Inspection Reports for Bridgeway Care and Rehabilitation Center at Bridgewater
NJ, 08807
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Routine
Census: 150
Deficiencies: 12
Mar 31, 2025
Visit Reason
A Recertification Survey was conducted from 3/25/25 to 3/31/25 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to abuse, neglect, exploitation, and mistreatment, as well as food safety and life safety code violations. The facility was found non-compliant with several federal and state regulations, including failure to report alleged violations timely and multiple life safety code deficiencies.
Complaint Details
The survey was partially complaint-driven with complaint NJ #177346. The facility failed to report results of an abuse allegation timely to the New Jersey Department of Health for 2 residents. The complaint was substantiated as evidenced by interviews, record reviews, and observations.
Severity Breakdown
Level D: 1
Level E: 1
Level F: 10
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to report results of an abuse allegation to the New Jersey Department of Health within five working days for 2 residents. | Level D |
| Outdated chicken salad sandwich and unidentified food items stored in the kitchen refrigerator. | Level E |
| Failure to ensure that passageways, corridors, exit discharges, exit locations, and access were continuously maintained free of obstructions. | Level F |
| Failure to ensure that doors in a required means of egress were equipped with a lock or latch in accordance with NFPA 101. | Level F |
| Failure to ensure that exit stairway enclosure doors were provided with fire exit hardware. | Level F |
| Failure to ensure that exit and directional signs were displayed in accordance with NFPA 101. | Level F |
| Failure to ensure that smoke detectors were inspected for sensitivity and battery powered smoke and carbon monoxide detectors were inspected, tested, and maintained. | Level F |
| Failure to ensure sprinkler system installation was in accordance with NFPA 101. | Level F |
| Failure to ensure fire doors were inspected, tested, and maintained annually in accordance with NFPA 80. | Level F |
| Failure to ensure inspection, testing, and maintenance of electrical systems and emergency lighting met NFPA requirements. | Level F |
| Failure to ensure inspection, testing, and maintenance of electrical equipment and emergency lighting was conducted and documented. | Level F |
| Failure to ensure inspection, testing, and maintenance of fire alarm system and emergency preparedness plan were conducted and documented. | Level F |
Report Facts
Census: 150
Survey Dates: 3/25/25 to 3/31/25
Deficiency Completion Dates: Various completion dates listed for deficiencies, e.g., 04/24/2025, 05/15/2025, 05/31/2025
Inspection Report
Abbreviated Survey
Census: 150
Deficiencies: 0
Mar 24, 2025
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and in substantial compliance with 42 CFR 483 subpart B for infection control.
Report Facts
Sample Size: 9
Supplemental: 0
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
Mar 7, 2024
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ171701.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint #: NJ171701. The facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 145
Deficiencies: 0
Dec 13, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 4
Sep 20, 2023
Visit Reason
The inspection was conducted based on complaints NJ00164556, NJ00151859, and NJ00153370, focusing on compliance with federal and state regulations regarding resident care, discharge policies, care planning, and staffing.
Findings
The facility was found not in substantial compliance with requirements related to permitting residents to return after hospitalization, developing comprehensive care plans for residents with specific conditions, quality of care including monitoring and documentation, and maintaining required staffing ratios. Specific deficiencies included failure to follow discharge policies for a resident with behavioral issues, inadequate care planning for a resident with recurrent infections, failure to complete ordered assessments and follow care plans for a resident with a serious medical condition, and insufficient certified nursing assistant staffing on multiple shifts.
Complaint Details
Complaint investigation based on complaints NJ00164556, NJ00151859, and NJ00153370. The facility was found not in substantial compliance with federal and state regulations related to resident discharge, care planning, quality of care, and staffing.
Severity Breakdown
SS=D: 1
SS=E: 1
SS=G: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to follow policies and procedures for facility-initiated discharge and permitting a resident to return after hospitalization. | SS=D |
| Failure to develop and implement a comprehensive person-centered care plan for a resident with recurrent infections. | SS=E |
| Failure to complete assessments in accordance with physician's orders and follow care plan interventions for a resident with a serious medical condition. | SS=G |
| Failure to maintain required minimum direct care staff-to-resident ratios, specifically Certified Nursing Assistants (CNAs), on multiple day and overnight shifts. | — |
Report Facts
Census: 142
Sample Size: 5
Staffing Deficiencies: 11
Staffing Deficiencies: 2
Staffing Deficiencies: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to monitoring and corrective actions for discharge and care plan deficiencies | |
| Licensed Nursing Home Administrator | Named in relation to discharge decisions and staffing issues | |
| Licensed Practical Nurse | Named in relation to care plan and monitoring practices | |
| Certified Nursing Assistant/Unit Secretary | Named in relation to daily weight monitoring | |
| Registered Nurse | Named in relation to care and monitoring of residents with specific diagnoses |
Inspection Report
Annual Inspection
Census: 128
Deficiencies: 4
Feb 21, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to accuracy of assessments, professional standards of nursing practice, respiratory care equipment dating, and staffing ratios including infection preventionist role compliance.
Severity Breakdown
SS=D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to accurately assess and properly code residents for contractures in Minimum Data Set assessments. | SS=D |
| Failed to maintain professional standards by not ensuring physician order was in place to check for proper feeding tube placement and contents, and failure to accurately document feeding tube content. | SS=D |
| Failed to ensure respiratory care equipment was dated properly. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios for the day shift and failed to designate a full-time infection preventionist as required by state regulations. | — |
Report Facts
Census: 128
Staffing Deficiency Days: 3
CNA Staffing Deficiency: 1
CNA Staffing Deficiency: 1
CNA Staffing Deficiency: 1
Infection Preventionist Vacancy Duration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as responsible for infection control and prevention program while seeking replacement for Infection Preventionist. | |
| Administrator | Acknowledged staffing ratios and infection preventionist vacancy. | |
| Licensed Practical Nurse Unit Manager | Confirmed respiratory care equipment was not dated. | |
| Registered Nurse Supervisor | Interviewed regarding nursing practices for feeding tube placement checks. | |
| Staffing Coordinator | Provided information on staffing ratios and efforts to fill staffing shortages. |
Inspection Report
Annual Inspection
Census: 127
Capacity: 151
Deficiencies: 5
Feb 21, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including life safety, fire safety, electrical systems, and facility maintenance.
Findings
The facility was found deficient in several areas including inadequate number of exits in the basement, improper exit discharge surfaces, improperly installed kitchen grease baffles, lack of documented fuel supply reliability for a generator, and failure to perform annual testing of non-hospital grade electrical receptacles. Plans of correction and timelines were provided for each deficiency.
Severity Breakdown
SS=F: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide two acceptable exits from the basement story. | SS=F |
| Exit discharge did not provide a level walking surface free of obstructions, with a soft grassy area instead of a hard packed all-weather travel surface. | SS=E |
| Two of four kitchen exhaust hood grease baffles were not properly installed, creating a fire hazard. | SS=F |
| Failed to demonstrate reliability regarding fuel supply for the 100 KW natural gas generator. | SS=E |
| Failed to functionally test electrical receptacles in residents' rooms annually for grounding, polarity, and blade tension. | SS=E |
Report Facts
Certified beds: 151
Census: 127
Exit discharge concrete pad dimensions: 25
Exit discharge concrete pad dimensions: 20
Soft grassy area length: 75
Number of kitchen hood grease baffles improperly installed: 2
Number of residents' rooms observed for electrical receptacle testing deficiency: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director from Sister Facility (MDSF) | Present during observations and interviews related to multiple deficiencies including exits, kitchen hood baffles, and electrical systems. | |
| Administrator | Provided progress reports and was notified of all findings at Life Safety Code exit conference. | |
| Dietary Director | Present during kitchen hood grease baffle inspection. |
Inspection Report
Routine
Census: 125
Deficiencies: 0
May 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 16
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 0
Apr 15, 2021
Visit Reason
Annual standard survey conducted to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements for long term care facilities.
Report Facts
Sample size: 27
Inspection Report
Life Safety
Census: 118
Capacity: 151
Deficiencies: 1
Apr 15, 2021
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 for Existing Health Care Occupancies.
Findings
The facility was found non-compliant due to failure to provide two acceptable exits from each story, specifically the Unit basement had only one exit. The basement was sprinklered and protected by a fire alarm system but lacked a second means of egress, posing a safety risk.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide two acceptable exits from each story; the Unit basement had only one exit consisting of a single stairway to the main floor. | SS=D |
Report Facts
Certified beds: 151
Census: 118
Fire Safety Evaluation System (FSES) score: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Director of Maintenance | Observed the single exit in the Unit basement during the survey |
| Administrator | Administrator | Provided statements regarding staff in-service and safety measures related to the basement exit |
| Plant Operation's Director | Plant Operation's Director | Received instructions regarding Fire Safety Evaluation System requirements |
Inspection Report
Routine
Census: 116
Deficiencies: 0
Jan 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Loading inspection reports...
