Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Old Bridge during CMS and state inspections, most recent first.
A facility failed to consistently apply a bolster to a resident's wheelchair as ordered by a physician, leading to multiple observations of the resident without the necessary support. The resident, with a history of transient cerebral ischemic attack and dementia, required the bolster for positioning. The Treatment Administration Record did not reflect the order, and there was a lack of documentation by CNAs. The CNA assigned was new and lacked access to the electronic Medical Record, contributing to the oversight.
A facility failed to adjust medication administration times for a resident undergoing dialysis, leading to missed doses while the resident was out for treatment. Despite having policies in place, the facility did not review and adjust medication times upon the resident's readmission, as confirmed by interviews with staff including an LPN, the Unit Manager, the DON, and the Consultant Pharmacist.
A medication administration error rate of 6.45% was observed in a facility when an LPN failed to prime insulin pen injectors before a resident self-administered doses. The resident, with type 2 Diabetes Mellitus, was prescribed Basaglar and Fiasp insulin pens, which require priming before each use. The LPN, unaware of this requirement, did not prime the pens, leading to improper insulin administration. The facility's policies and manufacturer instructions confirmed the necessity of priming to ensure correct dosage.
A long-term care facility failed to provide timely medication administration and proper documentation for two residents. One resident did not receive their medications, including fast-acting insulin, within the prescribed time frame, while another resident experienced issues with the availability of their prescribed Oxycodone. The facility's policies on medication administration and backup supply management were not followed, leading to these deficiencies.
Failure to Apply and Document Bolster Use for Resident
Penalty
Summary
The facility failed to consistently follow a physician's order for the application of a bolster to the left armrest of a wheelchair for a resident with decreased range of motion and mobility. This deficiency was identified for a resident who was observed multiple times without the bolster applied, despite a physician's order and an individualized comprehensive care plan (ICCP) indicating its necessity for positioning. The resident had a history of transient cerebral ischemic attack and unspecified dementia, with a severely impaired cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. The facility's Treatment Administration Record (TAR) did not reflect the physician's order for the bolster, and there was a lack of documented accountability for its placement by the Certified Nursing Assistants (CNAs) for 13 out of 30 days reviewed. The Licensed Practical Nurse/Unit Manager (LPN/UM) acknowledged the absence of the bolster and the lack of documentation, stating that it was the CNA's responsibility to apply the device and document its placement. However, the CNA assigned to the resident was new, did not have access to the electronic Medical Record (eMR), and was not informed of the resident's need for the bolster. The staffing coordinator confirmed that the CNA should have received eMR access but had not due to oversight. The Director of Rehabilitation and the Director of Nursing (DON) also acknowledged the failure to ensure the bolster was applied and documented. The facility's policies on Activities of Daily Living (ADLs), Assistive Devices and Equipment, and Comprehensive Person-Centered Care Plans emphasize the importance of maintaining and supervising the use of assistive devices based on comprehensive assessments, which was not adhered to in this case.
Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not adjusting medication administration times to accommodate a resident's dialysis schedule. The deficiency was identified for a resident who required dialysis services. The resident, who had end-stage renal disease and was dependent on renal dialysis, was scheduled for dialysis on Monday, Wednesday, and Friday, with a pick-up time of 3:15 PM and a chair time of 4:15 PM. However, the resident's medication administration times were not adjusted to account for the time they were out of the facility for dialysis. The resident's medical records revealed active physician's orders for several medications, including Ascorbic Acid, Insulin Lispro, Calcium Acetate, and Prostat, which were scheduled to be administered during the time the resident was at dialysis. The electronic medication administration record (eMAR) indicated that these medications were marked as not administered due to the resident being out for dialysis. Interviews with facility staff, including an LPN, the Unit Manager, the Director of Nursing, and the Consultant Pharmacist, confirmed that medication times should have been reviewed and adjusted to accommodate the resident's dialysis schedule. The facility's policies on administering medications and hemodialysis care emphasized the need for timely medication administration and ensuring physician's orders for dialysis include medication administration or withholding instructions. Despite these policies, the facility did not adjust the medication administration times for the resident upon their readmission, leading to the deficiency identified by the surveyor.
Medication Administration Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 6.45%, which exceeds the acceptable threshold of 5%. During a medication observation, a surveyor noted that an LPN did not prime insulin pen injectors before administering them to a resident. The resident, who had poor eyesight but was alert and oriented, self-administered the insulin doses under the supervision of the LPN. The LPN did not perform the necessary priming of the insulin pens, which is required to ensure the correct dosage is delivered. The resident involved had a medical history of type 2 Diabetes Mellitus with unspecified complications and was prescribed Basaglar and Fiasp insulin pen injectors. The physician's orders required specific dosages and administration techniques, including priming the pens before each use. However, the LPN, who had been working at the facility for six months, was unaware of the need to prime the pens before each injection, believing it would waste insulin. This lack of knowledge led to the improper administration of insulin to the resident. The surveyor's review of the facility's policies and manufacturer instructions confirmed that priming the insulin pens before each injection was necessary. The LPN's failure to follow these guidelines resulted in the medication errors observed. The facility's Director of Nursing acknowledged the oversight and the potential impact on insulin dosage accuracy due to not following the manufacturer's specifications for priming the insulin pen injectors.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards of practice, as evidenced by two main deficiencies. Firstly, a resident with multiple health conditions, including diabetes and glaucoma, did not receive their medications in a timely manner as ordered by a physician. The resident, who was blind but cognitively intact, reported receiving their fast-acting insulin late, which was confirmed by a review of the Medication Administration Audit Report. The report showed that on two consecutive days, several medications were administered outside the allowed time range, contradicting the electronic medication administration record that indicated timely administration. Secondly, another resident reported frequent issues with the availability of their prescribed Oxycodone, a controlled drug. The resident stated that they did not receive their medication at the scheduled times due to the facility running out of stock, which was corroborated by the electronic medication administration record and nurse's notes. The facility had a backup supply of Oxycodone, but it was not utilized, and there was no documentation of a physician's order to administer the available doses from the backup supply. This discrepancy was acknowledged by the Director of Nursing, who confirmed that the medication was not administered as ordered. The facility's policies on medication administration and backup supply management were not adhered to, leading to these deficiencies. The policies required timely administration of medications and proper documentation of any deviations, which were not followed in these cases. The Consultant Pharmacist emphasized the importance of matching the administered dose with the physician's order, highlighting the facility's failure to ensure accurate medication management and documentation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Old Bridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Preferred Care At Old Bridge, Llc | 1.8 mi | — | 2 | 0 |
| Reformed Church Home | 2 mi | — | 0 | 0 |
| Careone At East Brunswick | 3.4 mi | — | 0 | 0 |
| Roosevelt Care Center At Old Bridge | 3.7 mi | — | 6 | 0 |
| Complete Care At Madison, Llc | 5.6 mi | — | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.