Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Roosevelt Care Center At Old Bridge during CMS and state inspections, most recent first.
MDS assessments were inaccurately coded for dialysis, weight loss, and restorative services. Two residents with ESRD and active dialysis orders had documented transport to and from dialysis, but their annual MDSs did not code dialysis received within the last 14 days. Another resident with neurodegenerative disease had documented significant weight loss, yet the MDS did not code the loss. A resident with stroke-related hemiplegia had documented ROM and splint/PRAFO assistance, but the MDS did not code restorative nursing days because staff treated the care as FMP rather than restorative care.
Failure to Document and Maintain Resident Code Status Orders: The facility did not ensure that code status and advance directive information was consistently entered and maintained in the EMR for three residents. Two residents had blank advance directive sections, no code status orders, and no POLST or other directive in the chart at the time of review, even though care plans identified them as Full Code and the residents stated that was their wish. A third resident had POLST documentation showing DNR/DNI status, but the current order had been discontinued and was not reinstated in the EMR when reviewed.
Failure to evaluate alternatives, obtain a physician order, and care plan bedrail use for a resident with a half siderail engaged. The resident had signed consent and was cognitively intact with a BIMS of 15/15, but the record did not show alternatives were tried before the siderail was used. The DON, RN, RM, and UM1 stated siderails were enablers and did not require an order or care plan, and the resident stated she used the siderail to pull herself up out of bed.
Failure to Honor Resident Food Preferences: A resident with vegan meal preferences was not served the food choices she selected from the facility menu. Staff records and interviews showed her baseline care plan did not reflect her dietary preferences, her tray tickets did not match her selected menu items, and the DDM determined her preferences were not entered correctly into the menu management system. The DON and DM acknowledged the mismatch between the resident’s selections and what was served.
A resident with severe cognitive impairment was found with unexplained facial bruising, but the LTC facility failed to report the injury to the NJDOH as required. Despite staff acknowledging the need for immediate reporting of such incidents, the investigation did not rule out abuse, and the incident was not reported. The facility's policy mandates reporting injuries of unknown origin to relevant authorities, but this was not followed in this case.
A resident with dementia and anxiety disorder was observed multiple times without heel booties, despite a physician's order and care plan requiring them at all times to prevent skin breakdown. Facility staff misunderstood the order, applying booties only when the resident was in bed, contrary to the care plan and facility policy on pressure injury prevention.
MDS assessments were inaccurately coded for dialysis, weight loss, and restorative services
Penalty
Summary
The facility failed to ensure accurate MDS coding for dialysis for two residents. One resident had diagnoses of end stage renal disease and dependence on renal dialysis and was transported by stretcher to and from dialysis on multiple documented days, with an active order for hemodialysis three times weekly. Another resident also had end stage renal disease and dependence on renal dialysis, with nursing notes showing transport for dialysis and return after treatment on multiple documented days and an order for dialysis on Tuesdays, Thursdays, and Saturdays. Despite these records, both annual MDS assessments failed to code that dialysis had been received while the residents were in the facility and within the last 14 days. During interview, the MDS Coordinator stated both residents received dialysis and that the omission was her mistake, and the Regional MDS Coordinator stated dialysis received was expected to be coded on the MDS. The facility also failed to accurately code weight loss for another resident. That resident had progressive supranuclear ophthalmoplegia and weighed 158.8 pounds on the ARD date, compared with 185.8 pounds about six months earlier and 184.4 pounds on another nearby prior weight, reflecting significant weight loss. A dietary note also documented 29.2 pounds of unplanned weight loss over 193 days. However, the significant change MDS recorded no weight loss of 5% or more in the last month or 10% or more in the last six months. The Registered Dietitian stated weight loss had been coded for 30 days and 180 days, but the 30-day loss was not significant and the 180-day weights used were outside the timeframe. The Regional MDS Coordinator stated the resident’s weights reflected significant weight loss when looking back 180 days, and the RD may have coded from facility policy rather than the RAI Manual. The facility further failed to code restorative nursing services for a resident with hemiplegia and hemiparesis following cerebral infarction. The resident had orders for active and passive range of motion to the right and left extremities and for splints and a PRAFO to be worn during care periods. Task documentation showed repeated range of motion and splint/brace assistance, including at least 15 minutes of splint or brace assistance on multiple days, and the resident was observed wearing the splint, hand roll, and PRAFO. Despite this, the quarterly MDS recorded range of motion impairment to one side but no days of restorative nursing, including no days for splint or brace assistance of at least 15 minutes per day. Staff interviews showed the CNA provided the splints and range of motion during care, but MDS staff stated they were instructed not to code range of motion or splint assistance because the facility used a functional maintenance program rather than a restorative program.
Failure to Document and Maintain Resident Code Status Orders
Penalty
Summary
The facility failed to ensure that emergency basic life support, including CPR, was immediately available and aligned with physician orders and residents’ advance directives for three residents reviewed for code status. The deficiency involved R14, R184, and R187, and the report states that the failure had the potential to cause basic life support needs to go unmet for residents in the facility. For R184, the admission record showed the Advance Directive section was blank, the Resident Header did not reflect a code status or advance directive, and the Order Summary Report did not contain an order for the resident’s presence or absence of an advance directive or a default Full Code direction. The Social Services Assessment documented that information about resident rights and advance directives was provided, but it did not reflect the resident’s wishes for Full Code, DNR, or DNI. The care plan identified the resident as Full Code and included an intervention to ensure orders reflected Full Code wishes, but no POLST or other advance directive was found in the Misc tab at the time of review. The resident stated she wanted Full Code and said she had been given advance directive resources that morning. A Full Code order was entered later in the Order Audit Report. For R187, the admission record also showed a blank Advance Directive section, and the Resident Header did not reflect a code status or advance directive. The Order Summary Report did not contain an order for advance directive status or Full Code direction. The Social Services Assessment documented that advance directive information was provided, but it did not reflect the resident’s wishes for Full Code, DNR, or DNI. The care plan identified the resident as Full Code and included an intervention to ensure orders reflected Full Code wishes, but no POLST or other advance directive was found in the Misc tab at the time of review. The resident stated she wanted Full Code and said she and her husband would review advance directive resources. The SW stated residents without an advance directive were considered Full Code unless otherwise documented, and an LPN and the DON both stated that code status should be entered as an order and reflected in the EMR, but the chart review showed no code status order, no POLST, and no code status listed at the time of review. A Full Code order was entered later in the Order Audit Report. For R14, the record showed the resident had been admitted with progressive supranuclear ophthalmoplegia. A nurses note documented that the responsible party signed an updated POLST changing the resident’s code status from Full Code to DNR/DNI, and the Misc tab contained POLST forms indicating do not attempt resuscitation. The care plan identified the resident as DNR/DNI and included an intervention to ensure orders reflected DNR/DNI wishes. However, the Order Recap Report showed the DNR/DNI order had been discontinued when the resident went to the hospital, and no current order was entered when reviewed. Staff interviews indicated nursing was expected to enter orders when a new POLST was signed and to reinstate orders when the resident returned from the hospital, but the current order was not present in the EMR at the time of review.
Failure to Evaluate Alternatives, Obtain Order, and Care Plan Bedrail Use
Penalty
Summary
The facility failed to ensure that alternative measures were evaluated before a bedrail was installed, failed to obtain a physician's order for the bedrail, and failed to care plan the bedrail for one resident reviewed, R112. The facility policy on enablers stated that bedrails are enablers that require an appropriate clinical assessment, voluntary agreement, and documentation of the clinical rationale and monitoring requirements in the care plan and clinical record. However, the policy did not indicate that alternatives to bedrail use were to be evaluated or that the attending physician was to be consulted before installation. R112 was admitted to the facility and had a quarterly side rail assessment indicating use of 1/2 side rails for positioning, mobility, and transfers, with signed consent in place, but the document did not show that alternatives were evaluated. The resident's annual MDS showed a BIMS score of 15/15, indicating cognitive intactness, and the resident did not have a fall during the assessment period. The care plan addressed limited mobility, assistance with turning and repositioning, and fall risk, but there was no evidence that the siderail was included as a positioning aid. The physician's orders did not include an order for siderails, and progress notes did not show that alternatives were attempted before the siderail was used. During observation, R112 was sitting in a wheelchair at bedside with a right upper half siderail engaged, and the resident stated she used the siderail to pull herself up out of bed. Staff interviews showed the DON, RN, RM, and UM1 stated that siderails were treated as enablers and did not require a physician order or care plan, and the DON could not provide evidence that alternatives had been attempted.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor known food preferences for one resident, R187, who was admitted on 09/17/25 and had selected vegan meal choices from the facility’s menu options. The facility’s policy required food preferences, allergies, intolerances, and dislikes to be identified and entered into the menu management system, and for tray tickets to reflect items appropriate for the resident based on diet order, allergies, intolerances, and preferences. R187’s baseline care plan completed on 09/18/25 did not reflect her dietary preferences, and during interview she stated she needed to speak with the dietician about her vegan food preferences or an alternative. R187 reported that the meals she received were limited and consisted mainly of bread, oatmeal for breakfast, a roll, and vegetables for dinner. On 09/24/25, she declined her dinner tray and had a family member obtain food for her. Observation of the dinner tray showed a roll, potatoes, vegetables, fruit, and a beverage, and the tray ticket listed a dinner roll, margarine, fruit, potatoes, squash medley, Lactaid milk, and coffee or hot tea. CNA 2 stated the tray ticket and meal tray should match before service and noted the milk listed on the ticket was missing from the tray. The DON reviewed the tray and stated it was appropriate for a vegan meal as written on the tray ticket, and that any concern should be discussed with the dietician. The DM stated residents’ food choices were entered into the menu management system by dietary staff, and the DDM later reviewed R187’s menu selections and tray tickets. The DDM determined that R187 did not receive her selected preferences and stated her preferences were not entered correctly into the menu management system. The DM confirmed that R187 was not served her food preferences as selected on the menu for dinner on 09/24/25 or breakfast on 09/25/25.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for a resident reviewed for accidents. The resident, who was severely cognitively impaired with a BIMS score of two, was observed with a red linear mark on the cheek and discoloration on the bridge of the nose. The resident's care plan noted behaviors such as bumping into furniture and crawling under beds, which could potentially lead to skin impairments. Despite these observations, the facility did not report the incident to the NJDOH as required. Interviews with staff, including LPNs, the Risk Manager, the DON, and the LNHA, revealed that the facility's policy required immediate reporting of injuries of unknown origin. The staff acknowledged that the incident should have been reported within two hours if it involved abuse or within 24 hours if it did not. However, the investigation conducted by the facility did not rule out abuse, and the incident was not reported to the NJDOH. The facility's policy on abuse, neglect, exploitation, or misappropriation required all reports of resident abuse, including injuries of unknown origin, to be reported to local, state, and federal agencies. The policy defined 'immediately' as within two hours for serious bodily injury or within 24 hours for other allegations. Despite this policy, the facility failed to report the incident involving the resident's unexplained facial bruising, which was not witnessed by staff, to the NJDOH.
Failure to Consistently Apply Heel Booties for Resident
Penalty
Summary
The facility failed to ensure that heel booties were consistently applied to a resident to prevent skin breakdown, as observed by a surveyor. The resident, who was admitted with diagnoses including unspecified dementia and anxiety disorder, was observed multiple times sitting in a reclining chair without heel booties, despite a physician's order for bilateral heel booties every shift. The resident's care plan also indicated that heel booties should be worn at all times to protect against skin integrity issues. Interviews with facility staff, including a CNA, LPN, RN/Clinical Coordinator, and the DON, revealed a misunderstanding of the physician's order and care plan. The CNA stated that heel booties were only applied when the resident was in bed, while the LPN and RN/CC initially interpreted the order as applying only during bed rest. However, upon review, the RN/CC and DON acknowledged that the order and care plan required heel booties to be worn at all times, including when the resident was in a recliner. The facility's policy on pressure injury prevention emphasized the implementation of evidence-based interventions according to physician orders, which was not adhered to in this case.
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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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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) |
|---|---|---|---|---|
| Reformed Church Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Preferred Care At Old Bridge, Llc | 2.4 mi | ★★★★★ | 2 | 0 |
| Autumn Lake Healthcare At Old Bridge | 3.7 mi | ★★★★★ | 15 | 0 |
| Excel Care At Manalapan | 3.8 mi | ★★★★★ | 24 | 0 |
| Meadowbrook Respiratory And Nursing Center | 4.9 mi | ★★★★★ | 0 | 0 |
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