Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 during CMS and state inspections, most recent first.
Cold shower water on the 4th floor: Two residents reported that shower water was too cold, leading them to receive bed baths instead of showers. One resident required substantial/maximal bathing assistance and the other was dependent for bathing; both had care plans that did not address bathing or showering. An LPN said residents sometimes complained about the water temperature, and the DOM measured the 4th-floor shower water at 92.5 degrees F.
A resident with severe cognitive impairment, limited mobility, diabetes with neuropathy, cancer, and an arterial ulcer on the left lateral malleolus was observed in a geriatric chair with the feet either resting on cardboard boxes and foam or dangling unsupported for hours. The care plan addressed skin impairment and pressure injury risk but did not include support for the feet and legs in the chair, and the DON was unaware the family had improvised a foot stool for support.
The facility failed to provide pharmaceutical services in accordance with professional standards, leading to discrepancies in narcotic medication documentation and reconciliation, including missing tablets, unrecorded administrations, and failure to remove discontinued medications from active inventory.
The facility failed to ensure a resident received the correct dosage of prn narcotic medication, leading to multiple instances of administering the wrong dose. The error involved four different nurses and occurred due to the presence of both discontinued and current medication cards in the narcotic drawer.
The facility failed to maintain proper kitchen sanitation practices, clean equipment, and properly store foods, leading to potential foodborne illness risks. Observations included unlabeled and unsealed food items, dirty kitchen equipment, and unsanitary nursing unit kitchenettes. Interviews with staff confirmed the lack of proper cleaning and maintenance procedures.
The facility failed to ensure proper handling and storage of linens, systematic water management, and infection control practices for a resident with a tube feeding and urinary catheter. Observations included exposed clean towels, improper storage of clean blankets, lack of water management accountability, and an uncapped hydration bag and urinary catheter drainage bag on the floor.
The facility failed to maintain a safe and sanitary environment in the laundry and shower rooms. Issues included water puddles, stagnant water in garbage containers, an open pipe, and hard water residue on shower heads. The Director of Housekeeping and the Director of Operations acknowledged the problems but cited a lack of communication and accountability. Facility management was notified of these deficiencies.
The facility failed to protect a resident's privacy and independence by posting unauthorized signs on the resident's door that disclosed personal information and instructions. The signs were against HIPAA regulations and were not noticed by the DON during rounds. The resident had a medical history including cerebral vascular infarction, dysphagia, bipolar disorder, morbid obesity, and COPD.
The facility failed to update a resident's DNR and DNI status in the care plan and physician's orders, despite the POLST being signed by the family and physician. The resident's medical records continued to reflect a Full Code Status, contradicting the signed POLST.
The facility failed to report injuries of unknown origin to the NJDOH as required for two residents. One resident with chronic conditions was found with a swollen leg and hematoma, and the incident was reported late after the condition escalated. Another resident on anticoagulant therapy had a bruise likely caused by a blood pressure cuff, but the incident was also reported late.
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for a resident. The care plan did not include specific interventions for the coccyx wound, and weekly skin review assessments were inaccurate. An RN did not follow infection control practices or physician's orders during wound treatment.
The facility failed to follow the Functional Maintenance Program (FMP) recommendations for splints and range of motion (ROM) exercises for two residents, resulting in untreated contractures and lack of necessary ROM exercises. Observations, interviews, and medical record reviews revealed inconsistencies and delays in the application and documentation of the prescribed treatments.
The facility failed to ensure adequate routine monitoring for a resident after returning from offsite hemodialysis. The staff did not consistently document post-dialysis vital signs and access site status, despite the resident's comprehensive medical history and the facility's established protocol. Interviews and record reviews confirmed these deficiencies, which were acknowledged by the Director of Nursing.
The facility failed to ensure consistent coordination and communication between staff and hospice for a resident with severe cognitive impairment and multiple diagnoses. There was a lack of documentation for hospice nurse visits and the termination of hospice services, and the hospice representative did not attend a care plan meeting.
A resident with C. diff was placed on contact precautions and isolated in a private room, but the facility failed to accurately code the resident's MDS for isolation. The discrepancy was identified during a survey, and facility staff later acknowledged the error.
Cold shower water on the 4th floor
Penalty
Summary
The facility failed to ensure water was at a comfortable temperature in the fourth-floor shower rooms for two residents. Resident council minutes documented that residents on the 4th floor reported the green hallway and shower room was cold, and that residents on N2 and N4 asked whether the water could be warmer. The facility told residents that, per State regulations, hot water boilers could only be set between 95 and 110 degrees. Resident R161 had an admission date of 08/01/25, a BIMS score of 13 out of 15, required substantial/maximal assistance for bathing, and had diagnoses including primary osteoarthritis of both shoulders and lymphedema. R161’s comprehensive MDS stated it was very important to choose between a tub bath, shower, bed bath, or sponge bath, but the care plan contained nothing about bathing or showering. Shower/bathing documentation showed R161 received bed baths except for one shower, and R161 stated the shower water was always too cold, so he/she had resorted to bed baths after reporting the issue to caregivers for more than a month without resolution. Resident R15 had an admission date of 12/01/22, a BIMS score of 11 out of 15, was dependent for bathing, and had diagnoses including cancer, fusion of the spine, and Waldenstrom macroglobulinemia not in remission. R15’s comprehensive MDS stated it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath, but the care plan also contained nothing about bathing or showering. Shower/bathing documentation showed R15 received only bed baths, and R15 stated satisfaction with care except that bed baths were used because the shower water was too cold. During interviews, an LPN stated residents sometimes complained the shower water was too cold, and the DOM measured the hot water in a 4th-floor shower stall at 92.5 degrees F, stating shower heads insert air and lower the temperature compared with resident sinks.
Failure to Support Feet and Legs in Geriatric Chair
Penalty
Summary
The facility failed to implement an appropriate intervention to keep the feet and legs elevated for a resident while in a geriatric chair. The resident had a severely impaired BIMS score, was dependent on staff for mobility, and had diagnoses including cancer, diabetes mellitus with neuropathy, and a pressure ulcer. The care plan identified skin impairment and potential for further skin breakdown related to impaired mobility, including a left lateral malleolus arterial ulcer and left bunion blanchable redness, but it did not address supporting the feet and legs when the resident was in the geriatric chair. Observation and record review showed the resident was in the same geriatric chair for several hours with the chair slightly reclined and the feet either resting on two short cardboard boxes and foam squares or dangling unsupported. The resident was observed asleep in the chair, later being fed by a family member, and later again with the feet unsupported. The family member confirmed the resident had a wound on the left outer ankle. The clinical coordinator demonstrated the use of the cardboard boxes and foam when asked about the resident's positioning, and the DON stated she was not aware the family had brought the boxes and foam for a foot stool. The facility policy titled Pressure Injury Prevention Guidelines stated that when in a chair, adequate seat tilt should be provided to prevent sliding forward and the feet should be properly supported.
Inaccurate Documentation and Reconciliation of Narcotic Medications
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, leading to several deficiencies. One significant issue was the inaccurate documentation of the removal of a controlled substance for a resident prescribed Oxycodone/Acetaminophen. The surveyor found discrepancies between the medication count in the bingo card and the Individual Patient's Controlled Drug Record (IPCDR), indicating a missing tablet that was not identified during the shift-to-shift count. Interviews with the Licensed Practical Nurse (LPN) and the Unit Manager confirmed that the inventory count should have matched, but it did not due to oversight by the nurses involved in the shift change process. Another deficiency involved the failure to accurately reconcile and administer narcotic medication, which had the potential for drug diversion. The surveyor found that 13 doses of Oxycodone/Acetaminophen were removed from inventory but not documented as administered on the electronic Medication Administration Record (eMAR) for one resident. This discrepancy involved six different nurses who either forgot to sign the eMAR or encountered technical issues with the laptop used for documentation. The Director of Nursing (DON) confirmed that there was no process in place to ensure that the medication removed from the bingo card was administered and documented correctly. Additional issues included the failure to remove discontinued narcotic medications from active inventory, as observed with a resident's Lorazepam that was discontinued five months prior but still present in the medication room. Another resident's Morphine Sulfate had a missing safety tamper seal, and there was no documentation of its administration or wastage. Furthermore, a resident's Midodrine was administered without documenting the required blood pressure checks, and another resident's discontinued Pregabalin was not removed from the medication cart, posing a risk for medication errors or drug diversion.
Failure to Administer Correct Dosage of PRN Narcotic Medication
Penalty
Summary
The facility failed to ensure that a resident received as needed (prn) narcotic medication in accordance with the prescriber's orders and accepted professional standards. This deficiency was identified for one resident who was receiving prn narcotic oxycodone 5/325 mg. The resident had a moderately impaired cognition and was receiving opioid medication for pain management related to Type 2 Diabetes mellitus with Diabetic polyneuropathy and Peripheral Vascular Disease. The resident's care plan included monitoring for pain and adjusting medications as needed, but the facility did not adhere to these interventions properly. The surveyors found discrepancies between the electronic Medication Administration Record (eMAR) and the Individual Patient Controlled Drug Record (IPCDR). Specifically, the eMAR documented that the resident received Oxycodone-Acetaminophen 5/325 mg at various times, but the IPCDR showed that Oxycodone-Acetaminophen 10/325 mg was administered instead. This error occurred multiple times over several days, involving four different nurses who administered the wrong dose six times. The facility's investigation confirmed that the discontinued Oxycodone 10/325 mg bingo card was not removed from the narcotic drawer, leading to the administration of the incorrect dosage. The facility's policy on medication errors emphasizes the importance of administering medications according to the physician's orders and professional standards. However, the nurses involved did not follow the five rights of medication administration: right resident, right medication, right dosage, right route, and right time. Despite previous medication pass observations indicating proper administration techniques, the error occurred due to the presence of both the discontinued and current medication cards in the narcotic drawer, leading to the administration of the wrong dose to the resident.
Facility Fails to Maintain Proper Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices and clean equipment, as observed by the surveyor. In the walk-in freezer, several boxes of opened food items were found unlabeled, unsealed, and exposed to freezer burn and frost. The food service manager was unable to provide information on when the packages were opened. Additionally, the cooktop food catch tray had hard, thick, flakey black sediment and visible food debris, and the fryer oil was heavily laden with sediment, indicating it had not been drained or cleaned as required. The food service director acknowledged these issues and admitted that the equipment did not meet his expectations of cleanliness. The facility also failed to properly store foods in a safe manner to prevent the development of foodborne illness. The surveyor observed that the fryer oil cleaning and disposal schedule was not being followed, and the facility was unable to provide an oil disposal policy or pickup invoices for the last 12 months. Interviews with the head chef and maintenance director revealed a lack of accountability and documentation for the disposal of used cooking oil. The maintenance director was unaware of any contracted company for oil pickup, and the facility president of clinical confirmed the absence of a process or policy for fryer oil disposal. Furthermore, the facility did not maintain the nursing unit kitchenettes in a sanitary manner. The surveyor found debris in the gaskets of refrigerator and freezer units, a build-up of icicles on the freezer door, and torn gaskets. The microwave in the 4th-floor unit kitchenette had heavily crusted sediment, and there was debris on the counter and black discolored sediment behind the sink. The ice machine/water dispensers on all nursing units were visibly dirty with white and brown sediment. Interviews with the registered nurse unit manager, licensed practical nurse unit manager, infection preventionist, maintenance director, and housekeeping director confirmed the lack of proper cleaning and maintenance, which could lead to cross-contamination and bacterial growth.
Infection Control Deficiencies in Linen Handling, Water Management, and Resident Care
Penalty
Summary
The facility failed to ensure proper handling, storage, and processing of linens and other supplies in a clean manner, as observed in the Laundry and Linen Storage rooms. The surveyor noted that the inside part of the washer had white dried substances, and clean towels were exposed to the environment, placed next to working supplies. Additionally, clean residents' clothes were left on a table with dried substances, and the laundry room lacked a cleaning accountability log. In the Linen Storage Room, clean blankets were not properly stored and were left open to the surrounding environment, contrary to the facility's policy and CDC guidelines. The facility also failed to conduct routine, ongoing, and systematic monitoring and tracking of its water management program. The Director of Maintenance and Director of Operations admitted that the facility did not have an accountability log for HVAC and PTAC units, and there was confusion about the responsibilities for water management. The facility's water management policy was not followed, and there was no accountability for control measures and corrective actions stipulated in the policy. The Infection Preventionist/Licensed Practical Nurse acknowledged the importance of following the water management policy but could not explain why it was not adhered to. Furthermore, the facility did not maintain proper infection control practices for a resident with a tube feeding and a urinary catheter. The surveyor observed an uncapped enteral tube feeding hydration bag and a urinary catheter drainage bag and tubing on the floor, intertwined with the resident's call bell and remote. The Licensed Practical Nurse confirmed that the urine bag should have had a privacy cover and should not have been on the floor. The facility's policies for enteral nutrition and catheter care were not followed, leading to potential contamination and infection risks for the resident.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in both the laundry and linen storage rooms, as well as the shower rooms. In the laundry room, the surveyor observed a puddle of water near the door and the washer, which had been reported to the maintenance department the previous week. Additionally, there were open garbage containers with stagnant, blackish water and grayish substances, and an open pipe from a previously removed dryer. The Director of Housekeeping (DH) and the Director of Operations (DoO) acknowledged the issues but indicated a breakdown in communication and lack of accountability for reporting and addressing these concerns. The DoO stated that the issues should have been reported to him for action, but there was no log or routine check in place to ensure this happened. In the shower rooms, the surveyor observed dried brownish discoloration and whitish substances on the shower heads, which the Director of Maintenance (DoM) identified as hard water residue. The vent in the ceiling also had an accumulation of grayish substances, which the DoM claimed was dust. The DH and a housekeeper (HK) confirmed that the housekeeping staff were responsible for cleaning the shower rooms daily, but there was no accountability log. The HK admitted that the grayish substances on the vent had likely not been cleaned for at least three days. The facility management, including the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), were notified of these findings and concerns. The report highlights a lack of proper maintenance and communication within the facility, leading to unsanitary conditions in both the laundry and shower rooms. The DoO acknowledged the issues but emphasized that they were not reported to him in a timely manner, and there was no system in place to ensure regular monitoring and cleaning. The facility management was made aware of these deficiencies, but the report does not mention any immediate corrective actions taken to address the issues.
Failure to Protect Resident's Privacy and Independence
Penalty
Summary
The facility failed to protect a resident's privacy and independence in a dignified manner. This was evidenced by signage on the resident's door that disclosed personal information and instructions, such as the need for the resident to be fed by a nurse and not to give the resident the remote control for the bed. These signs were observed by the surveyor on multiple occasions. The resident in question had a medical history that included cerebral vascular infarction, dysphagia, bipolar disorder, morbid obesity, and chronic obstructive pulmonary disease. The resident's care plan included monitoring intake of solid food and liquids to prevent aspiration or choking. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA), revealed that the signs were not authorized and were against HIPAA regulations. The DON admitted to not noticing the signs during her rounds, and the LNHA acknowledged that the signs should not have been posted. The facility's policies on resident rights and room postings were reviewed and found to support the need for privacy and confidentiality, which were not upheld in this instance.
Failure to Update DNR/DNI Status in Resident's Care Plan
Penalty
Summary
The facility failed to address a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) code status order for a resident, despite the order being signed by the resident's family and physician. The resident's medical record and care plan continued to reflect a Full Code Status, which contradicted the signed POLST indicating DNR and DNI. This discrepancy was identified during a surveyor's review of the resident's medical records and was acknowledged by the Registered Nurse/Unit Manager (RN/UM) and the facility Social Worker (SW), who confirmed that the POLST was signed in their presence but not updated in the resident's care plan or physician's orders. The resident, who had severe cognitive impairment with a BIMS score of 4 out of 15, was observed receiving oxygen via a nasal cannula. The resident's medical history included heart failure, chronic obstructive pulmonary disease, major depressive disorder, and hypertension. Despite the POLST being signed by the family and physician, the facility failed to update the resident's code status in the medical records and care plan, leaving the resident listed as Full Code. The facility's policy for Advance Directives required the interdisciplinary team to review and update the resident's advance directives annually and inform the care plan team of any changes. However, this procedure was not followed in the case of the resident, leading to a significant oversight. The RN/UM and SW both acknowledged the importance of the POLST and the need for immediate updates to the care plan and physician's orders, but this was not done, resulting in the deficiency.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required and according to the facility's policy for two residents. Resident #210, who was moderately cognitively impaired and had multiple diagnoses including chronic kidney disease and chronic embolism, was found with a swollen right lower leg and a hematoma. Despite the facility's internal investigation and initial belief that the cause of the injury was known, the incident was not reported to the NJDOH until several days later when the resident's condition escalated and an allegation of abuse was made by the resident's daughter. Resident #211, who was cognitively intact and on anticoagulant therapy, was found with a bruise on the right shoulder. The facility's investigation determined that the bruising was likely caused by a blood pressure cuff during dialysis. However, the incident was reported to the NJDOH later than required by the facility's policy. The Licensed Nursing Home Administrator (LNHA) acknowledged that the report was made past the time limit. The facility's policy mandates that any suspicion of abuse, neglect, exploitation, or injury of unknown origin must be reported immediately to the administrator and relevant authorities. The policy specifies that incidents involving serious bodily injury must be reported within two hours, and other incidents within 24 hours. The facility failed to adhere to these reporting timelines for both residents, leading to a repeat deficiency citation.
Failure to Provide Appropriate Pressure Ulcer Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #122. The facility did not follow physician's orders, ensure an individualized comprehensive care plan, accurately perform weekly skin review assessments, or appropriately perform infection control practices during wound treatment. The resident had a facility-acquired wound to the sacrum and was on Enhanced Barrier Precautions (EBP), requiring the use of personal protective equipment (PPE) during direct care. However, the care plan did not include specific interventions for the coccyx wound, and the weekly skin review assessments did not document the coccyx wound accurately. During an observation, a registered nurse (RN) failed to perform hand hygiene before entering the resident's room, did not change gloves or perform hand hygiene after cleaning the wound, and did not follow the physician's order to apply Vitamin A&D ointment to the periwound area. The RN also touched the resident's personal items without performing hand hygiene afterward. The infection preventionist and other staff acknowledged these lapses in infection control practices and the failure to follow the care plan. The facility's policies and procedures for comprehensive person-centered care plans and Enhanced Barrier Precautions were not followed. The care plan for Resident #122 did not include specific goals and interventions for the coccyx wound, and the weekly skin review assessments were not accurate. The facility management acknowledged these deficiencies and the need for accurate documentation and adherence to care plans and infection control practices.
Failure to Follow Functional Maintenance Program for ROM and Splints
Penalty
Summary
The facility failed to ensure that residents with decreased range of motion and mobility received treatments to prevent contractures or further contraction. Specifically, the facility did not follow the Functional Maintenance Program (FMP) recommendations for splints for Resident #20 and for range of motion (ROM) exercises for Resident #112. This deficiency was evidenced by multiple observations, interviews, and reviews of medical records and facility documentation. Resident #20, who had diagnoses including quadriplegia and anoxic brain damage, was observed without the prescribed splints on multiple occasions. The resident's medical records indicated orders for bilateral elbow braces and a left resting hand splint, but there was no documentation that these splints were applied from 4/12/24 to 4/22/24. Interviews with various staff members, including CNAs, therapists, and the Director of Nursing (DON), revealed inconsistencies and delays in the application and documentation of the splints. The facility's failure to implement the FMP recommendations in a timely manner contributed to this deficiency. Resident #112, who had severe cognitive impairment and physical limitations, was observed without receiving the prescribed passive range of motion (PROM) exercises. The resident's care plan included a focus on maintaining strength and ROM, with specific orders for PROM to both upper and lower extremities. However, the CNA tasks revealed multiple instances where the PROM exercises were marked as 'not applicable,' indicating that they were not performed. Interviews with the assigned CNA, the FMP CNA, and the unit manager confirmed that there was confusion and lack of clarity regarding the responsibility for performing the PROM exercises. This lack of adherence to the FMP recommendations resulted in the resident not receiving the necessary ROM exercises to maintain their function.
Failure to Ensure Adequate Post-Dialysis Monitoring
Penalty
Summary
The facility failed to ensure adequate routine monitoring for a resident after returning from offsite hemodialysis. The deficiency was identified through observation, interview, and record review, revealing that the staff did not consistently document post-dialysis vital signs and access site status for one of the residents. Specifically, the Nursing Facility/Dialysis Center Communication Record (NF/DCCR) lacked post-dialysis vital signs and access site documentation for several dates in April 2024. Additionally, the electronic Medical Record (eMR) did not reflect the necessary vital signs upon the resident's return from hemodialysis on multiple occasions. The resident involved had a comprehensive medical history, including essential hypertension, hydrocephalus, diabetes mellitus with diabetic polyneuropathy, end-stage renal disease, and dependence on renal dialysis. Despite the resident's intact cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, the facility staff failed to follow the established protocol for post-dialysis care. Interviews with the Registered Nurse/Unit Manager (RN/UM) and Licensed Practical Nurse (LPN) confirmed that the facility's practice required immediate checking of vital signs and access site assessment upon the resident's return from hemodialysis. However, these steps were not consistently documented in the NF/DCCR or the eMR. The Director of Nursing (DON) acknowledged the importance of checking vital signs and the access site to prevent potential complications such as bleeding and low blood pressure after dialysis. Despite the facility's policy and expectations, the survey revealed inconsistencies in documentation and adherence to the protocol. The survey team notified the facility management of these concerns, highlighting the need for immediate corrective actions to ensure compliance with professional standards of clinical practice for dialysis care.
Failure to Ensure Consistent Coordination and Communication with Hospice Staff
Penalty
Summary
The facility failed to ensure consistent coordination and communication between facility staff and hospice staff for a resident receiving hospice services. The resident, who had severe cognitive impairment and was diagnosed with Parkinson's disease and heart failure, was observed asleep in bed. The medical records indicated that the resident was on hospice services, but there was a lack of documentation from the hospice nurse after a visit on 01/29/24. The Licensed Practical Nurse (LPN) and Unit Manager/Registered Nurse (UM/RN) confirmed the absence of subsequent hospice summary notes and were unaware of the reasons for this lapse in documentation. The Director of Social Services (DSS) and the Director of Nursing (DON) both acknowledged that the resident had been on hospice services since May 2023 and was discharged on 4/26/24. However, there was no documentation of the hospice nurse's visits or the termination of hospice services in the resident's medical record. The hospice provider's Clinical Director also confirmed that weekly visits were made, but the documentation was not left in the facility binder as required. The facility's written agreement with the hospice provider and its policy on hospice programs emphasized the need for documented communication, which was not adhered to in this case. The surveyor's interviews with various staff members revealed that the hospice nurse's visits and the discharge from hospice services were communicated verbally but not documented. Additionally, the hospice representative did not attend the care plan meeting on 02/28/24, and there was no documentation of their participation. The facility's failure to document these communications and visits led to the deficiency, as it did not meet the required standards for coordination and communication with the hospice provider.
Failure to Accurately Code MDS for Isolation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one of the residents, leading to a deficiency. The resident in question, who had a diagnosis including essential hypertension, dementia, type 2 diabetes mellitus, and unspecified diarrhea, was placed on contact precautions for Clostridioides difficile (C. diff) starting in early April 2024. Despite being in a private room with isolation precautions in place, the resident's quarterly MDS with an assessment reference date of April 9, 2024, did not reflect the isolation status in Section O, which should have been coded for isolation or quarantine for active infectious disease according to the Resident Assessment Instrument (RAI) Manual guidelines. This discrepancy was identified during a surveyor's review of the resident's medical records and interviews with facility staff, including the Registered Nurse/MDS Coordinator (RN/MDSC) and the Registered Nurse/Unit Manager (RN/UM). The RN/MDSC initially stated that the resident did not meet the criteria for isolation according to the RAI Manual, but later acknowledged that the isolation should have been captured in the MDS after further review and consultation with the Regional MDS person. The surveyor's findings were communicated to the facility's management team, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the President of Clinical (VPoC), who confirmed that the MDS should have been coded for isolation. The facility's failure to accurately code the MDS for isolation was a clear deficiency in ensuring that each resident receives an accurate assessment, as required by regulatory standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,043 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Edison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Jersey Veterans Memorial Home Menlo | 0.2 mi | ★★★★★ | 13 | 0 |
| Brighton Gardens Of Edison | 1.6 mi | ★★★★★ | 1 | 0 |
| Hartwyck At Oak Tree | 2.6 mi | ★★★★★ | 0 | 0 |
| St Joseph's Home Al & Nc, Inc | 2.6 mi | ★★★★★ | 0 | 0 |
| Spring Creek Healthcare Center | 3.2 mi | ★★★★★ | 0 | 0 |
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