Inspection Reports for Roosevelt Care Center At Old Bridge

1133 Marlboro Road, Old Bridge, NJ, 08857

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 2.6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

50% better than New Jersey average
New Jersey average: 5.2 deficiencies/year

Deficiencies per year

12 9 6 3 0
2020
2021
2022
2024
2025

Census

Latest occupancy rate 166 residents

Based on a August 2024 inspection.

Census over time

144 153 162 171 180 189 Nov 2020 Oct 2021 Aug 2022 Dec 2022 Aug 2024

Notice

Deficiencies: 0 Date: Nov 20, 2025

Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.

Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.

Report Facts
Effective date: 2011

Employees mentioned
NameTitleContext
Devon L. GrafDirector, NJDHSS Privacy OfficerContact person for privacy practices and rights

Inspection Report

Complaint Investigation
Census: 166 Deficiencies: 3 Date: Aug 27, 2024

Visit Reason
A recertification survey was conducted from 08/19/24 to 08/27/24 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations identified by complaint numbers NJ00165563, NJ00171643, and NJ00172586.

Complaint Details
Complaint investigation was substantiated as evidenced by failure to report alleged violations to the New Jersey Department of Health (NJDOH) as required. The facility failed to report an incident involving Resident #138 to NJDOH within required timeframes.
Findings
Deficiencies were cited related to failure to report alleged violations of abuse, neglect, exploitation, or mistreatment timely and appropriately, and quality of care issues including failure to consistently apply interventions to prevent harm to residents. The facility was found not in substantial compliance with certain regulatory requirements.

Deficiencies (3)
Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment immediately, but not later than 2 hours after the allegation if serious bodily injury or within 24 hours if no serious injury.
Failure to ensure quality of care by consistently applying interventions to prevent harm to residents.
Failure to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 9 of 14 day shifts reviewed.
Report Facts
Census: 166 Sample size: 34 Staffing deficiency days: 9 CNA staffing counts: 16 CNA staffing counts: 20 CNA staffing counts: 20 CNA staffing counts: 20 CNA staffing counts: 18 CNA staffing counts: 20 CNA staffing counts: 19 CNA staffing counts: 20 CNA staffing counts: 18

Inspection Report

Renewal
Census: 167 Capacity: 180 Deficiencies: 9 Date: Dec 8, 2022

Visit Reason
A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health (NJDOH) to assess compliance with regulatory requirements for Roosevelt Care Center at Old Bridge.

Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Multiple deficiencies were cited related to resident rights, medication administration, accuracy of assessments, ADL care, infection control, bedrails, lab services, garbage disposal, and infection prevention and control. Corrective actions and monitoring plans were outlined for each deficiency.

Deficiencies (9)
Facility failed to assure that three sampled residents were treated in a respectful and dignified manner during dining.
Facility failed to assure one resident did not self-administer medication without assessment, resulting in an extra dose.
Facility failed to ensure accuracy of assessments for two residents.
Facility failed to provide assistance with ADLs for two residents dependent on staff.
Facility failed to ensure proper care for residents with bowel/bladder incontinence, catheter, and UTI.
Facility failed to ensure prompt notification of lab results to physician.
Facility failed to properly dispose of garbage and refuse, resulting in potential pest harborage.
Facility failed to ensure infection prevention and control program was fully implemented.
Facility failed to ensure proper use and maintenance of bedrails, resulting in entrapment risk.
Report Facts
Survey Census: 167 Total Capacity: 180 Sample Size: 36 Deficiencies cited: 9 Residents reviewed for CNA staffing: 167 CNA staffing deficiencies: 9

Employees mentioned
NameTitleContext
Licensed Practical Nurse 1Licensed Practical NurseNamed in feeding and wound care findings
Director of NursingDirector of NursingInterviewed regarding feeding practices, medication error, and corrective actions
Certified Nursing Assistant 1Certified Nursing AssistantObserved feeding residents and interviewed about feeding practices
Licensed Practical Nurse 2Licensed Practical NurseEducated on self-administration of medication
Licensed Practical Nurse 3Licensed Practical NursePerformed wound care competency
Certified Nursing Assistant 3Certified Nursing AssistantEducated on facility policy and oral hygiene
Certified Nursing Assistant 4Certified Nursing AssistantInterviewed regarding nail care and hygiene
Licensed Practical Nurse 10Licensed Practical NurseInterviewed regarding resident care and equipment
Director of OperationsDirector of OperationsInterviewed regarding bed rail entrapment risk and garbage disposal
Dietary ManagerDietary ManagerInterviewed regarding garbage disposal area
Regional Registered DieticianRegistered DieticianInterviewed regarding garbage disposal area
Social WorkerSocial WorkerInterviewed regarding feeding practices and resident dignity

Inspection Report

Abbreviated Survey
Census: 162 Deficiencies: 1 Date: Sep 30, 2022

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19. Additionally, a review of staffing ratios was conducted to evaluate compliance with New Jersey state staffing requirements.

Findings
The facility was found to be in compliance with infection control regulations related to COVID-19. However, the facility was not in compliance with New Jersey staffing requirements, failing to maintain the required minimum direct care staff-to-resident ratios on multiple day shifts during July and September 2022.

Deficiencies (1)
Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Census: 162 Sample Size: 7 COVID+ In-house: 21 Deficiencies in CNA staffing: 9 CNA staffing counts: 16.5 CNA staffing counts: 16 CNA staffing counts: 17 CNA staffing counts: 19.5 CNA staffing counts: 19 CNA staffing counts: 15 CNA staffing counts: 19 CNA staffing counts: 19 CNA staffing counts: 17 CNA staffing counts: 18

Employees mentioned
NameTitleContext
AdministratorDiscussed staffing ratio concerns with surveyor
Director of NursingDiscussed staffing ratio concerns with surveyor
Administrator DONWill work with staffing coordinator to transfer staff to day shift to fulfill staffing requirements
Staffing CoordinatorWill work with Administrator DON to transfer staff and conduct weekly analysis on CNA needs
Director of NursingDirector of NursingWill conduct staffing/scheduling audits with Assistant Director of Nursing and staffing coordinator
Assistant Director of NursingAssistant Director of NursingWill conduct staffing/scheduling audits with Director of Nursing and staffing coordinator

Inspection Report

Routine
Census: 158 Deficiencies: 0 Date: Aug 10, 2022

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS and CDC recommended practices for COVID-19.

Report Facts
Sample size: 7 COVID + in-house: 12

Inspection Report

Complaint Investigation
Census: 154 Deficiencies: 0 Date: Mar 14, 2022

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health based on a complaint (NJ00151673).

Complaint Details
Complaint #: NJ00151673. The facility was found in compliance based on this complaint survey.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and implemented CMS and CDC recommended practices for COVID-19. The facility met the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.

Report Facts
Sample size: 7

Inspection Report

Abbreviated Survey
Census: 168 Deficiencies: 0 Date: Oct 13, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.

Report Facts
Sample size: 6

Inspection Report

Routine
Census: 155 Deficiencies: 0 Date: Feb 4, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.

Report Facts
Sample size: 5

Inspection Report

Routine
Census: 156 Deficiencies: 0 Date: Nov 23, 2020

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.

Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.

Report Facts
Sample size: 3

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