Federal inspectors found that the facility failed to report abuse allegations involving four residents during a complaint investigation in August. The violations centered on incidents from May when multiple residents complained about the same two certified nursing assistants.
Resident #6, who has intact mental capacity according to assessments, filed a complaint on May 23 saying they didn't feel safe when CNA #1 and CNA #2 were caring for them. The resident specifically requested that both nursing assistants be removed from their assignment because "they are mean and rude."
The facility's own investigation revealed similar complaints from two other alert residents. Resident #54 told the social worker that CNA #2 "is just not compassionate" and described an incident where the nursing assistant took soda and chips from the resident's meal tray. The resident had to ask for the items back.
Resident #25 made more serious allegations, telling investigators that CNA #1 "made him/her feel humiliated by being exposed during care." This resident also requested that CNA #1 be removed from their assignment.
None of these incidents were reported to the New Jersey Department of Health, despite facility policies requiring immediate notification within two hours of any abuse allegation.
The Licensed Nursing Home Administrator acknowledged the failure during interviews with federal inspectors. She initially explained that the incident was "treated as a grievance and not reported because Resident #6 had a history of fixating on their care" and was "unsure what that meant because the resident had requested specific CNAs in the past."
The administrator added that both nursing assistants were not working on May 23 and were "immediately reported to be reassigned from all three residents." She stated that alert residents on the floor were "particular about who they want to care for them and it is not unusual for the residents to request certain CNAs."
But after reviewing the complaint forms, the administrator admitted she should have reported the incidents. "After reading the wording on the form, that she should have completed a report to the NJDOH," inspection records show.
During a follow-up meeting, the administrator said she "could not remember back in May why the incident was not reported and stated based on the wording of the report that she should have reported it."
The facility's own policies contradict the administrator's handling of the complaints. According to the grievance policy dated June 21, 2024, "All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under the guidelines for reporting abuse, neglect and misappropriation of property, as per state law."
The abuse prevention policy, dated October 4, 2023, requires staff to "investigate and report any allegations within timeframes required by federal and state requirements."
Inspectors found a fourth violation involving Resident #15, whose wallet containing identification cards went missing in March. The resident's daughter reported the missing wallet on March 10, which contained the resident's driver's license, social security card, and insurance cards but no money.
A police report was filed three days later on March 13. The facility only reported the incident to state health officials after making an inquiry to the department that same day, rather than reporting it immediately as required.
Resident #15 has moderate cognitive impairment according to assessment scores, with diagnoses including arthritis and hypertension.
The inspection revealed systemic problems with the facility's reporting procedures. The administrator told inspectors she was responsible for reporting to state health officials and confirmed that facility policies required reporting "any allegation of abuse immediately within 2 hours to the NJDOH and complete a NJDOH reportable form within 24 hours."
The Director of Social Work, who served as the Grievance Official, was on leave during the inspection and unavailable for interviews. The Director of Nursing was also unavailable when inspectors initially requested interviews.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" and affecting "some" residents. The deficiencies were identified in four of nine residents reviewed during the investigation.
The complaint forms show that after the May incidents, the facility provided education to the nursing assistants regarding "abuse prevention, resident's rights, customer service and reassignment." The forms were signed by various administrators including the Director of Nursing and reviewed by the Grievance Official on May 28.
Resident #6 participated in conversations and ate lunch with other residents during the inspection, appearing willing to speak with surveyors. The resident's medical record showed diagnoses including depression, morbid obesity, and heart failure, with assessment scores indicating intact mental capacity.
The violations highlight gaps between facility policies and actual practice. While written procedures required immediate reporting of abuse allegations, administrators treated serious resident complaints as routine grievances requiring no outside notification.
The administrator's explanation that residents were "particular" about their caregivers and frequently requested reassignments suggests a pattern of resident dissatisfaction that may have desensitized staff to legitimate abuse concerns.
Federal regulations require nursing homes to report suspected abuse, neglect, exploitation, or misappropriation to state health officials immediately. The failure to report can result in federal fines and increased oversight.
The three residents who complained about the nursing assistants remain at the facility. Their requests to have specific CNAs removed from their care assignments were granted, but only after they endured treatment that made them feel unsafe and humiliated.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bridgeway Care and Rehab Center At Hillsborough from 2024-08-19 including all violations, facility responses, and corrective action plans.
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