Inspection Reports for
Roosevelt Care Center At Old Bridge

The facility failed to ensure accurate Minimum Data Set (MDS) coding for dialysis, weight loss, and restorative nursing programs for some residents. It also failed to provide emergency basic life support orders and documentation for some residents, did not properly assess or document alternatives and orders for bedrail use, and did not honor known food preferences for a resident, potentially affecting care planning, safety, and nutritional needs.

The complaint investigation focused on the failure to report an injury of unknown origin for Resident #138. The investigation included interviews with nursing staff, the Director of Nursing, Risk Manager, and Licensed Nursing Home Administrator. The facility acknowledged the incident was not reported to the NJDOH as required. The resident's behaviors were cited as the cause of the injury. The complaint was substantiated as the facility failed to report the injury timely.

The facility failed to timely report an injury of unknown origin for Resident #138 and did not consistently apply heel booties to Resident #89 to prevent skin breakdown. Investigations revealed the resident's behaviors contributed to the injury, but the incident was not reported as required. The facility's policies on abuse reporting and pressure injury prevention were reviewed and found to be in place but not fully followed.

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.

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.

The facility was found deficient in multiple areas including failure to treat residents with dignity during feeding, medication self-administration errors, inaccurate resident assessments, inadequate assistance with activities of daily living, improper catheter care, unsafe use and maintenance of bed rails, failure to promptly notify physicians of lab results, unclean oxygen concentrator filters and improper storage of respiratory equipment, failure to maintain dumpster area free of debris, and failure to follow infection prevention protocols during wound care.

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.

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.