Roosevelt Care Center at Old Bridge

Inspectors wroteBased on observations, record review, interviews, review of facility policy and review of the Resident Assessment Instrument (RAI), the facility failed to ensure four residents Minimum Data Set (MDS) assessments were accurately coded regarding dialysis (Resident (R) 6 and R135), weight loss (R14) and restorative nursing program (R8) out of 33 sampled residents. This failure had the potential to affect the care planning and provision of needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility was able to provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physicians orders and the resident's advance directives for three of five residents (Resident (R) R14, R184, and R187) reviewed for code status out of 36 sampled residents. This failure had the potential to cause basic life support needs to go unmet for residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received alternative measures prior to installation of bedrails, obtain physician's order for bedrail, and care plan the bedrail for one of two residents reviewed for bedrails (Resident (R) 112) of 30 sampled residents. The lack of alternative bedrail measures, orders, and care plan could lead to potential safety concerns related to bed rail use for residents with bed rails.

Inspectors wroteBased on observations, record reviews, interviews and policy review, the facility failed to honor known food preferences for one of three residents (Resident (R) 187) reviewed for food choices out of 43 sampled residents. This failure had the potential to cause nutritional needs to go unmet for residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observations, interviews, record review and facility documents, it was determined that the facility failed to report an Injury of Unknown origin to the New Jersey Department of Health (NJDOH), for 1 of 7 residents (Resident #138), reviewed for accidents. This deficient practice was evidenced by the following: On 08/19/24 at 11:27 AM, during initial tour, the surveyor observed Resident #138 sitting with staff, in the main activity area. The resident was wearing a black helmet. On 08/21/24 at 09:30 AM, the surveyor reviewed the electronic Medical Record (eMR) for Resident #138 which revealed the following: A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's Disease, Unspecified and Anxiety Disorder, Unspecified. [...]

Inspectors wroteBased on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to ensure heel booties (minimize the risk of pressure damage to heels) were consistently applied to prevent skin breakdown. This deficient practice was identified for Resident #89, 1 of 2 residents reviewed for position and mobility. This deficient practice was evidenced by the following: On 08/19/24 at 12:14 PM, during initial tour, the surveyor observed Resident #89 sitting in a reclining chair in the main activity area. The resident was wearing blue socks with their heels resting on the footrest. On 08/19/24 at 12:31 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #89 which revealed the following: A review of the admission Record revealed the resident was admitted to the facility with diagnoses including but not limited to: [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the dumpster area remained free of garbage to prevent the harborage of pests and rodents on three of three days for which observations were made during the survey. This had the potential to affect staff, visitors, and all 167 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to assure that three (Resident (R) 80, R92, and R22) of 36 sampled residents were treated in a respectful and dignified manner during dining. Staff stood over the residents while feeding them their meals, rather than sitting at the resident's eye level, maintaining face-to-face contact. In addition, staff failed to refer to an unidentified resident with dignity. Staff referred to a resident by the level of assistance they need, rather than in a person-centered manner.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure four (Resident (R) R557, R133, R5, and R43) of five residents reviewed for catheter use received appropriate catheter care. Specifically, R557 had no order to indicate the size of the condom catheter needed to prevent leakage. R133 had two conflicting orders for catheter sizes. R5's catheter tubing was in contact with the floor, and R143's catheter tubing was not anchored as ordered. These failures had the potential to lead to increased urinary tract infections, pulling of the catheter tubing, or use of the wrong size catheter.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assure that one (Resident (R) 408) of 36 sampled residents did not self-administer medication without first being assessed to determine whether the self-administration of medication by the resident was clinically appropriate. This failure resulted in R408 receiving an extra dose of her prescribed medication.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that each mandatory assessment accurately reflected the resident's status for two residents (Resident (R) 144 and R23) reviewed in a total sample of 36 residents. Minimum Data Set (MDS) inaccuracies were noted in the areas of Active Diagnoses and Falls.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide assistance with Activities of Daily Living (ADL) for two (Resident (R) 127 and R49) of three residents reviewed for ADLs in a total sample of 36 residents. Facility staff failed to provide nail care and/or oral care for the two residents, who were dependent on staff for assistance with ADLs.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for two (Resident (R) 97 and R40) of two residents reviewed for respiratory care out of a total sample of 36 residents. Oxygen concentrator filters were not cleaned as needed, Respiratory equipment, such as tubing and/or nasal cannulas, was not stored in a sanitary manner.

Inspectors wroteBased on observation, interview, record review, and review of facility policy and Food and Drug Administration (FDA) information, the facility failed to attempt alternatives prior to installing bed rails for one (Resident (R)23) of four residents reviewed for accident hazards. In addition, the facility failed to ensure the correct installation, use, and ongoing maintenance of bed rails (also known as side rails) for R23, which placed the resident at unnecessary risk of injury or entrapment.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to promptly notify the physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results for one (Resident (R) 86) of a total sample of 36 residents. This failure had the potential to delay treatment or lead to a worsening condition.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure staff followed standard infection prevention precautions for one (Resident (R) 407) of five residents reviewed for wound care. The failure to perform hand hygiene and change gloves as indicated during wound care has the potential to lead to cross contamination and infection.