The resident filed the complaint on May 23, 2024, saying they didn't want the two CNAs caring for them anymore. Within hours, administrators had reassigned the staff members and scheduled them for customer service training. Case closed.
Nobody interviewed the CNAs about what happened. Nobody documented witness statements. Nobody filed the required report to state health officials.
"I should have completed a report to the NJDOH," Licensed Nursing Home Administrator told federal inspectors in August, acknowledging the investigation was incomplete.
The facility's own policy requires reporting "all alleged violations of neglect, abuse and/or misappropriation of property" to state authorities within required timeframes. The policy also mandates that the grievance officer "investigate the allegations and submit a written report of such findings to the administrator within five working days."
None of that happened.
When the Social Worker interviewed two other residents about the same CNAs, she discovered additional problems. One resident said CNA #2 "took soda and chips from the resident's tray and the resident had to ask for them back." Another resident said CNA #1 "made him/her feel humiliated by being exposed during care" and specifically requested not to have that assistant assigned to them.
The Social Worker documented these statements on May 23 but conducted no follow-up investigation. Both CNAs received brief customer service training on May 25 and returned to work.
Federal inspectors discovered the incomplete investigation in August during a routine survey. The administrator initially defended the decision, explaining that the complaining resident "had a history of fixating on their care and saying that the CNAs were rude and mean."
She described the resident as "usually very selective with CNAs" who had requested reassignments before. The administrator said alert residents on that floor were "particular about who they want to care for them, and it was not unusual for the residents to request certain CNAs."
But the administrator's explanation shifted when inspectors pressed for details. "After reading the wording on the form, that she should have completed a report to the NJDOH," the inspection report noted. The administrator acknowledged "further investigation documentation was needed."
When inspectors interviewed the original complainant, Resident #6, the person couldn't recall specific incidents with the problematic CNAs. "CNA #1 gives them anxiety but was unable to speak to a specific incident or occurrence," inspectors found. The resident said they "just felt that CNA #1 was reluctant to help them."
The resident added that the two CNAs "were friends with" each other "and that together they were not good." But the resident also acknowledged having "a tendency to get anxious over everything."
Resident #25, who complained about feeling "humiliated by being exposed during care," refused to discuss the matter with inspectors. "The resident stated that she had nothing to say and had no concerns," the report noted.
Administrators later tried to minimize that resident's complaint, explaining that CNA #1 was helping train a new assistant when they noticed skin redness and called a nurse to examine it. The administrator said the resident "understood that there was 2 CNAs and a nurse trying to provide care for a medical reason and just preferred not to have CNA #1 assigned to them."
The third resident who complained, Resident #54, had left the facility by the time inspectors arrived. That resident's complaint about staff taking food from their meal tray was never fully investigated either.
The administrator eventually acknowledged that the investigation was "handled as a grievance because the residents were not in danger and that the residents were not satisfied with the care that they received." She explained the grievance process was used for issues "not considered abuse such as a CNA that was rushing them or the CNA was task oriented, and more customer service was needed."
But federal inspectors found the facility's own documentation contradicted that characterization. The original complaint form specifically stated residents "does not feel safe" with the two CNAs.
The Social Worker who initially handled the complaint told inspectors she "always asks the residents if they feel safe and when the answer was no, then she reports that to the LNHA." She acknowledged that "she should have documented more" about the investigation.
Only after federal inspectors began questioning the incomplete investigation did administrators attempt to conduct proper interviews and documentation. "The LNHA and DON stated that they had been working on completing the investigations after surveyor inquiry," the report noted.
The facility's medication practices also drew scrutiny during the August inspection. Inspectors observed a registered nurse improperly administering insulin to a diabetic resident, failing to follow manufacturer specifications for priming insulin pens before injection.
The nurse administered both long-acting and short-acting insulin without properly priming the pen injectors, which requires holding them vertically and visually confirming insulin appears at the needle tip. The nurse mistakenly believed seeing the plunger return to zero indicated proper priming.
"By not following the manufacturer's specifications for priming an insulin pen injector or incorrectly priming an insulin pen injector could affect the dosage of the insulin," administrators acknowledged to inspectors.
The medication errors contributed to an overall error rate of 7.69 percent during the inspection, exceeding the federal threshold of 5 percent.
Inspectors also found food safety violations in the kitchen, including unlabeled packages of opened biscuits and spinach lasagna rolls in the freezer. Wet cooking pans were improperly stacked together, violating sanitation protocols.
The facility operated without a required infection preventionist for more than two months, from June 8 through the August inspection. Federal regulations require nursing homes to have at least a part-time infection control specialist working on-site.
The missing infection preventionist also failed to attend a required quarterly quality assurance meeting in July, violating committee membership requirements.
All violations were classified as causing "minimal harm or potential for actual harm" to residents. But the investigation failures highlighted how facilities can minimize serious complaints by treating them as routine customer service issues rather than potential abuse requiring mandatory reporting and thorough investigation.
The resident who originally complained about feeling unsafe with the two CNAs told inspectors they were "very vocal with the staff" and felt "comfortable" speaking up about problems. That resident now receives care from different nursing assistants, as requested.
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
- View all inspection reports for Bridgeway Care and Rehab Center At Hillsborough
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