Inspection Reports for Bridgeway Care and Rehabilitation Center at Hillsborough
NJ, 08844
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Census Over Time
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 explains 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 9
Aug 19, 2024
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 failure to report alleged violations timely, incomplete investigations, medication administration errors, food safety violations, quality assurance committee deficiencies, infection preventionist qualifications, and life safety code violations including sprinkler system maintenance, corridor door smoke resistance, and emergency power system testing.
Severity Breakdown
SS=E: 4
SS=D: 3
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation or mistreatment timely to NJDOH and follow facility policy. | SS=E |
| Failure to conduct timely and thorough investigations of alleged abuse for multiple residents. | SS=E |
| Medication error rate exceeded 5 percent; improper insulin administration technique observed. | SS=D |
| Failure to properly label and date opened food items and wet nesting of pans in kitchen. | SS=E |
| Quality Assessment and Assurance (QAA) committee did not meet all regulatory requirements; infection preventionist role not fully staffed. | SS=D |
| Facility failed to have a qualified infection preventionist working at least part-time with specialized training. | SS=D |
| Fire sprinkler system maintenance deficiencies including missing escutcheon plates, sprinkler hanging down, and open space around sprinkler head. | SS=F |
| Corridor double smoke doors had a 1/4-inch gap between door leaves, compromising smoke resistance. | SS=E |
| Emergency power supply failed to meet NFPA requirements for load testing and documentation. | SS=F |
Report Facts
Census: 120
Medication error rate: 7.69
Number of residents reviewed for abuse investigations: 9
Number of residents sampled for complaint investigation: 25
Number of closed records reviewed: 3
Number of sprinkler heads missing escutcheon plates: 2
Number of sprinklers hanging down: 1
Gap between double smoke doors: 0.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to failure to report alleged violations and corrective actions | |
| Administrator | Involved in corrective actions and oversight of complaint investigations and infection preventionist role | |
| Director of Maintenance | Responsible for sprinkler system and emergency power system corrective actions and monitoring | |
| Interim Infection Preventionist | Named as interim IP with completed CDC training | |
| Surveyor | Observed deficiencies and conducted interviews |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Jul 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #165398 regarding compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance due to failure to revise/update a person-centered care plan for a resident with wandering behavior and failure to maintain required minimum direct care staff to resident ratios on multiple day shifts.
Complaint Details
Complaint #165398 was substantiated with findings that the facility failed to update a resident's care plan related to wandering behavior and failed to maintain required staffing ratios on multiple days.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to revise/update a person-centered care plan for a resident who was wandering on another unit and failure to follow the facility's Incident Report policy. | SS=D |
| Failure to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for 7 out of 21 day shifts reviewed. | — |
Report Facts
Census: 119
Sample Size: 3
Deficient Staffing Days: 7
Staffing Ratios: 14
Staffing Ratios: 12
Staffing Ratios: 14
Staffing Ratios: 12
Staffing Ratios: 12
Staffing Ratios: 14
Staffing Ratios: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to care plan update and monitoring of resident wandering behavior. |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding supervision and redirection of wandering resident. |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Apr 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ160620, NJ160665, and NJ163052 to assess compliance with long term care facility regulations.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet required staffing ratios on 3 of 7 day shifts reviewed, potentially affecting all residents. No negative outcomes were reported from the deficient staffing practice.
Complaint Details
Complaint investigation based on complaints NJ160620, NJ160665, NJ163052. The facility was found deficient in CNA staffing ratios on 3 of 7 day shifts during the week of 3/26/2023 to 4/1/2023, with 14 CNAs present when 15 were required on 3/26/23, 3/27/23, and 3/31/23. No residents were negatively affected and no negative outcomes were reported.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 3 of 7 day shifts reviewed, specifically CNA staffing was below required levels. |
Report Facts
CNA staffing deficiency: 3
Census: 122
Required CNAs: 15
Actual CNAs: 14
Inspection Report
Annual Inspection
Census: 123
Deficiencies: 8
Nov 7, 2022
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 staffing ratios, resident rights including dignified meal service, privacy in mail delivery, treatment procedures, nutrition and hydration monitoring, physician supervision, medication administration, and compliance with state staffing requirements.
Severity Breakdown
SS=E: 1
SS=D: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | — |
| Failed to ensure residents were served their meals in a dignified manner during meal services. | SS=E |
| Failed to provide privacy when receiving and delivering mail and deliver mail within a reasonable timeframe for 2 residents. | SS=D |
| Failed to consistently provide care to reduce spread of infection and promote healing during wound treatment for 1 resident. | SS=D |
| Failed to ensure accuracy of a resident's weight who had a history of thyroid disorder. | — |
| Failed to ensure physician provided an order for routine laboratory tests for a resident diagnosed with thyroid disorder. | SS=D |
| Failed to ensure medications were administered in accordance with professional standards of practice; medication was left at resident's bedside and documentation errors occurred. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for multiple shifts. | — |
Report Facts
CNA staffing: 12
CNA staffing: 13
CNA staffing: 14
CNA staffing: 13
CNA staffing: 11.5
CNA staffing: 12
CNA staffing: 14
CNA staffing: 13
CNA staffing: 14
CNA staffing: 12
CNA staffing: 12.5
Resident census: 123
Resident assignment: 18
Resident assignment: 11
Resident assignment: 13
Resident assignment: 14
Resident assignment: 12
Resident assignment: 13
Resident weight: 123
Resident weight: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #10 | Observed waiting for lunch tray during meal service | |
| Resident #20 | Observed waiting for lunch tray during meal service | |
| Resident #115 | Observed waiting for lunch tray during meal service | |
| Resident #221 | Observed waiting for lunch tray and served late | |
| Director of Nursing | DON | Interviewed regarding staffing and mail delivery |
| Licensed Nursing Home Administrator | LNHA | Provided nurse staffing report and interviewed about staffing |
| Licensed Practical Nurse | LPN | Observed performing wound treatment with deficient technique |
| Certified Nursing Assistant | CNA #1 | Interviewed about weight measurement process and staffing |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Interviewed about staffing and medication administration |
| Director of Activities | DOA | Interviewed about mail delivery issues |
| Director of Purchasing | DOP | Interviewed about mail delivery errors |
| Primary Medical Physician | PMD | Interviewed about weight monitoring and lab orders |
| Registered Dietician | RD | Interviewed about weight monitoring process |
| Registered Nurse | RN | Interviewed about medication administration to Resident #57 |
Inspection Report
Annual Inspection
Deficiencies: 8
Nov 7, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations on 11/3/22 and 11/7/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including emergency illumination, emergency lighting, cooking facilities inspection, fire alarm system installation, sprinkler system coverage and maintenance, electrical system maintenance, generator remote manual stop station, and gas equipment safety in the liquid oxygen trans filling room. Corrective actions were planned or implemented for each deficiency.
Severity Breakdown
SS=F: 6
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide emergency illumination that would operate automatically along the means of egress. | SS=F |
| Failed to provide battery back-up emergency light above the emergency generator transfer switches independent of the building's electrical system and emergency generator. | SS=F |
| Failed to ensure monthly inspection of the kitchen ansul system was logged. | SS=E |
| Failed to install supervised smoke/heat detection in the main kitchen area as required. | SS=E |
| Failed to provide complete sprinkler coverage for 4 exterior attached overhangs. | SS=F |
| Failed to maintain sprinkler system by ensuring ceiling was smoke resistant and fire rated in 9 of 30 observed areas. | SS=F |
| Failed to ensure a remote manual stop station for the generator was installed outside the generator location. | SS=F |
| Failed to maintain the liquid oxygen trans filling room to prevent accidental ignition by having a light switch and non-explosion proof light fixture in the room. | SS=F |
Report Facts
Deficiencies cited: 8
Facility stories: 3
Smoke zones: 12
Emergency light duration: 90
Sprinkler system coverage areas: 4
Sprinkler system deficient areas: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations confirming deficiencies. | |
| Director of Facilities | Present during observations confirming deficiencies. | |
| Licensed Nursing Home Administrator | Informed of findings at Life Safety Code exit conferences. |
Inspection Report
Routine
Census: 110
Deficiencies: 0
Apr 13, 2022
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
Inspection Report
Routine
Census: 101
Deficiencies: 0
May 10, 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 and recommended COVID-19 practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 129
Deficiencies: 0
Jan 22, 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: 13
Inspection Report
Routine
Census: 97
Deficiencies: 0
Dec 31, 2020
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 related to COVID-19.
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: 1
Inspection Report
Routine
Census: 101
Deficiencies: 0
Nov 23, 2020
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 related to COVID-19.
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: 3
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