Cycle 1
Health 2024-05-02 · Fire 2024-05-02
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Edison, NJ
Roosevelt Care Center
4-star overall rating with 2-star inspections with $27,360 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
118 Parsonage Road, Edison, NJ
(732) 321-6800
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
161
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.71
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.08
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
4.42
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
4.59
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,130
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.41
Baseline 19.91% · Performance 20.78% · Measure score 1.41 · Achievement 1.41 · Improvement 0
Healthcare-associated infections
0
Baseline 8.37% · Performance 8.60% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.84
Performance 35.71% · Measure score 6.84 · Achievement 6.84 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.01
Baseline 3.91 hours · Performance 4.22 hours · Measure score 4.01 · Achievement 4.01 · Improvement 1.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.15% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 306 · Observed rate 9.15% · Lower 95% interval 7.19% |
| Discharge to community | 62.5% |
50.57%
11.9 pts better
|
Better than the National Rate · Eligible stays 284 · Observed rate 51.41% · Lower 95% interval 56.6% |
| Medicare spending per beneficiary | 1.39 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.98% |
95.27%
3.7 pts better
|
Numerator 195 · Denominator 197 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 197 |
| Discharge self-care score | 62.22% |
53.69%
8.5 pts better
|
Numerator 84 · Denominator 135 |
| Discharge mobility score | 63.7% |
50.94%
12.8 pts better
|
Numerator 86 · Denominator 135 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 197 · Adjusted rate 0.73% |
| Healthcare-associated infections requiring hospitalization | 8.6% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 209 · Observed rate 11% · Lower 95% interval 6.18% |
| Staff COVID-19 vaccination coverage | 3.73% |
8.2%
4.5 pts worse
|
Numerator 6 · Denominator 161 |
| Staff flu vaccination coverage | 97.59% |
42%
55.6 pts better
|
Numerator 162 · Denominator 166 |
| Discharge function score | 65.19% |
56.45%
8.7 pts better
|
Numerator 88 · Denominator 135 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 62 · Denominator 62 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 78 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 6 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.1
About the same
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
93.0%
6.2 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 99.2% · Q4 99.2% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.4%
0.5 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.3% · Q3 2.4% · Q4 3.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.1% |
11.4%
5.7 pts worse
|
11.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 20.0% · Q3 17.9% · Q4 11.8% · 4Q avg 17.1% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.6%
3.3 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
19.0%
11 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 7.5% · Q3 9.2% · Q4 8.8% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
13.5%
1.2 pts worse
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 15.6% · Q3 18.1% · Q4 14.1% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.4% |
9.8%
6.4 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 6.7% · Q4 2.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
9.7%
6.3 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.1% · Q3 5.3% · Q4 3.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.3% |
15.9%
4.6 pts better
|
19.8%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.7% · Q3 12.9% · Q4 12.2% · 4Q avg 11.3% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.0%
1.9 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.2% · Q3 3.4% · Q4 3.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
78.7%
14.1 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 95.4% · Q3 92.1% · Q4 89.2% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
8.2%
2.7 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 4.9% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 1.1% · Q4 1.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
80.1%
9.6 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
25.4%
3.3 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 23.3% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-29 · Fire 2021-12-29
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2020-01-24 · Fire 2020-01-24
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-02
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-05-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-05-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-24
D · Potential for more than minimal harm
2021-12-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-02-04
D · Potential for more than minimal harm
2021-12-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-02-04
D · Potential for more than minimal harm
2021-12-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-01-28
D · Potential for more than minimal harm
2020-01-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-02-29
C · Minimal harm
2020-01-24
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2020-02-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-05-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-05-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-05-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-05-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-05-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-02
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-02
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-05-30
C · Minimal harm
2024-05-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-30
D · Potential for more than minimal harm
2023-06-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-07
G · Actual harm
2021-12-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-02-11
E · Potential for more than minimal harm
2021-12-29
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-02-11
E · Potential for more than minimal harm
2021-12-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-07
D · Potential for more than minimal harm
2021-12-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-11
D · Potential for more than minimal harm
2021-12-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-02-11
E · Potential for more than minimal harm
2020-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-02-29
D · Potential for more than minimal harm
2020-01-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2020-02-29
C · Minimal harm
2020-01-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-02-29
Penalties and ownership
What sits behind the stars
$27,360
2024-05-02
Fine
Fine · fine $27,360
Fine
Ownership
Middlesex County Improvement Authority
5% Or Greater Direct Ownership Interest · Organization
Sorrento, Mark
Operational/Managerial Control · Individual
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