Bridgeway Care And Rehab Center At Hillsborough

F-F610

Based on observations, interviews and record review, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and follow facility policy and procedures for reporting for a) allegations of abuse (Sampled Resident #6, unsampled Resident #25 and #54), and b) a missing wallet with

a resdient's identification (Resident #15). The deficient practice was identified for four (4) of nine (9) residents reviewed for investigations and was evidenced by the following:

1. On 8/5/24 at 12:10 PM, the surveyor observed Resident #6 participating in conversation and eating lunch at a table with three other residents. The resident stated that they were willing to talk with the surveyor at another time.

The surveyor reviewed the medical record for Resident #6.

According to the quarterly Minimum Data Set (MDS) (an assessment tool) dated 5/8/24, reflected that the resident had diagnoses which included but not limited to; depression, morbid obesity and heart failure. The MDS assessment reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated an intact cognition.

On 8/6/24 at 10:06 AM, the surveyor reviewed a Complaint/Grievance Form, dated 5/23/24, provided by the Licensed Nursing Home Administrator (LNHA). The form was completed by the Social Worker (SW) and revealed that Resident #6 reported issues and concerns with two CNAs, (CNA#1 and CNA#2). The form indicated 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. Resident stated they are mean and rude. The form was referred to nursing and signed by the Director of Social Work (DOS), who was the Grievance Official (GO), on 5/24/24.

According to the form, the corrective action taken to rectify the concern, indicated that Education provided to CNAs regarding: abuse prevention, resident's rights, customer service and reassignment. It was signed by

the Director of Nursing (DON). The form had a Final Review by Grievance Official: Nature of Concern/Grievance: CNA interaction signed by the LNHA and GO and dated 5/28/24.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 3 315510 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315510 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 There was no indication that a report was sent to the NJDOH.

Level of Harm - Minimal harm or Further review of the attached Investigation Statement Form revealed that the date of the incident was potential for actual harm 5/18-5/19 (reported 5/23/24) and the type of investigation was issues with CNA #1 and CNA #2. The SW documented follow up interviews with two alert and oriented residents, unsampled Residents #25 and #54 on Residents Affected - Some 5/23/24, that were under the care of CNA #1 and CNA #2. The SW indicated on the form that unsampled Resident #54 made a statement that CNA #2 is just not compassionate. He/She doesn't want CNA #2 on his/her assignment as he/she does not feel good with CNA #2. The unsampled Resident #54 made a statement that CNA #2 took soda and chips from the resident's tray and the resident had to ask for them back.

In addition, the Investigation Statement Form revealed a follow up interview with unsampled Resident #25 who, according to the statement, indicated that CNA #1 made him/her feel humiliated by being exposed

during care. The form reflected that the unsampled Resident #25 had requested that CNA #1 not be on their assignment.

There was no indication that a report was sent to the NJDOH.

On 8/6/24 at 10:17 AM, the surveyor interviewed the LNHA regarding the Complaint/Grievance Form dated 5/23/24 for Resident #6. The LNHA confirmed that there was no report to the NJDOH. The LNHA stated that

the incident was treated as a grievance and not reported because Resident #6 had a history of fixating on their care and was saying that the CNAs were rude and mean and unsure what that meant because the resident had requested specific CNAs in the past. The LNHA stated that both CNAs were not working on 5/23/24 and were immediately reported to be reassigned from all three residents. The LNHA acknowledged that after reading the wording on the form, that she should have completed a report to the NJDOH. The LNHA stated that the DOSW/GO and SW had done the statements. The LNHA stated that the Director of Nursing (DON) was currently not available and the DOSW/GO was currently on leave. The LNHA added that

she could not recall why a report was not done and needed to do a review.

On 8/6/24 at 10:49 AM, the LNHA returned to discuss Resident #6 in the presence of the survey team. The LNHA stated that she had not reported because Resident #6 is usually very selective with CNAs and had asked for reassignments of CNAs in the past. The LNHA added that in general the alert and oriented 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. The LNHA stated that none of the three residents had initiated a concern and Resident #6 had been told in the past to immediately report any issues. The LNHA acknowledged that according to the wording on the form, the incidents should have been reported to the NJDOH.

On 8/6/24 at 11:09 AM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA stated that the required timeframes referred to in the facility Abuse Policy were to report any allegation of abuse immediately within 2 hours to the NJDOH and complete a NJDOH reportable form within 24 hours.

On 8/13/24 at 9:13 AM, the survey team met with the LNHA and DON, the LNHA stated that she was responsible for reporting to the NJDOH. The LNHA also 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 315510 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315510 B. Wing 08/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeway Care and Rehab Center at Hillsborough 395 Amwell Road Hillsborough, NJ 08844

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 48964

Level of Harm - Minimal harm or 2. The surveyor reviewed the medical record for Resident #15. potential for actual harm According to the Annual MDS, dated [DATE REDACTED], the resident had diagnosis including but not limited to; arthritis Residents Affected - Some and hypertension. The MDS reflected a BIMS score of 11, indicating moderate cognitive impairment.

On 08/06/24 at 01:38 PM, the surveyor reviewed the facility's investigation report which indicated that the resident's daughter reported Resident #15's wallet was missing on 03/10/24. The wallet did not contain any money, but did contain Resident #15's driver's license, social security card, and insurance cards. A police report was filed on 03/13/24.

After inquiry to the NJDOH by the facility on 03/13/24, the facility reported the above incident.

A review of the facility policy for Grievances/Complaints, Filing dated 6/21/24 provided by the LNHA included Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint. In addition, The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. 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.

A review of the facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 10/4/23 provided by the LNHA included to investigate and report any allegations within timeframes required by federal and state requirements.

N.J.A.C. 8:39-4.1(a)(15), 9.4(f)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 315510