Inspection Reports for Bridgeway Care and Rehabilitation Center at Hillsborough
NJ, 08844
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
120 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
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
Complaint Investigation
Deficiencies: 2
Nov 5, 2025
Visit Reason
The inspection was conducted based on complaint #268245 regarding failure to notify a resident's physician of a change in condition and complaint #2648245 regarding inadequate pain management for Resident #3.
Findings
The facility failed to notify the physician of Resident #3's significant change in condition and pain, did not obtain timely physician orders for pain management, and failed to assess, document, and manage the resident's pain appropriately, resulting in actual harm to the resident.
Complaint Details
Complaint #268245 and #2648245 involved Resident #3. The facility failed to notify the physician of a change in condition and failed to properly assess, document, and manage pain, including obtaining physician orders and providing pain relief, despite multiple reports of pain and an unwitnessed fall. Interviews with staff confirmed these failures and lack of documentation.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the resident's physician of a significant change in condition for Resident #3. | Level of Harm - Actual harm |
| Failed to provide safe and appropriate pain management, including assessment, documentation, obtaining orders, and re-evaluation for Resident #3. | Level of Harm - Actual harm |
Report Facts
Residents reviewed for pain management: 3
BIMS score: 8
Pain rating: 5
Pain rating: 8
Fall time: 145
Hospital transfer time: 1800
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Wrote nursing note about Resident #3's fall and denied pain. |
| LPN #3 | Licensed Practical Nurse | Assigned to give medication on 10/10/2025; did not document administering pain medication or notifying physician. |
| UM #1 | Unit Manager | Evaluated Resident #3 with Nurse Practitioner; instructed LPN #3 to give pain medication; stated responsibility of primary nurse to notify physician. |
| NP #1 | Nurse Practitioner | Ordered x-rays and evaluated Resident #3; could not recall ordering pain medication. |
| DON | Director of Nursing | Reported family member's notification of pain; stated LPN #3 failed to follow policies; confirmed lack of physician notification and pain management. |
| CNA #1 | Certified Nursing Assistant | Reported Resident #3 in pain and informed UM #1; observed resident screaming in pain. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse, neglect, or theft and to report the results of the investigation to proper authorities.
Findings
The facility failed to report allegations of abuse involving multiple residents and a missing wallet containing personal identification. Investigations revealed that concerns raised by residents about certain CNAs were treated as grievances rather than reported to the New Jersey Department of Health (NJDOH), contrary to policy requirements. The facility also delayed reporting a missing wallet incident until after inquiry by NJDOH.
Complaint Details
Complaint #NJ00172165 involved allegations of abuse by CNAs and a missing wallet containing resident identification. The complaint was substantiated by interviews and record reviews showing failure to report to NJDOH. The facility acknowledged the failure and the responsible administrator stated she should have reported the incidents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse and theft to the New Jersey Department of Health as required by facility policy and state regulations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for investigations: 9
Date of incident: May 18, 2024
Date complaint form: May 23, 2024
Date survey completed: Aug 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding failure to report incidents to NJDOH and acknowledged responsibility. |
| Director of Social Work | DOSW | Signed grievance form and was grievance official involved in investigation. |
| Director of Nursing | DON | Signed corrective action on grievance form and was involved in investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Aug 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to timely report suspected abuse, neglect, or theft and failure to conduct timely and thorough investigations of alleged violations.
Findings
The facility failed to report allegations of abuse and a missing wallet to the New Jersey Department of Health (NJDOH) and failed to conduct timely and thorough investigations for several residents. Additionally, medication administration errors were observed, food safety and sanitation issues were noted, and the facility lacked a dedicated Infection Preventionist for several months.
Complaint Details
Complaint #NJ00172165 involved failure to report abuse allegations concerning Resident #6, unsampled Residents #25 and #54, and a missing wallet incident involving Resident #15. The complaint also included failure to conduct timely investigations and medication administration errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct a timely and thorough investigation for alleged violations. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration error rate of 7.69% due to failure to properly prime insulin pen injectors before administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, including unlabeled opened food packages and wet nested pans. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have the Infection Preventionist present for one of seven Quality Assurance and Performance Improvement (QAPI) meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have a qualified Infection Preventionist dedicated solely to the infection prevention and control program from 06/08/24 to present. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration opportunities: 26
Medication administration errors: 2
Medication administration error rate: 7.69
QAPI meetings: 7
QAPI meetings without IP attendance: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding failure to report abuse and investigation deficiencies. |
| Director of Nursing | DON | Involved in investigation and acknowledged deficiencies in reporting and documentation. |
| Social Worker | SW | Completed grievance forms and conducted resident interviews related to abuse allegations. |
| Staff Development/Advanced Practice Nurse | SD/APN | Interviewed regarding proper insulin pen administration technique and training. |
| Registered Nurse | RN | Observed administering medications with errors in insulin pen priming. |
| Consultant Pharmacist | CP | Interviewed regarding insulin pen priming technique and medication pass inservice. |
| Nursing Supervisor | NS | Certified in infection control but not designated Infection Preventionist. |
| Food Service Director | FSD | Accompanied surveyor during kitchen inspection and noted food safety deficiencies. |
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
Deficiencies: 1
Jul 6, 2023
Visit Reason
The inspection was conducted based on Complaint #NJ 165398 regarding the facility's failure to revise and update a person-centered Care Plan for Resident #2 who was wandering into another unit, and failure to follow the facility's Incident Report policy.
Findings
The facility failed to update Resident #2's Care Plan after an incident of wandering into another resident's room and did not implement new interventions to prevent further wandering. The facility also failed to follow its Incident Report policy requiring updates to the Care Plan after incidents.
Complaint Details
Complaint #NJ 165398 involved Resident #2 wandering into another resident's room on 2 South and taking a nap on the resident's chair. The resident was redirected back to his/her room. The complaint was substantiated with findings that the Care Plan was not updated to address the wandering incident and no new interventions were implemented. The facility policy requires updating the Care Plan after incidents, which was not followed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to revise/update a person centered Care Plan for Resident #2 who was wandering on another unit and failed to follow the facility's Incident Report policy. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
BIMS score: 0
Date of wandering incident: Jun 26, 2023
Date of survey completion: Jul 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding supervision and redirection of Resident #2 wandering. |
| Director of Nursing | DON | Provided summary statement and interview about monitoring and documentation related to Resident #2 wandering incident. |
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
Routine
Census: 119
Deficiencies: 7
Nov 7, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, including meal service, communication privacy, wound care, nutrition, medication management, and staffing levels.
Findings
The facility was found deficient in multiple areas including failure to serve meals in a dignified manner, delayed and mishandled mail delivery, improper wound care technique, inaccurate resident weight monitoring, failure to monitor thyroid labs for a resident on Levothyroxine, medication administration errors, and inadequate staffing levels on the nursing unit.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure residents were served their meals in a dignified manner during meal services, with delayed meal tray delivery and inconsistent meal service times. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide privacy and timely delivery of mail to residents, with mail mistakenly opened and delayed delivery. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to consistently provide wound care with proper infection control technique, including failure to perform hand hygiene between glove changes and failure to date and initial dressings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accuracy of resident weight measurements and failure to conduct re-weighs for flagged weight variances. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain physician orders for routine thyroid laboratory monitoring for a resident on Levothyroxine, resulting in lack of monitoring for over a year. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure medication administration was properly documented and witnessed, including leaving medication at bedside and documenting administration before resident took medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain required minimum direct care staff-to-resident ratios on the nursing unit, with documented shortages on multiple days and shifts. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents observed during meal service: 18
Residents assigned to CNA #2: 18
Residents assigned to CNA #3: 11
Residents assigned to CNA #2: 13
CNAs scheduled: 12
CNAs required: 15
Resident census: 119
CNAs scheduled: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/Unit Manager | LPN/UM | Acknowledged meal service issues and staffing assignments |
| Director of Nursing | DON | Acknowledged deficiencies in wound care, medication administration, thyroid lab monitoring, and staffing |
| Licensed Nursing Home Administrator | LNHA | Provided meal times lists and staffing reports, acknowledged meal service and staffing issues |
| Director of Activities | DOA | Investigated mail delivery issues |
| Director of Purchasing | DOP | Mistakenly opened resident mail packages |
| Primary Medical Physician | PMD | Discussed weight monitoring and thyroid lab monitoring for Resident #42 |
| Registered Nurse | RN | Administered medication to Resident #57 and acknowledged documentation errors |
| Certified Nursing Assistant | CNA #1 | Described weight measurement process and staffing assignments |
| Certified Nursing Assistant | CNA #2 | Described staffing assignments and workload |
| Certified Nursing Assistant | CNA #3 | Described staffing assignments and workload |
| Acting Staff Coordinator | Staff Coordinator | Described scheduling process |
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
Inspection Report
Deficiencies: 1
Mar 9, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control requirements, specifically evaluating hand hygiene practices among dietary employees during food service operations.
Findings
The facility staff failed to ensure that 2 of 7 dietary employees performed proper hand hygiene, including insufficient handwashing duration and failure to wash hands before glove use, posing a potential risk for infection transmission.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper hand hygiene by dietary employees during food service operations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dietary employees observed: 7
Dietary employees failed hand hygiene: 2
Handwashing duration observed: 5
Handwashing duration observed: 12
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