Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Bridgeway Care And Rehab Center At Hillsborough during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and on anticoagulant therapy was found by a CNA to have a bruise/hematoma on the left elbow that no prior shift had reported. The CNA immediately informed an LPN, but the injury of unknown origin was not reported to a supervisor at that time, and the initial report to the State Agency was not made within the required two-hour window. Interviews showed that the LPN did not immediately escalate the unwitnessed injury, the DON was unaware that such injuries must be reported within two hours of discovery, and the Administrator believed injury of unknown origin could be reported within 24 hours and stated that police are not contacted by the facility but left to residents or families.
The facility failed to conduct and document thorough investigations into two separate incidents involving alleged abuse and injury of unknown origin. In one case, a resident with severe cognitive impairment and on anticoagulant therapy was found with a hematoma on the elbow; the facility’s 5‑day summary claimed a thorough investigation and attributed the bruise to a prior shower, but there was no documentation of resident interviews or an interview with the LPN who was notified of the injury. In the second case, a cognitively intact resident reported that a CNA grabbed her arm and forcibly removed her dress, causing pain and leading to a substantiated finding of staff‑to‑resident abuse; however, not all on‑duty staff were interviewed, and there was no documentation of interviews with the roommate or other residents, despite facility policy requiring comprehensive, documented interviews of residents, witnesses, and involved staff.
A resident with multiple medical conditions and cognitive impairment experienced pain following a fall. Despite care plan interventions for pain management and staff awareness of the resident's pain, no pain assessment was documented, no physician was notified, and no orders for pain relief were obtained or administered. The resident continued to report significant pain until being sent to the emergency department, with facility policy and professional standards for pain management not followed.
A resident with multiple medical conditions and impaired cognition developed constant, worsening left hip pain after an unwitnessed fall. Although the care plan required physician notification for significant pain changes, staff did not notify the physician or obtain pain medication orders as directed. Documentation and interviews confirmed that facility policies for prompt physician notification and pain management were not followed.
A facility failed to investigate allegations of inappropriate behavior by two CNAs towards three residents. One resident reported feeling unsafe, another claimed a CNA lacked compassion and took items from their meal tray, and a third felt humiliated during care. The facility did not report these incidents to the NJDOH and treated them as grievances, failing to conduct a thorough investigation or document follow-up actions.
The facility failed to handle potentially hazardous foods and maintain sanitation properly. In the walk-in freezer, opened packages of biscuits and spinach lasagna rolls lacked dates or labels. Additionally, wet nesting of pans was observed, contrary to facility policies. The Food Service Director confirmed these practices were not in line with the facility's standards.
The facility failed to report allegations of abuse involving two CNAs and a missing wallet to the NJDOH. A resident felt unsafe with the CNAs, and two others reported negative experiences, but no report was made. Additionally, a resident's missing wallet was not promptly reported. The facility's policies required immediate reporting, which was not followed.
A medication administration error occurred when a nurse failed to properly prime insulin pens before administering doses to a resident, resulting in a 7.69% error rate. The nurse did not follow the correct procedure of holding the pen vertically and removing the needle cap to visualize the insulin, leading to incorrect dosage delivery. Interviews revealed inconsistencies in training and understanding of the proper technique for insulin pen use.
The facility did not ensure the presence of the Infection Preventionist (IP) at a required QAPI meeting. The IP position was vacant, and the IP did not attend the July meeting, as confirmed by the LNHA. The IP is a required member of the QAPI committee, which also includes the administrator, DON, Medical Director, and two other staff members. The IP's responsibilities include providing reports for the QAPI committee.
The facility failed to have a dedicated Infection Preventionist (IP) responsible for the infection prevention and control program from June 8, 2024, to the present. The LNHA admitted that the facility did not have an IP, and no one was certified in infection control and prevention. The Nursing Supervisor, although involved in PPE education and COVID surveillance, was not the designated IP. The absence of a designated IP meant that responsibilities such as developing policies and conducting quality improvement audits were not being fulfilled.
Failure to Timely Report Injury of Unknown Origin as Required
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin as a suspected abuse/neglect incident to the State Agency (SA) within the required two-hour timeframe. Facility policy, revised 02/19/25, states that all staff must immediately report any allegation or suspicion of abuse, neglect, exploitation, or mistreatment, and that initial reports to the Department of Health must be made within two hours if the incident involves serious bodily injury and/or is related to abuse/neglect. Resident 104, who had dementia and a BIMS score of 0/15 indicating severely impaired cognition, was re-admitted on an unspecified date and had diagnoses including dementia, muscle weakness, and a bone density disorder, and was on anticoagulant therapy with a care plan for risk of bruising and bleeding. On 09/14/25 at 11:20 PM, CNA2 informed LPN4 during shift report that the resident had a hematoma/bruise on the left elbow, discovered when CNA2 began the 11–7 shift and changed the resident. CNA4, who had been assigned to the resident on the 3–11 shift, stated he had not seen the hematoma because the resident was wearing arm sleeves, and the 7–3 nurse had not reported any skin changes. The nursing note documented that there was no evidence of the injury of unknown origin being reported to the supervisor at that time. The facility’s initial Facility Information Report to the Department of Health was dated 09/15/25 and indicated the resident had a bruise to the left elbow and was unable to say what occurred. Interviews revealed that LPN4 did not notify the supervisor when the unwitnessed injury was identified and instead spoke with the DON the next morning, and the DON stated he was unaware that an injury of unknown origin should be reported to the SA within two hours of knowledge of the incident. The Administrator acknowledged the two-hour reporting requirement for abuse allegations but stated that, in their understanding, injury of unknown origin had a 24-hour reporting timeframe and that the facility does not contact police, leaving that to the resident or family.
Failure to Thoroughly Investigate Injury of Unknown Origin and Alleged Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for one resident with severe cognitive impairment and dementia. The resident was re-admitted with dementia and had a BIMS score of 0/15, indicating severely impaired cognition. A nursing note documented that a CNA informed an LPN during report that the resident had a hematoma on the left elbow, and the resident was noted to be on an anticoagulant. A facility report indicated the resident was reported to have a bruise on the left elbow and was unable to say what occurred. A 5‑day summary stated that a thorough investigation was conducted and concluded that a shower the prior day was the most probable cause of the bruise. However, review of the investigation showed there was no evidence of resident interviews and no evidence that the LPN who was notified of the bruise was interviewed. The LPN later stated he had observed the resident pulling on his Geri‑sleeves and had spoken with the DON the next morning, and the DON confirmed that the LPN was not interviewed during the investigation and stated that no resident interviews would be conducted because it was an injury of unknown origin. The deficiency also involves the facility’s failure to thoroughly investigate an allegation of physical abuse for another resident who was cognitively intact with a BIMS score of 14/15. A nurse’s note documented that the resident had a care concern with a CNA, and that the CNA was immediately removed from assignment. A 5‑day follow‑up report described that the resident reported to the supervisor that while she was looking for her cell phone, the assigned CNA insisted on putting her to bed first, then looking for the phone, and that the CNA grabbed her arm and removed her dress with force, causing the resident to scream that her arm was being hurt. The facility’s summary and conclusion substantiated staff‑to‑resident abuse. However, review of the investigation revealed that not all staff working at the time were interviewed, and there was no documentation of interviews with the roommate or other residents. The DON stated that roommate and other resident interviews were not documented and that additional staff were not interviewed because the roommate’s confirmation of the abuse was considered sufficient, despite the facility’s policy requiring that all incidents be investigated promptly and thoroughly, including interviewing residents, witnesses, and involved staff, with all interviews and findings documented in a confidential investigation report.
Failure to Assess, Document, and Manage Resident Pain Following Fall
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident who required such services. The resident, who had multiple diagnoses including acidosis, major depressive disorder, muscle weakness, and cognitive communication deficits, was identified as being at risk for pain and had care plan interventions in place for pain monitoring and management. Despite these interventions, after an unwitnessed fall, the resident began to complain of pain, specifically in the left hip and leg, as reported by both the resident and their family member. Staff, including a unit manager and a certified nursing assistant, were made aware of the resident's pain, and the care plan called for monitoring, reporting, and intervention for pain. However, the medical record review revealed that no orders for pain medication or non-pharmaceutical pain relief methods were obtained or administered after the resident's pain was reported. There was no documentation of pain assessment, physician notification, or follow-up to obtain pain management orders. Interviews with staff confirmed that the responsibility to notify the physician and obtain pain medication orders was not fulfilled, and the electronic medical record showed no evidence of pain medication administration. The resident continued to experience significant pain throughout the day, as documented by physical therapy and nursing notes, and was eventually sent to the emergency department for evaluation. The facility's own pain assessment and management policy required appropriate assessment, documentation, physician notification, and intervention for pain, but these steps were not followed. The director of nursing acknowledged that the required assessments, notifications, and documentation were not completed, and that the facility's policies and procedures were not adhered to in this case. This resulted in a failure to provide appropriate pain management for the resident as required by professional standards and facility policy.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, specifically the development of constant left hip pain that worsened with movement and limited mobility, following an unwitnessed fall. The resident, who had multiple diagnoses including acidosis, major depressive disorder, muscle weakness, and cognitive communication deficits, was assessed as having moderately impaired cognition. The care plan required staff to monitor for pain, encourage reporting, and notify the physician if pain interventions were unsuccessful or if the pain was a significant change from the resident's past experience. On the day of the incident, the resident reported constant left hip pain rated as five out of ten at rest and eight out of ten with movement, and was unable to move the left leg through its full range of motion. Documentation showed that the resident's family and physician were notified of the fall, but there was no documentation that the physician was notified of the new or worsening pain. The unit manager instructed the primary nurse to notify the physician and obtain an order for pain medication, but this was not done, and no pain medication order was obtained. The nurse practitioner later ordered an x-ray, and the resident was eventually sent to the hospital for evaluation of left hip pain. Interviews with facility staff confirmed that the responsibility to notify the physician and obtain pain medication orders was not fulfilled, and the facility's policies required prompt notification of the physician for significant changes in condition or new pain. The director of nursing acknowledged that the required notifications and documentation were not completed, and that the facility's policies and procedures were not followed in this instance.
Failure to Investigate Allegations of Inappropriate CNA Behavior
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into allegations of inappropriate behavior by two CNAs towards three residents. Resident #6 reported feeling unsafe and described the CNAs as mean and rude, while unsampled Resident #54 claimed that CNA #2 lacked compassion and took items from their meal tray. Unsampled Resident #25 felt humiliated by CNA #1 during care. Despite these serious allegations, the facility did not report the incidents to the NJDOH and treated them as grievances rather than potential abuse or neglect cases. The Licensed Nursing Home Administrator (LNHA) and Social Worker (SW) did not document a comprehensive investigation or follow-up actions. The SW conducted interviews with two alert and oriented residents but did not provide further documentation or report the findings to the appropriate authorities. The LNHA acknowledged that the incidents should have been reported and further investigation was necessary, but no immediate action was taken to address the concerns raised by the residents. The facility's policies on grievances and abuse prevention require timely reporting and investigation of such allegations, but these procedures were not followed. The LNHA and Director of Nursing (DON) later admitted that more documentation and investigation were needed, but this acknowledgment came only after surveyor inquiry. The failure to properly investigate and report the allegations left the residents' concerns unaddressed and potentially compromised their safety and well-being.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed during a survey. In the walk-in freezer, two opened packages of biscuits and a tied shut, clear plastic bag of spinach lasagna rolls were found without any dates or labels. The Food Service Director (FSD) confirmed that all opened food in the freezer should have opened and use-by labels and dates. Additionally, on a storage rack, a stack of three 3rd pans and four 6th pans were observed wet nested, which the FSD stated should not occur. A review of the facility's undated policy on Food Receiving and Storage indicated that all food stored in the refrigerator or freezer should be covered, labeled, and dated, with frozen foods maintained at a temperature to keep them frozen solid. The policy also stated that wrappers of frozen foods must stay intact until thawing, and opened items should be labeled with an open date and used by the manufacturer's expiration date or discarded after six months. Furthermore, the facility's policy on Sanitization, revised in July 2023, specified that wet nesting should be avoided when pots, pans, and other kitchen products are put to dry.
Failure to Report Allegations of Abuse and Missing Property
Penalty
Summary
The facility failed to report allegations of abuse and a missing wallet to the New Jersey Department of Health (NJDOH) as required. The deficiency involved four residents, including one who reported feeling unsafe with two CNAs due to their rude and mean behavior. The resident, who had an intact cognition, expressed concerns about the CNAs, which were documented in a grievance form. Despite the grievance being reviewed and signed by the Director of Social Work and the Licensed Nursing Home Administrator (LNHA), no report was made to the NJDOH. Further investigation revealed that two other residents under the care of the same CNAs also had negative experiences. One resident reported that a CNA took items from their tray, while another felt humiliated during care. These incidents were documented, but again, no report was sent to the NJDOH. The LNHA acknowledged the oversight, stating that the incidents were treated as grievances rather than reportable events. Additionally, a resident's wallet containing important identification documents was reported missing by the resident's daughter. Although a police report was filed, the facility delayed reporting the incident to the NJDOH. The facility's policies required immediate reporting of such allegations, but these procedures were not followed, leading to the identified deficiencies.
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 7.69%. During a medication observation, a surveyor noted that two nurses administered medications to four residents, with 26 opportunities for error. Two errors were observed, specifically involving the administration of insulin to one resident. The Registered Nurse (RN) did not properly prime the insulin pens before administering the doses, which is a critical step to ensure the correct dosage is delivered. The RN was observed preparing and administering insulin to a resident without priming the insulin pens as per the manufacturer's instructions. The RN believed that the insulin pens were primed correctly because the plunger returned to zero, indicating no resistance. However, the RN did not hold the pens vertically or remove the needle cap to visualize the insulin liquid, which is necessary to confirm that the pen is functioning correctly and that air bubbles are removed. This misunderstanding of the priming process led to the medication errors. Interviews with the Staff Development/Advanced Practice Nurse (SD/APN) and the Consultant Pharmacist (CP) revealed inconsistencies in the training and understanding of the proper technique for insulin pen use. The SD/APN confirmed that the correct method involves holding the pen vertically and removing the needle cap to see the insulin liquid. The CP acknowledged the importance of priming but was unsure if the training included specific instructions for insulin pen technique. The facility's policy and manufacturer instructions clearly outlined the correct priming procedure, which was not followed during the medication pass.
Infection Preventionist Absence in QAPI Meeting
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance and Performance Improvement (QAPI) committee were present during a meeting, specifically the Infection Preventionist (IP). A review of the facility's Quality Assessment and Assurance (QAA) Committee Information, updated on 06/07/24, showed that the position of the IP was vacant. Additionally, the sign-in sheet for the QAPI meeting held on 07/12/24 did not include the IP's attendance. During an interview, the Licensed Nursing Home Administrator (LNHA) confirmed that the IP was a required member of the QAPI committee, which also included the administrator, the Director of Nursing (DON), the Medical Director, and two other staff members. The LNHA acknowledged that the IP did not attend the July 2024 meeting. The facility's job description for the IP position indicated that one of the primary responsibilities was to provide reports for the QAPI committee to the administrator. The facility's policy on the Quality Assurance Performance Improvement Plan also listed the IP as a member of the QAA Committee.
Facility Lacks Designated Infection Preventionist
Penalty
Summary
The facility failed to have a dedicated Infection Preventionist (IP) responsible for the infection prevention and control program (IPCP) from June 8, 2024, to the present. This deficiency was identified through interviews and a review of facility documents, revealing that the facility did not employ an IP who worked at least part-time and had completed specialized training in infection control and prevention. The NJ Executive Directive 21-012 and CMS QSO-22-19-NH Memo require facilities to have a part-time IP who meets the needs of the facility and works onsite. However, during the entrance conference on August 5, 2024, the Licensed Nursing Home Administrator (LNHA) admitted that the facility did not have an IP at that time, and no one was certified in infection control and prevention. Further investigation revealed that the last day of work for the previous IP was June 7, 2024. Although the Nursing Supervisor (NS) was involved in staff education for Personal Protective Equipment (PPE) and COVID surveillance and testing, the LNHA confirmed that the NS was not the designated IP. The NS had a CDC certification dated May 16, 2023, but was not officially assigned the role of IP. The facility's job description for the IP position outlined responsibilities such as developing policies, conducting internal quality improvement audits, and monitoring infection prevention and control policies, which were not being fulfilled due to the absence of a designated IP.
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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 Hillsborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Foothill Acres Rehabilitation & Nursing Center | 2.8 mi | — | 0 | 0 |
| Waterfront Rehabilitation And Healthcare Center | 5.3 mi | — | 13 | 0 |
| Bridgeway Care And Rehab Center At Bridgewater | 5.3 mi | — | 3 | 1 |
| N J Eastern Star Home | 5.6 mi | — | 16 | 0 |
| The Arbor At Laurel Circle | 5.7 mi | — | 8 | 0 |
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