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Roosevelt Care Center At Old Bridge

1133 Marlboro Road, Old Bridge, NJ 08857 · Government - County · 180 certified beds · (732) 360-9830 Medicare & Medicaid certified

Call the home — (732) 360-9830 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Aug 2024
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 5 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
74 U.S. 9 · (732) 972-1015 · Call to confirm hours
Pharmacy
2825 Highway Route 18 · (732) 955-0770 · Call to confirm hours
Grocery
2825 Highway Route 18 · (732) 609-0559 · Call to confirm hours
Park
E Francis Ave · (732) 617-0100 · Typically dawn to dusk
Place of worship
8998 State Route 18 · (732) 444-8166

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.2%8.7%15.4%better
Long-stay residents who lose too much weight2.7%4.6%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.2%0.8%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms1.4%12.1%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.8%2.3%3.3%worse
Long-stay residents whose ability to walk worsened4.9%8.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.3%18.8%18.9%better
Long-stay residents given the seasonal flu vaccine96.5%97.2%95.3%typical
Long-stay residents with pressure ulcers4.4%5.4%4.7%typical
Long-stay residents with worsening bladder/bowel control13.7%15.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.0%12.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine83.4%80.1%79.4%typical
Short-stay residents rehospitalized after admission26.5%24.9%22.6%worse
Short-stay residents with an outpatient ER visit7.6%8.1%12.0%better
Long-stay hospitalizations per 1,000 resident days1.562.071.67typical
Long-stay outpatient ER visits per 1,000 resident days0.831.111.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

63.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 426 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.4%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
75.3%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 75.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 194 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.4%CMS range 58.4–68.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 8.7–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge75.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge75.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge83.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 4.8–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.71
RN hours/ resident / day
1.27
LPN hours/ resident / day
2.59
Aide hours/ resident / day
4.56
Total nurse hours/ resident / day
0.52
RN hoursweekends
31.4%
Total nursing turnover
23.1%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 163.1 residents a day — about 91% occupied, or roughly 17 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.28 hrs/resident/day on weekends vs 4.68 on weekdays — 8% thinner on weekends. RN hours go from 0.78 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2025-09-25)
2
at the previous standard inspection (2024-08-27)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.

  • Potential for harm · Ecited before2025-09-25 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: 1.a. Review of the admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R6 was admitted to the facility on [DATE]. She had diagnoses of end stage renal disease and dependence on renal dialysis with an onset date of 10/01/24. Review of Nurses Notes, dated 07/26/25, 07/29/25, and 07/31/25, and located in the EMR under the Progress Notes tab revealed R6 was picked up by stretcher for dialysis and returned via stretcher following dialysis on those days. Review of R6's Order Summary Report, dated 08/01/25,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included: Review of the facility's policy titled, Communication of Code Status, dated February 2023, indicated, Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. 2.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's policy titled, Enablers updated 10/19 indicated An enabler limits a person's normal freedom of movement and can only be used after appropriate clinical assessment and requires voluntary agreement with the user. Items that constitute an enable include, but are not limited to, bedrails, tray tables, chair that patient cannot move out of independently. The use of enablers is a clinical decision by the inter-disciplinary team (IDT), and is made in partnership with the patient and family/[whanau] following an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings included: Review of the facility's policy titled, Dining and Food Preferences, revised 10/2022, indicated, Policy Statement: Individual dining, food, and beverage preferences arc identified for all residents/patients. 2. The Dining Services Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 72 hours of admission. The purpose of this interview will be to identify individual preferences for dining location, meal times, including times outside of the routine schedule, food and beverage preferences. 4. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. A review of the quarterly Minimum Data Set, an assessment tool dated 05/07/24, revealed the resident had a Brief Interview for Mental Status (BIMS) of two (2), indicating the resident was severely cognitively impaired. Further review revealed, the resident did not have…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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: unspecified dementia and anxiety disorder. A review of the annual Minimum Data Set, an assessment tool dated 06/16/24, revealed the resident was unable to be interviewed for Brief Interview for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-08 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings include: During an observation on 12/05/22 at 09:55 AM, the outside dumpster area revealed two dumpsters next to each other. Dumpster 1 had a lid broken off at the hinge on one side and the other side was propped up and open with a mound of garbage bags. Dumpster 2 had a lid that was open and had four garbage bags in it. Two gloves, a spoon, two plastic knives, a grape and other garbage was noted on the ground around the dumpsters. During an observation on 12/06/22 at 08:37 AM, Dumpster 1 was full and overflowing with garbage bags. One lid remained completely broken off, while the other was unable to close due to it resting on piled garbage bags. Dumpster 2's bin was a quarter full and both lids were open. During an observation on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-08 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of R80's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R80 was admitted on [DATE] and had diagnoses including dementia. Review of R80's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/21/22, revealed the resident required supervision during meals. Per this MDS, the resident was severely cognitively impaired,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-08 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of R557's undated admission Record, located in Profile tab of the electronic medical record (EMR) revealed R557 was admitted to the facility on [DATE] with a diagnosis of urinary tract infection. Review of R557's 12/06/22 Active Orders, found in the Orders tab of the EMR, revealed orders for Texas (condom) catheter care every shift and to document Texas…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of R408's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE]. R408's diagnoses included heart failure, chronic obstructive pulmonary disease, cardiomyopathy, and hypertension. Review of R408's Brief Interview for Mental Status (BIMS) located in the Minimum Data Set (MDS) with a date of 12/05/22 located in the Assessment tab of the EMR, revealed R408 scored a 15/15, which indicated R408 was cognitively intact. Review of R408's Clinical Physician Orders located in the Orders tab of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 6 citations
  • Potential for harm · Dcited before2022-12-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of R144's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R144 was admitted on [DATE] with a diagnosis of dementia. Review of R144's New Jersey Universal Transfer Form dated 07/11/22, located in the EMR under the Misc tab, also revealed a diagnosis of dementia. Review of R144's 'Physician Note in the Progress Note tab dated 09/29/22 revealed the physician had documented that the resident had a diagnosis of dementia with behavior issues. Review of the resident's comprehensive Care Plan related to dementia, which was dated 07/12/22 and revised 07/20/22, revealed that the resident had impaired…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of R127's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R127 was admitted on [DATE] with diagnoses of hemiplegia affecting right side and diabetes. Review of R127's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/22/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Per the MDS, R127 required extensive assistance with personal hygiene. During an observation on 12/05/22 at 1:01 PM,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Review of R97's undated admission Record, located in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had multiple diagnoses including heart failure. Review of R97's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/22 and located in the EMR under the MDS tab, revealed the resident was cognitively intact, based on a Brief Interview for Mental Status (BIMS) score of 13/15, Review of R97's current 12/2002 Physician's Orders, under the Orders tab located in the EMR, revealed staff were to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-08 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of R23's undated admission Record, located in R23's electronic medical record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R23's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/13/22 and located in the MDS tab of the EMR, indicated R23 was unable to complete the Brief Interview for Mental Status test and staff assessed her with memory problems and severely impaired…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of R86's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R86 was admitted to the facility on [DATE]. R86's diagnoses included diabetes, chronic kidney disease, obstructive uropathy (blockage in the urinary tract), and chronic urinary tract infection. Review of R86's 11/30/22 Nurses Note located in the Progress Notes tab of the EMR documented that the Writer informed of resident's aggressive behavior cursing and yelling. Ordered UA/CS [urinalysis/culture and sensitivity] for change in behavior and ID [infectious disease] consult to review lab [laboratory] results. On 12/06/22, review of R86's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of R407's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R407 was admitted to the facility on [DATE]. R407's diagnoses included sepsis (severe infection complication) pressure ulcers, and urinary tract infection. Review of R408's current Clinical Physician Orders, located in the Orders tab of the EMR revealed that on 12/02/22, R407 had an order for daily dressing change orders for pressure ulcers at the sacrum and right lateral ankle areas. During the wound care observation on 12/07/22 at 4:10 PM, Licensed Practical Nurse (LPN) 3 washed her hands, applied gloves,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
MIDDLESEX COUNTY IMPROVEMENT AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 03/01/2012
GOLD, EVANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/23/2023
NIEMIERA, MARKIndividualADP OF THE SNFsince 03/01/2012

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$27.0M
Net patient revenuemost recent cost report
-2.4%
Operating marginrevenue minus expenses
$250K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 14%Other / private 15%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $250K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$454per resident / day
operating cost
$13,811per month
≈ monthly operating cost
$444per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NJ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Jersey Medicaid page.

Typical monthly cost in New Jersey
$12,775/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$8,710/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 315509. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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