents receiving HD. Both residents had renal dialysis dependence and anemia in CKD, with physician orders and MAR sign-offs indicating dialysis documentation should be completed, but the EMR lacked multiple notes for outgoing and return dialysis care. An RN and an LPN/UM stated that pre- and post-HD VS, access checks, bleeding assessment, and any concerns should be documented in the EMR.
Failure to post the daily NHRCSR. The surveyor observed the staffing report in the main lobby posted with an outdated date for all shifts. The SC said she was responsible for completing the report and acknowledged it should have been changed every day, and the LNHA confirmed the SC posted during the week while the weekend supervisor posted on weekends. Facility policy stated the Nurse Staffing sheet would be posted on a daily basis.
A resident with ESRD, HTN, and DM had medication administration errors involving insulin and Midodrine. The eMAR showed NovoLOG was given when blood glucose was below the ordered hold parameter, and Midodrine was withheld when BP was within range and given when BP was above the ordered hold parameter. An LPN/UM confirmed the MAR entries reflected administration and acknowledged the doses did not follow the PO parameters.
A facility failed to consistently apply a bolster to a resident's wheelchair as ordered by a physician, leading to multiple observations of the resident without the necessary support. The resident, with a history of transient cerebral ischemic attack and dementia, required the bolster for positioning. The Treatment Administration Record did not reflect the order, and there was a lack of documentation by CNAs. The CNA assigned was new and lacked access to the electronic Medical Record, contributing to the oversight.
A facility failed to adjust medication administration times for a resident undergoing dialysis, leading to missed doses while the resident was out for treatment. Despite having policies in place, the facility did not review and adjust medication times upon the resident's readmission, as confirmed by interviews with staff including an LPN, the Unit Manager, the DON, and the Consultant Pharmacist.
A medication administration error rate of 6.45% was observed in a facility when an LPN failed to prime insulin pen injectors before a resident self-administered doses. The resident, with type 2 Diabetes Mellitus, was prescribed Basaglar and Fiasp insulin pens, which require priming before each use. The LPN, unaware of this requirement, did not prime the pens, leading to improper insulin administration. The facility's policies and manufacturer instructions confirmed the necessity of priming to ensure correct dosage.
A long-term care facility failed to provide timely medication administration and proper documentation for two residents. One resident did not receive their medications, including fast-acting insulin, within the prescribed time frame, while another resident experienced issues with the availability of their prescribed Oxycodone. The facility's policies on medication administration and backup supply management were not followed, leading to these deficiencies.
Improper Food Storage, Labeling, and Dating
Penalty
Summary
The facility failed to properly store, label, and date foods in the main kitchen and in one pantry by the A-wing nurse's station. During a kitchen tour, the surveyor observed two cardboard boxes of bananas near the dry storage room, including a partially open box containing several dark discolored bananas in a clear plastic bag with dark brown liquid; the RFSD stated the bananas were rotten and removed them from the kitchen area. In the front refrigerator, the surveyor observed twenty-five cups of chocolate pudding, but only five lids had use-by dates while twenty did not, and the RFSD acknowledged that each item should have been labeled individually. The surveyor also observed eight sandwiches in a silver pan, with only two sandwiches labeled with a use-by date of 1/26/26 and the other six unlabeled; the RFSD acknowledged all eight sandwiches were past their use-by date and removed them. In the same refrigerator, twenty cups containing ground pears were observed, with only one cup labeled and the others unlabeled; the RFSD acknowledged each cup should have been labeled individually. In the A-wing pantry refrigerator, the surveyor observed five individually wrapped sandwiches on the top shelf that did not appear to have labels. The LPN at the nurse's station stated the kitchen provided the sandwiches as snacks for residents and could not say when they were placed in the refrigerator. On inspection, all five sandwiches were found to be unlabeled, and the LPN acknowledged she could not identify when they were prepared or when they should have been used by; she removed and discarded them. The facility's FSD later acknowledged that brown or black bananas should not be served, that refrigerated food should be labeled individually rather than only one item in a group, and that the eight sandwiches should have been disposed of before their expiration date. The facility policy stated that foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use-by date, and that food items kept on nursing units must be labeled with a use-by date.
Respiratory Care Deficiencies With Oxygen Equipment and Missing Order
Penalty
Summary
The facility failed to maintain necessary respiratory care for residents receiving oxygen and failed to obtain a physician’s order for one resident who was receiving oxygen. The deficient practice involved three residents reviewed for respiratory care: one resident with a tracheostomy and chronic respiratory failure with hypoxia, another resident with a tracheostomy and severe cognitive impairment, and a third resident with acute respiratory failure with hypoxia and COPD. Surveyors observed problems with oxygen equipment dating, storage, labeling, and availability, as well as the absence of an active oxygen order for one resident who was still receiving oxygen. For the resident with a tracheostomy and chronic respiratory failure, surveyors observed oxygen tubing, the trach collar, and the humidification water bottle that were not dated on one observation, and later observed the tubing and water bottle dated several days earlier. The resident had physician orders for trach checks, pulse oximetry, weekly changes of oxygen-related supplies, and head-of-bed elevation, but the care plan did not reflect how often oxygen supplies should be changed or dated. A unit manager stated that the tubing and water bottle should have been dated when actually changed and that dating was important for infection control and monitoring humidification. For the resident with a tracheostomy and severe cognitive impairment, surveyors observed trach oxygen tubing and humidification tubing that were not labeled or dated on one observation, and later observed tubing dated several days earlier. The resident’s record showed orders for trach oxygen, weekly or protocol-based changes of oxygen equipment and nebulizer tubing, and trach care every shift. Staff interviewed about the tubing stated that it was changed weekly to help prevent infections, and the DON stated the tubing was labeled so staff would know when it needed to be changed. For the resident with COPD and acute respiratory failure with hypoxia, surveyors observed a nasal cannula connected to oxygen equipment that was hanging exposed and not stored in a protective covering, and no oxygen-in-use sign was posted at the room door. The resident was observed using oxygen in the dining room and later in the room, but the order summary did not show an active order for continuous or PRN oxygen administration. During interview, an RN stated oxygen is a medication and should not be administered without a physician’s order, yet also stated the resident was on continuous oxygen at 2 LPM. The RN and LPN/UM later found the oxygen tank empty while the cannula was still applied, and the LPN/UM confirmed the resident did not have an oxygen administration order and should not have been on oxygen.
Routine medications were not available or administered as ordered
Penalty
Summary
Pharmaceutical services were not provided in accordance with professional standards when routine medications were not obtained in a timely manner and were not administered as ordered for one resident with intact cognition and diagnoses including hypertension, alcoholic liver disease, and major depressive disorder. The resident reported that medications were frequently unavailable, including a liver medication, Zoloft, and blood pressure medication, and stated that nurses would tell them the medication was not in the cart and they would not receive it that day. Review of the EMAR showed multiple missed doses of prescribed medications, including Rifaximin, Fluticasone nasal spray, Artificial Tears, Sertraline, Carvedilol, and Polyethylene Glycol, with documentation such as "on order," "awaiting delivery," "reorder," or "not at hand." The record review also showed that there was no documentation that the physician was notified about the missed doses or that follow-up orders were obtained. The DON stated that nurses were expected to call the physician if a medication was not available, check backup supply, and document in the EPN, but she was unable to explain why the medications were not administered or why the documentation reflected they were unavailable. The resident also stated they had not left the facility on the date one medication was documented as not given because they were out of the facility, and they described prior problems with Morphine being unavailable in March 2025. Review of that earlier EMAR showed Morphine ER doses were not administered and were documented as pending delivery or awaiting pharmacy, again without documentation that the physician was notified. A second resident with diagnoses including hypertension, dementia, and schizoaffective disorder was observed during medication administration when the nurse could not locate Lactulose and Fluticasone in the cart. The nurse stated the medications were not house stock and said she would need to check whether they could be obtained and administered as ordered. She later stated she had called the physician and received an order to give the medications when obtained, and the DON confirmed that neither medication was stored as house stock and that the routine medications had not been ordered in time to be available for administration. The resident stated they needed their medications every day for pain and constipation.
Unrepaired Wall Damage and Visible Spackle in Resident Room
Penalty
Summary
The facility failed to maintain a clean, homelike, and sanitary environment for one of two nursing units, B Wing, based on observations and interviews. During an environmental tour of B Wing, a surveyor observed in Resident #30’s room a large white patched area with a hole in the wall below the patch on the left wall just beyond the bathroom door, a white patched area around the soap dispenser near the sink, and a large white patch area on the right side wall near the resident’s bed. When asked about the walls, the resident stated they did not know what happened because the condition had been present since they were admitted in October, and said the walls were “not pretty.” The Director of Maintenance later acknowledged the white patches as spackle from wall repairs and stated he could not explain why the walls had not been repainted. He said the condition had been present for about 2 months and was not aware of the hole in the wall, which he said he would fix right away to keep dust and dirt out of the room. The LNHA stated the walls should have been painted as soon as the spackle was dry and that the purpose was to support resident rights to a home-like environment. The facility policy stated that staff are responsible for promptly reporting maintenance or environmental issues and that the Maintenance Department will address issues in a timely and documented manner.
Failure to Protect Resident Income
Penalty
Summary
The facility failed to ensure that a resident was free from exploitation and misappropriation of resident income. Resident #115 had diagnoses including major depressive disorder and altered mental status, and the Quarterly MDS dated 12/6/25 reflected a BIMS score of 7 out of 15, indicating moderate cognitive impairment. The resident’s admission record identified one person as financial POA and another as care POA, and the admission agreement stated the resident had the right to manage his or her own financial affairs under the Resident’s Bill of Rights. During the investigation, the Director of Admissions stated the Business Office handled all resident financial information, and the Administrator acknowledged awareness of concerns from the financial POA related to the resident’s income going directly to the facility. The Business Office Medicaid biller stated the facility filed to become representative payee with Social Security in November 2025 to help manage the resident’s income and said consent was not needed. The representative payee application, signed by the BO manager, stated the resident was unable to handle finances and listed the nursing facility as the reason it should be payee, while the section for relatives or close friends who provided support was left blank. The Administrator, DON, and Regional Director were informed of the findings, and the facility was unable to provide the date it was approved as representative payee, documentation that the financial POA was notified, or a policy or agreement authorizing the facility to apply for representative payee status.
Incomplete Care Plans for Anticoagulant Use and Suprapubic Catheter
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents with identified clinical needs. For one resident, the record showed diagnoses including paroxysmal A-fib and hypertension, and the resident was receiving apixaban 5 mg by mouth twice daily for A-fib with orders to monitor for bleeding, bruising, and black tarry stools. The resident’s comprehensive care plan included focus areas for malnutrition risk, falls risk, and hypertension, but it did not include a care plan focus or interventions for paroxysmal A-fib or anticoagulant use. For the second resident, the record showed diagnoses including dementia, disorientation, neuromuscular dysfunction of the bladder, and urinary tract infection, and the resident had a suprapubic catheter with an order for SPC care and to measure and record output every shift. The resident’s care plan included focus areas for nutrition risk, recreational programming, left patella fracture, pain, falls risk, ADL self-care deficit, and chronic/progressive decline in intellectual functioning, but no focus area was identified for the suprapubic catheter. During observation, the resident was sitting in a wheelchair eating lunch, and an EBP sign and PPE were observed outside the room. Facility staff acknowledged during interview that both residents should have had focused care plan items for these conditions. The RN stated that a resident with A-fib receiving blood thinners should have a care plan with interventions to monitor for bleeding risks, and the LPN/UM stated that blood thinners and suprapubic catheters should be included in the care plan. The LPN/UM also confirmed that the resident with the suprapubic catheter had no focused care plan item for the catheter and stated there should have been one.
Improperly Set Pressure-Reducing Mattresses
Penalty
Summary
The facility failed to ensure that low air loss or alternating air pressure mattresses were functioning properly and set according to manufacturer instructions and physician orders for two residents with impaired skin integrity or risk for pressure injuries. Resident #14 had diagnoses including hydrocephalus, encephalopathy, acute kidney failure, protein-calorie malnutrition, Down syndrome, traumatic subdural hemorrhage, and altered mental status, and the most recent MDS indicated severe cognitive impairment and risk for pressure ulcer/injury. The resident’s care plan and physician order required an alternating air pressure mattress with monitoring for functioning every shift, and the wound notes documented a history of wound care and use of the mattress as part of treatment and prevention. Survey observations showed Resident #14 lying in bed on the air mattress with the pump repeatedly set to 200 pounds on multiple dates, while the resident’s last recorded weight was 117.6 pounds. The LPN stated the mattress should be set to the resident’s weight and that staff were responsible for checking proper function. During the survey, the DON confirmed the mattress was set to 200 pounds and adjusted it to 120 pounds after the surveyor and DON entered the room. The DON also stated that air mattresses were to be set according to resident weight and checked every shift for proper function. Resident #48 had diagnoses including fracture of the right femur, protein-calorie malnutrition, hydrocephalus, cerebellar stroke syndrome, and acute and chronic respiratory failure with hypoxia. The resident’s MDS indicated moderately impaired cognition, risk for pressure ulcer/injury, and one stage 4 pressure ulcer, with a recorded weight of 99 pounds. The care plan and physician order required an alternating air mattress with monitoring for functioning every shift. Survey observations found the mattress pump repeatedly set to 280 pounds, and the resident stated they were unsure when it had last been checked or adjusted. The DON confirmed the setting was 280 pounds and adjusted it to 100 pounds during the survey.
Missing Dialysis Progress Notes
Penalty
Summary
The facility failed to consistently document Progress Notes for two residents receiving hemodialysis, despite physician orders requiring pre-dialysis and post-dialysis documentation. Resident #6 was admitted with dependence on renal dialysis and anemia in chronic kidney disease, had intact cognition, and had a care plan identifying hemodialysis on Monday and Friday. Resident #1 was also admitted with dependence on renal dialysis and anemia in chronic kidney disease, had intact cognition, and had a care plan identifying hemodialysis on Monday, Wednesday, and Friday. For Resident #6, the Order Summary Sheet included physician orders for dialysis outgoing documentation and dialysis return documentation under Progress Notes, and the MAR showed nurses signed off that the notes were completed on dialysis days. However, the EMR lacked multiple pre-HD notes and multiple post-HD notes across December 2025 and January 2026. For Resident #1, the Order Summary Sheet also included physician orders for dialysis outgoing documentation and dialysis return documentation under Progress Notes, and the MAR showed nurses signed off that the notes were completed on dialysis days. However, the EMR lacked multiple pre-HD notes and multiple post-HD notes across December 2025 and January 2026. During interviews, the assigned RN and the LPN/Unit Manager stated that pre- and post-HD vital signs, access assessments, bleeding checks, and any concerns should be documented in the EMR Progress Notes, and that nurses signing the MAR should also be documenting the notes. The facility’s Hemodialysis policy stated it would provide care consistent with professional standards and physician orders, and the Documentation in Medical Record policy required accurate, complete, and timely documentation. The surveyor informed the LPN/UM, DON, Regional DON, and LNHA of the missing dialysis Progress Notes.
Failure to Post Current Staffing Report
Penalty
Summary
The facility failed to post the daily Nursing Home Resident Care Staffing Report (NHRCSR) so that it was up to date. On 1/29/2026 at 8:55 AM, the surveyor observed the NHRCSR posted in the main lobby with a date of 1/22/2026 for all three shifts: 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM. On 1/30/2026 at 11:41 AM, the Staffing Coordinator stated she was responsible for completing the staffing report and said it was posted daily during the week, with the weekend supervisor posting it on weekends; after being informed of the observation, she acknowledged the report should have been changed every day. On 1/30/2026 at 11:55 AM, the LNHA stated the SC posted the staffing report during the week and the weekend supervisor posted it on weekends. The facility policy stated that staffing information must be readily available in a readable format and that the Nurse Staffing sheet will be posted on a daily basis.
Failure to Follow Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders and accepted professional standards of practice for medication administration for one resident with end stage renal disease, hypertension, and type 2 diabetes mellitus. The resident’s care plan included diabetes medication as ordered and antihypertensive medications as ordered. The resident’s February 2026 order summary included NovoLOG FlexPen 4 units subcutaneously on specified days with a hold parameter for blood sugar less than 120, and Midodrine 5 mg by mouth on specified days with a hold parameter for systolic blood pressure greater than 140. Review of the eMAR showed that NovoLOG was marked as administered on multiple occasions when the resident’s blood sugar was below 120, including readings of 114, 107, 110, 109, and 118. Review of the eMAR also showed Midodrine was not administered when the resident’s blood pressure was 137/77 even though the order allowed administration when systolic blood pressure was 140 or less, and was administered when the resident’s blood pressure was 146/72 even though the order required it to be held when systolic blood pressure was greater than 140. During interview, the LPN/UM stated the check mark on the MAR meant the medication was administered and confirmed that insulin should have been held when blood sugar was below 120. The LPN/UM also confirmed that Midodrine should have been given for the 137/77 blood pressure and held for the 146/72 blood pressure. The LPN/UM stated these were medication errors and that nurses were expected to follow physician orders correctly and not administer medications when they were out of parameters.
Failure to Apply and Document Bolster Use for Resident
Penalty
Summary
The facility failed to consistently follow a physician's order for the application of a bolster to the left armrest of a wheelchair for a resident with decreased range of motion and mobility. This deficiency was identified for a resident who was observed multiple times without the bolster applied, despite a physician's order and an individualized comprehensive care plan (ICCP) indicating its necessity for positioning. The resident had a history of transient cerebral ischemic attack and unspecified dementia, with a severely impaired cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. The facility's Treatment Administration Record (TAR) did not reflect the physician's order for the bolster, and there was a lack of documented accountability for its placement by the Certified Nursing Assistants (CNAs) for 13 out of 30 days reviewed. The Licensed Practical Nurse/Unit Manager (LPN/UM) acknowledged the absence of the bolster and the lack of documentation, stating that it was the CNA's responsibility to apply the device and document its placement. However, the CNA assigned to the resident was new, did not have access to the electronic Medical Record (eMR), and was not informed of the resident's need for the bolster. The staffing coordinator confirmed that the CNA should have received eMR access but had not due to oversight. The Director of Rehabilitation and the Director of Nursing (DON) also acknowledged the failure to ensure the bolster was applied and documented. The facility's policies on Activities of Daily Living (ADLs), Assistive Devices and Equipment, and Comprehensive Person-Centered Care Plans emphasize the importance of maintaining and supervising the use of assistive devices based on comprehensive assessments, which was not adhered to in this case.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not adjusting medication administration times to accommodate a resident's dialysis schedule. The deficiency was identified for a resident who required dialysis services. The resident, who had end-stage renal disease and was dependent on renal dialysis, was scheduled for dialysis on Monday, Wednesday, and Friday, with a pick-up time of 3:15 PM and a chair time of 4:15 PM. However, the resident's medication administration times were not adjusted to account for the time they were out of the facility for dialysis. The resident's medical records revealed active physician's orders for several medications, including Ascorbic Acid, Insulin Lispro, Calcium Acetate, and Prostat, which were scheduled to be administered during the time the resident was at dialysis. The electronic medication administration record (eMAR) indicated that these medications were marked as not administered due to the resident being out for dialysis. Interviews with facility staff, including an LPN, the Unit Manager, the Director of Nursing, and the Consultant Pharmacist, confirmed that medication times should have been reviewed and adjusted to accommodate the resident's dialysis schedule. The facility's policies on administering medications and hemodialysis care emphasized the need for timely medication administration and ensuring physician's orders for dialysis include medication administration or withholding instructions. Despite these policies, the facility did not adjust the medication administration times for the resident upon their readmission, leading to the deficiency identified by the surveyor.
Medication Administration Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 6.45%, which exceeds the acceptable threshold of 5%. During a medication observation, a surveyor noted that an LPN did not prime insulin pen injectors before administering them to a resident. The resident, who had poor eyesight but was alert and oriented, self-administered the insulin doses under the supervision of the LPN. The LPN did not perform the necessary priming of the insulin pens, which is required to ensure the correct dosage is delivered. The resident involved had a medical history of type 2 Diabetes Mellitus with unspecified complications and was prescribed Basaglar and Fiasp insulin pen injectors. The physician's orders required specific dosages and administration techniques, including priming the pens before each use. However, the LPN, who had been working at the facility for six months, was unaware of the need to prime the pens before each injection, believing it would waste insulin. This lack of knowledge led to the improper administration of insulin to the resident. The surveyor's review of the facility's policies and manufacturer instructions confirmed that priming the insulin pens before each injection was necessary. The LPN's failure to follow these guidelines resulted in the medication errors observed. The facility's Director of Nursing acknowledged the oversight and the potential impact on insulin dosage accuracy due to not following the manufacturer's specifications for priming the insulin pen injectors.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards of practice, as evidenced by two main deficiencies. Firstly, a resident with multiple health conditions, including diabetes and glaucoma, did not receive their medications in a timely manner as ordered by a physician. The resident, who was blind but cognitively intact, reported receiving their fast-acting insulin late, which was confirmed by a review of the Medication Administration Audit Report. The report showed that on two consecutive days, several medications were administered outside the allowed time range, contradicting the electronic medication administration record that indicated timely administration. Secondly, another resident reported frequent issues with the availability of their prescribed Oxycodone, a controlled drug. The resident stated that they did not receive their medication at the scheduled times due to the facility running out of stock, which was corroborated by the electronic medication administration record and nurse's notes. The facility had a backup supply of Oxycodone, but it was not utilized, and there was no documentation of a physician's order to administer the available doses from the backup supply. This discrepancy was acknowledged by the Director of Nursing, who confirmed that the medication was not administered as ordered. The facility's policies on medication administration and backup supply management were not adhered to, leading to these deficiencies. The policies required timely administration of medications and proper documentation of any deviations, which were not followed in these cases. The Consultant Pharmacist emphasized the importance of matching the administered dose with the physician's order, highlighting the facility's failure to ensure accurate medication management and documentation.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Old Bridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Preferred Care At Old Bridge, Llc | 1.8 mi | ★★★★★ | 2 | 0 |
| Reformed Church Home | 2 mi | ★★★★★ | 0 | 0 |
| Careone At East Brunswick | 3.4 mi | ★★★★★ | 0 | 0 |
| Roosevelt Care Center At Old Bridge | 3.7 mi | ★★★★★ | 6 | 0 |
| Complete Care At Madison, Llc | 5.6 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.