The complaint involved three residents who all requested that the same two certified nursing assistants be removed from their care assignments. One resident said a nursing assistant had exposed them during care, making them feel "humiliated." Another reported that a nursing assistant took soda and chips from their meal tray and the resident had to ask for them back.
Federal inspectors discovered the unreported allegations during an August inspection and cited the facility for failing to follow state reporting requirements and its own policies for investigating abuse claims.
The trouble began on May 18 and 19 when incidents occurred involving the two nursing assistants, later identified as CNA #1 and CNA #2. Resident #6, who had intact mental capacity according to assessment scores, filed a formal complaint on May 23.
The resident "does not feel safe when CNA#1 and CNA#2 were caring for him/her and does not want them on his/her assignment," according to the complaint form completed by the facility's social worker. "Resident stated they are mean and rude."
Social workers interviewed two other residents who had been under the care of the same nursing assistants. Resident #54 said CNA #2 "is just not compassionate" and didn't want the assistant on their care assignment because "he/she does not feel good with CNA #2." This resident also reported that CNA #2 had taken food from their meal tray.
The third resident, #25, told investigators that CNA #1 had "made him/her feel humiliated by being exposed during care" and requested that the nursing assistant not be assigned to their care.
Despite these serious allegations involving multiple residents, administrators never filed the required reports with the New Jersey Department of Health. The facility's own policies require reporting any allegations of abuse immediately within two hours to state health officials and completing formal documentation within 24 hours.
When federal inspectors questioned the Licensed Nursing Home Administrator about the missing reports, she initially said the incident was treated as a grievance rather than an abuse allegation. The administrator explained that Resident #6 "had a history of fixating on their care" and had requested specific nursing assistants in the past.
She told inspectors that "both CNAs were not working on 5/23/24 and were immediately reported to be reassigned from all three residents." The administrator acknowledged that after reviewing the wording on the complaint form, "she should have completed a report to the NJDOH."
The administrator couldn't remember why no report was filed. "The LNHA stated that she could not recall why a report was not done and needed to do a review," inspectors noted.
Later that same day, the administrator met again with the inspection team. She explained that Resident #6 "is usually very selective with CNAs and had asked for reassignments of CNAs in the past." She added that alert residents on the unit were often "particular about who they want to care for them and it is not unusual for the residents to request certain CNAs."
The administrator said none of the three residents had initiated concerns on their own and that Resident #6 "had been told in the past to immediately report any issues." Still, she acknowledged that "according to the wording on the form, the incidents should have been reported to the NJDOH."
A week later, when inspectors returned to discuss the matter, the administrator remained unable to explain the decision. "The LNHA stated that 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 did take some corrective action internally. According to the complaint form, nursing assistants received education about "abuse prevention, resident's rights, customer service and reassignment." The Director of Nursing signed off on these measures, and the grievance was marked resolved on May 28.
But the failure to report extended beyond this single incident. Inspectors also found that the facility had delayed reporting another case involving a missing wallet belonging to Resident #15, who had moderate cognitive impairment.
The resident's daughter reported the missing wallet on March 10. The wallet contained no money but held the resident's driver's license, social security card, and insurance cards. 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 New Jersey Department of Health on March 13 — the same day the police report was filed.
The facility's policies clearly outline reporting requirements. The grievance policy states that "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 requires staff "to investigate and report any allegations within timeframes required by federal and state requirements."
Federal inspectors found that four of the nine residents they reviewed for investigations had cases where proper reporting procedures weren't followed.
The administrator confirmed she was responsible for making reports to state health officials. When asked about the required timeframes, she correctly stated that facility policy required reporting "any allegation of abuse immediately within 2 hours to the NJDOH and complete a NJDOH reportable form within 24 hours."
Resident #6, who had diagnoses including depression, morbid obesity and heart failure, scored 14 out of 15 on cognitive assessments, indicating intact mental function. Inspectors observed the resident "participating in conversation and eating lunch at a table with three other residents" during their visit.
The violations occurred despite the facility having clear policies and an established chain of command for handling such reports. The Director of Social Work served as the Grievance Official, and the Director of Nursing was involved in the corrective actions, yet the required state notifications never happened.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" and affecting "some" residents at the facility.
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.
Additional Resources
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