BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER
For profit - Corporation
151 Beds
Independent
Data: November 2025
Trust Grade
73/100
#98 of 344 in NJ
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bridgeway Care and Rehab Center at Bridgewater has a Trust Grade of B, indicating it is a good choice among nursing homes, with solid overall performance. It ranks #98 out of 344 facilities in New Jersey, placing it in the top half of the state, and #6 out of 15 in Somerset County, meaning only five local options are better. The facility is improving, with issues reducing from six in 2023 to two in 2025, which is a positive trend. Staffing is a strength, with a rating of 4 out of 5 stars, and while turnover is at 45%, it is close to the state average. However, the center has faced some concerning incidents, such as a resident with congestive heart failure who was not weighed as required, leading to a hospital transfer in respiratory distress, and issues with food safety in the kitchen that could pose health risks. Overall, while the facility has strengths in staffing and improving conditions, families should be aware of the specific incidents that highlight areas needing attention.
- Trust Score
- B
- In New Jersey
- #98/344
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 45% turnover. Near New Jersey's 48% average. Typical for the industry.
- Penalties ✓ Good
- $7,901 in fines. Lower than most New Jersey facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 54 minutes of Registered Nurse (RN) attention daily — more than average for New Jersey. RNs are trained to catch health problems early.
- Violations ○ Average
- 8 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
73/100
Top 28%
Needs review
6 → 2 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 6 issues
2025: 2 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (45%)
3 points below New Jersey average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 45%
Near New Jersey avg (46%)
Typical for the industry
Federal Fines: $7,901
Below median ($33,413)
Minor penalties assessed
The Ugly 8 deficiencies on record
1 actual harm
Mar 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Complaint #: NJ177346
Based on interview, record review, and review of facility documents, it was determined that the facility failed to report the results of an allegation of resident-to-resident abu...
Read full inspector narrative →
Complaint #: NJ177346
Based on interview, record review, and review of facility documents, it was determined that the facility failed to report the results of an allegation of resident-to-resident abuse to the New Jersey Department of Health (NJDOH) within five working days for 2 of 2 residents (Resident #74 and Resident #195) reviewed for abuse.
This deficient practice was evidenced by the following:
On 3/25/25 at 10:42 AM, the surveyor observed Resident #74 who was seated in a wheelchair with a transfer pad beneath of him/her and the resident was engaged in a group activity. When interviewed at that time, the Activity Aide stated that the resident frequently called out for the nurse.
On 3/25/25 at 1:09 PM, the surveyor reviewed the medical record of Resident #74.
A review of the admission Record, and admission summary, revealed that the resident had diagnoses which included, but were not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side and anxiety disorder, unspecified.
A review of the the resident's quarterly Minimum Data Set (MDS) , an assessment tool used to facilitate the management of care, dated 12/26/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident's cognition was intact.
A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/19/23, which indicated that the resident had a behavior problem of calling out for the nurse without knowing what he/she wanted. Interventions included: providing a program of activities that was of interest and accommodated the resident's status.
A review of the resident's Progress Notes (PN) included an entry dated 8/2/24 at 11:27 PM, which revealed that while the Certified Nursing Assistant (CNA) propelled the resident back to his/her room, they passed by Resident #195. Resident #195 slapped the notebook that he/she was holding on Resident #74's left arm. The supervisor was made aware of the incident and a body check was done with no visible injury noted. Resident #74 was wearing a long sweat shirt at the time of the incident and denied pain.
On 3/26/25 at 10:18 AM, the surveyor requested and reviewed a copy of the abuse investigation which included a Reportable Event Record (RER). The RER indicated that on 8/3/24, the facility notified the NJDOH of a Resident-to-Resident Abuse event that occurred on 8/2/24 at 7:00 PM, which involved both Resident #74 and Resident #195. Further review of the RER revealed that as Resident #74 was being brought back to their room, Resident #195 reached out and softly hit Resident #74 on the left forearm with a notebook he/she was holding. Interventions included that the residents were separated with supervision, a skin assessment was conducted and the Medical Doctor and Family were notified.
At that time, the surveyor noted that there were no employee statements included in the investigation and notified the Licensed Nursing Home Administrator (LNHA). The LNHA stated that he had the employee statements in his email account and he agreed to provide them.
On 3/26/25 at 11:57 AM, the LNHA provided the surveyor with two employee statements that were written by both Registered Nurse (RN) #1 and RN #2 that were sent to the LNHA via email on 8/2/24.
A review of the email that was written by RN #1, dated 8/2/25 at 11:58 PM, indicated that Resident #195 hit Resident #74 in the arm with a notebook when Resident #74 was shouting for a nurse as Resident #195 was passing by in his/her wheelchair. Resident #195 told Resident #74 to shut up as Resident #195 hit Resident #74 lightly on the arm.
Further review of the investigation revealed an undated Summary of Resident-to-Resident Abuse Investigation related to Resident #74 and Resident #195. A review of the undated Summary included the conclusion: After investigation it was concluded that the allegation of abuse was substantiated.
On 3/31/25 at 9:38 AM, the surveyor interviewed the LNHA and asked him if he sent a copy of the summary and conclusion of the allegation of Resident-to-Resident abuse that occurred on 8/2/24 between Resident #74 and Resident #195 to the Department of Health, and the LNHA stated that he waited until he had all of the information that was requested and sent it to the DOH on 10/4/24, 64 days later. When the surveyor asked the LNHA what the required time frame was to submit a summary and conclusion was, he stated that he was required to submit the summary and conclusion within five days of the reportable event submission.
A review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, included: Investigate and report any allegations within timeframes required by federal requirements.
NJAC 8:39-9.4(e)(2)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food to prevent food-borne illness.
This defici...
Read full inspector narrative →
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food to prevent food-borne illness.
This deficient practice was evidenced by the following:
On 3/25/25 from 9:58 AM until 10:51 AM, the surveyor observed the following in the kitchen in the presence of the Food Service Director (FSD):
1. In the bay marine refrigerator, on a shelf, there was a chicken salad sandwich labeled with a use-by date of 3/21/25. The FSD stated that the sandwich can be stored for three (3) days after it was prepared and should be discarded by the Use by date. The FSD stated that she would discard the chicken salad sandwich.
2. In the same refrigerator, there was an unlabeled large block of a white, round, solid food item wrapped in white paper on the shelf. The FSD was unable to identify the food item. At that time, the Chef Manager approached the surveyor and FSD and stated that it was a block of cheese that belonged to the kitchen staff. The FSD stated that staff were not supposed to store their personal food in the bay marine refrigerator. The FSD removed the cheese.
3. In the dry food storage area, there was a bag of tricolor pasta that did not have an opened date. At that time, the FSD stated that the tricolor pasta was no longer on the menu because they were now using a different menu for the summer. She further stated that the pasta should have been dated when it was opened and that she would discard the pasta.
On 3/31/25 at 11:41 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that staff members' personal food items should not be stored in the kitchen refrigerator designated for resident food. He also stated that prepared foods should not be kept for longer than 3 days and should be discarded if not consumed by the use-by date.
A review of the facility's Food Receiving and Storage policy, revised November 2022, revealed, Dry Food Storage 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date), and, Refrigerated/Frozen Storage 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.
NJAC 8:39-17.2(g)
Sept 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00153370
Based on interview, medical record review, and review of other pertinent facility documentation on 09/19...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00153370
Based on interview, medical record review, and review of other pertinent facility documentation on 09/19/23 and 09/20/23, it was determined that the facility failed to: a.) complete daily weights in accordance with a physician's order and b.) follow care plan (CP) interventions for a resident with congestive heart failure (CHF). The resident gained 31 pounds (Lbs.) of fluid in 10 days and was transferred to the hospital in respiratory distress where they were admitted to the intermediate care unit.
The deficient practice was identifed for Resident #1, 1 of 5 residents reviewed for quality of care and was evidenced by the following:
The surveyor reviewed the closed medical record for Resident #1:
According to the admission Record, Resident #1 was admitted on [DATE] with diagnoses which included but were not limited to Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure (a condition where the heart can't pump well enough to give the body a normal blood supply), Unspecified Atrial Fibrillation (irregular heart rhythm), and Type 2 Diabetes Mellitus (inadequate blood sugar control).
The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/21, indicated that Resident #1 had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident weighed 178 lbs.
Review of Resident #1's CP revealed a Focus, initiated on 05/18/21, that Resident #1 was at risk for acute exacerbation of CHF. Under the Interventions/Tasks section, included the following interventions, initiated on 05/18/21: Assess for shortness of breath and notify physician of new or worsening shortness of breath, aucultate (listen to) lung sounds daily and notify physician if adventitious breath sounds observed and daily assessment of peripheral edema.
Review of Resident #1's Order Recap Report (ORR) did not include physician's orders (PO) to assess for shortness of breath and to notify the physician of new or worsening shortness of breath, auscultate lung sounds daily and notify physician if adventitious breath sounds observed, or to complete daily assessment of peripheral edema.
Review of the May and June 2021 Treatment Administration Records failed to include documentation of assessment for shortness of breath, daily lung sound auscultation, or daily assessment of peripheral edema.
Review of Resident #1's Progress Notes (PN) revealed a 06/14/21 Q8hr [Every 8 hour] Respiratory Surveillance note that indicated the resident was noted as having shortness of breath. The PN revealed that the resident had Shortness of breath or trouble breathing is present with exertion (e.g. walking bathing, transferring) Shortness of breath or trouble breathing is present when lying flat (reported by the resident/resident representative and/or observed by staff) Shortness of breath is a new symptom. [ .] The PN failed did not include documentation that the nurse auscultated the resident's lung sounds or notified the physician of the new onset shortness of breath.
Review of Resident #1's medical record failed to reveal that Resident #1's breath sounds were auscultated on 05/18/21, 05/19/21, 05/28/21, 05/29/21, 05/30/21, 06/01/21, 06/02/21, 06/05/21, 06/09/21, 06/11/21, 06/12/21, 06/12/21, 06/13/21, 06/14/21, 06/16/21, 06/17/21, 06/18/21, 06/19/21, 06/20/21, 06/21/21, or 06/25/21.
Review of Resident #1's medical record failed to reveal that Resident #1's peripheral edema was assessed on 05/18/21, 05/19/21, 05/28/21, 05/29/21, 05/30/21, 06/02/21, 06/05/21, 06/09/21, 06/11/21, 06/12/21, 06/13/21, 06/14/21, 06/17/21, 06/19/21, 06/20/21, or 06/26/21.
The CP revealed an intervention, initiated on 05/18/21, for daily weights and to notify the physician if weight gain of 2 Lbs in one day or 5 Lbs. in one week is noted.
The ORR revealed that physician's orders for CHF Protocol: Daily Weights. were active from 05/19/21 to 5/26/21 and from 06/10/21 to 06/27/2.
Review of the May 2021 Medication Administration Record (MAR) revealed the following weights:
05/19: 178.2 Lbs.
05/20: 178.2 Lbs.
05/21: hospitalized
Review of the Patient Care Summary from the resident's 05/21/21 hospitalization indicated that Resident #1 weighed 87.2 KG (192.2 Lbs.)
05/22: hospitalized
05/23: hospitalized
05/24: hospitalized
The Patient Care Summary from 05/24/21 indicated that Resident #1 weighed 84.4 KG (186.0 Lbs.)
05/25: hospitalized
05/26: hospitalized
Review of the 05/26/21 Clinical admission Evaluation did not include documentation of Resident #1's readmission weight.
Review of the ORR did not include a PO for daily weights from 05/26/21-06/09/21
Further review of the May and June 2021 MARs did not include daily weights documented from 05/27/21-06/09/21.
The June 2021 MAR recorded the following weight:
06/10: 178.2 Lbs.
06/11: 178.2 Lbs.
06/12: 178.2 Lbs.
06/13: 178.2 Lbs.
06/14: 178.0 Lbs.
06/15: 178.0 Lbs.
06/16: No weight recorded.
06/17: 178.0 Lbs.
06/18: 178.0 Lbs.
06/19: 178.0 Lbs.
06/20: Refused
06/21: No weight recorded.
06/22: No weight recorded.
06/23: 209.6 Lbs.
06/24: 205 Lbs.
06/25: 209.4 Lbs.
Review of the 06/22/21 Emergency Department Triage Hospital paperwork indicated that Resident #1 weighed 221.78 Lbs.
The 06/16/21 Q8hr Respiratory Surveillance note indicated, [ .] Yes, shortness of breath is noted. Shortness of breath or trouble breathing is present with exertion (e.g. walking, bathing, transferring) Shortness of breath or trouble breathing is present when lying flat (reported by the resident/resident representative and/or observed by staff). Shortness of breath is not a new symptom. [ .].
Further review of the PN failed to indicate that the nurse auscultated the resident's lung sounds.
The 06/20/21 Q12hr [Every 12 hour] Respiratory Surveillance Progress Note indicated, [ .] Yes, shortness of breath noted. Shortness of breath or trouble breathing is present with exertion (e.g. walking, bathing, transferring) Shortness of breath is not a new symptom [ .].
Further review of the PN failed to indicate that the nurse auscultated the resident's lung sounds.
Review of the PNs revealed a 06/23/21 Physician Note-Narrative that the resident had a questionable weight gain of 31 pounds over 10 days and lower extremity edema in both legs.
Review of the PNs revealed a 06/25/21 Physician Note-Narrative that the resident had a weight gain of 31 pounds over 10 days, wheezing in their lungs, and lower extremity edema in both legs.
Review of the PNs revealed a 06/26/21 Nursing Note-Narrative (NN) that at 12:30 PM, Resident #2's oxygen saturation dropped to 70% (normal oxygen saturation is 90-100%), that the doctor was called, and that the resident was ordered to be sent to the hospital.
Further review of the the PNs revealed a 06/27/21 NN that Resident #2 was admitted to the intermediate care unit with a diagnosis of CHF.
During an interview with the surveyor on 09/19/23 at 12:25 PM, the Certified Nursing Assistant/Unit Secretary (CNA/US) stated that they do daily weights on residents with CHF. The CNAs weighed the residents and would write it in a weight binder or give the weight verbally to the nurse. The CNA/US added that the nurse documented the weights in the electronic medical record. The CNA/US continued that CHF could cause retention of fluids and that the daily weights are completed to make sure that the residents were not retaining any fluids.
During an interview with the surveyor on 09/19/23 at 1:42 PM, the Licensed Practical Nurse (LPN) #1 stated that care for a resident diagnosed with CHF was driven by whatever was specified by the CP. LPN #1 added that CHF residents were weighed more frequently and, in the morning, when the resident woke up. LPN #1 stated CNAs tell the nurses the weight and that the nurses put the weights onto the MAR. LPN #1 stated that there could be little fluctuations with a resident's weights day to day. LPN #1 stated that drastic changed in the resident's weight would be a problem. LPN #1 further stated that if a resident had new onset shortness of breath, the nurse would notify the Unit Manager and notify the physician to get an order for oxygen. LPN #1 added that the resident could be sent to the emergency room because shortness of breath could be an emergency.
During an interview with the surveyor on 09/19/23 at 2:02 PM, the Registered Nurse (RN) #1 stated that the physician would usually with order daily weights for residents with a CHF diagnosis. RN #1 stated the resident would be weighed in the morning before breakfast and that if there was a weight gain or loss, the nurse would communicate with the physician for interventions. The surveyor asked if RN #1 would expect for several weights to be exactly the same day after day. RN #1 stated that the weight usually fluctuates and that, today is different from tomorrow. RN #1 stated that it was important to monitor residents with CHF to prevent an exacerbation of CHF. RN #1 stated that if a resident is ordered daily weights that they should be done and documented. RN #1 continued that if there was a new onset of shortness of breath in a CHF resident, the nurse would check their oxygen saturation, communicate with the doctor, and document the communication in the resident's PN.
During an interview with the surveyor on 09/19/23 at 2:33 PM, the Licensed Practical Nurse/UM (LPN/UM) stated that staff needed to be monitoring residents with CHF by following the CHF protocol to determine if the resident experienced any changes. The LPN/UM stated that residents with CHF could be ordered daily weights and that they would have to be completed the same time and would have to be documented. The LPN/UM stated that the nurse would also monitor the resident for breathing or edema and would tell the doctor. The LPN/UM stated that there should not be instances on Resident #1's MAR where no weight was recorded.
During an interview with the surveyor on 09/20/23 at 12:55 PM, the Licensed Practical Nurse (LPN) #2 stated that a care plan reflected cooperation between all the different disciplines on how to fully care for a resident.
During an interview with the surveyor on 09/20/23 at 2:58 PM, the Director of Nursing (DON) stated residents admitted with CHF would have a CP developed to manage their CHF. The DON stated that the purpose of monitoring residents with CHF was to check for fluid overload. The DON added that ultimately death could be caused if a resident had too much fluid backed up. The DON stated that she expected weights to be recorded daily for a resident who was ordered daily weights. The DON continued that if a resident had a new onset of shortness of breath that she would expect to see at least a phone call to the resident's care provider. The DON stated that the purpose of a CP was to provide communication between the nursing team regarding the customized needs of a resident.
The facility policy, Congestive Heart Failure Protocol dated 11/01/2012 indicated under the Procedure section, The nurse, in consult with the attending physician shall initiate measures to assess and manage residents who are admitted with a primary diagnosis of CHF, or develop new onset CHF. These may include: Daily Weights, Daily assessment of peripheral edema [ .], Daily auscultation of lungs [ .]. The policy continued, The nurse will notify the physician at early onset if the following are present: [ .] New or worsening shortness of breath [ .].
The 11/28/17 facility policy, Baseline and Comprehensive Care Plans indicated under the Procedure section, The comprehensive care plan must describe the following: A. The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being [ .] All care plans will be reviewed quarterly by each discipline and interdisciplinary team members, unless needed sooner due to a significant change in condition.
The 04/20/12 facility policy, Weight and Height inidcated under the Procedure section, A resident's height and weight will be taken and recorded upon admission/readmission on the nursing admission assessment.
NJAC 8:39-27.1(a)
NJAC 8:39-11.1.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00164556
Based on interviews, medical records review, and review of other pertinent facility documentation on [DAT...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00164556
Based on interviews, medical records review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #3) exhibited aggressive behaviors and was sent to the hospital for a behavioral evaluation. When the resident was discharged from the hospital, the facility would not permit a return back to the facility. The deficient practice was identified for Resident #3, 1 of 3 residents reviewed for transfer and discharge, and was evidenced by the following:
The surveyor reviewed the closed medical record for Resident #3:
According to the admission Record, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Parkinson's Disease, Major Depressive Disorder, Bipolar Disorder, and Generalized Anxiety Disorder.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE], revealed that Resident #3 had a Brief Interview for Mental Status score of 5, which indicated the resident had severe cognitive impairment. The MDS failed to indicate that Resident #3 had any behavioral symptoms.
Review of Resident #3's Clinical Census revealed that their Primary Payer at the facility was Medicaid-Managed Care.
The [DATE] Pre-admission Screening And Resident Review (PASRR) Level I Screen (a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long trem care) indicated that Resident #3 had a diagnosis of a major mental illness but that the resident did not have a significant impairment in functioning related to the diagnosis. The PASRR also indicated that Resident #3 should be admitted to the nursing facility.
The care plan dated [DATE] indicated focuses for difficulty relating to staff and other residents in stressful situations, trouble coping with change, risk for social isolation due to a behavior problems, physical aggression, verbal aggression, use of lithium (mood stabilizing medication), antidepressant, and antianxiety medications.
Review of the [DATE] Physician Note- Narrative (PNN) written by the Attending Physician revealed that Resident #3 was aggressive at times, was followed closely by psych, and was less anxious. The PNN did not include any physician documentation of the specific needs that could not be met at the facility for Resident #3.
Review of the [DATE] Psychiatry Progress Note (PPN) completed by the Advanced Practice Nurse (APN) revealed, [ .] LTC resident with history of bipolar disorder, depression, Parkinson's disease, and insomnia. Patient is evaluated following episodes of behavior outbursts including physical aggression and mood lability. Staff reports that pt [patient] has become a danger to others, as [he/she] is attacking other residents who are [NAME] [vulnerable] and unable to proactively avoid contact or protect themselves from [his/her] random aggression. At this time pt needs an emergency high level of care for stabilization and safety. When pt returns and if medications are not adjusted at the hospital, will recommend increasing the Vraylar [antipsychotic medication] to 3 mg, and if behavior persist an in-patient admission for medication management will be appropriate [ .]. The PPN did not include any documentation of the specific needs that could not be met at the facility for Resident #3.
According to the [DATE] Nursing Note-Narrative, [ .] Due to circumstances of aggressive behavior and for the safety of the other residents and discussion with Psych [ .] APN, it was determined to send out 911 to ER for evaluation. Called 911. [ .] Resident was picked up via stretcher at 11:15 am.
According to the communication chain from the facility's Admission's Clinical Liaison to the hospital on [DATE], Status changed to Decline. [He/She] is from our facility but [he/she] has surpassed [his/her] 10 day Medicaid bed hold. Also we are unable to take [him/her] back with the need of a [1 to 1 monitoring system] and [his/her] behaviors under control. No Bed Available.
According to the [DATE] Daily Census (census sheet), there were 151 available beds, 134 total residents, and 17 empty beds.
According to the Psychiatric Consultation completed by the Psychiatric Nurse Practitioner (NP) at the hospital on [DATE], Patient does not have acute psychiatric symptoms, warranting acute psychiatric care at this time. Patient is not a threat to self or others and is not psychotic. Patient required, not aggressive and responded to verbal stimuli very little[.] Patient adamantly denies any thought or intention to hurt self or anyone else. Patient doesn't meet commitment criteria and requesting discharge. Patient can be discharged , once medically clear to SAR [sub-acute rehabilitation], or group home.
According to the communication chain from the hospital to the facility on [DATE], Attached is patient's psych clearance. [He/she] clearly does not meet criteria for a facility with a higher level of behavioral support. This would not be an appropriate referral. [ .] It is not the responsibility of the hospital to place one of your long term care residents that has resided with you for over 2 years.
According to the communication chain from the facility's Director of Admissions (DOA) to the hospital on [DATE], [He/She] could be on the wait list should [he/she] be appropriate at that time. Thank you.
According to the [DATE] communication chain from the hospital to the facility, According to the law, [he/she] is to receive the NEXT available bed, not placed back on your waiting list. [ .] This is where expecting the hospital to pursue alternate placement for you is unacceptable.
During an interview with the surveyor on [DATE] at 12:36 PM, the DOA stated the main reason for the resident's discharge from the facility was a nursing decision because of the resident's wellbeing, behaviors, and the safety of the other residents and staff at the facility. The DOA stated that when Resident #3 was sent out, there was a 10-day bed hold in place. The resident was not safe to return to the facility before the bed hold expired. The DOA continued that once the resident's bed hold expired, the family wound have to pay to keep the bed held for longer. The DOA stated the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) would know more about the resident's discharge because it was a clinical decision.
During an interview with the surveyor on [DATE] at 2:03 PM, the LNHA stated that on [DATE] that the facility had denied the hospital's referral to readmit Resident #3 because of their behaviors and out of concern for the safety of the other residents. The LNHA stated that Resident #3's bed was occupied on 05/23 but there were open beds available at the facility. The LNHA continued that the facility's Admissions Clinical Liaison and DOA did not give accurate information to the hospital that no beds were available.
Review of the [DATE] census sheet revealed that Resident #3's room was documented as Empty.
During an interview with the surveyor on [DATE] at 2:58 PM, the DON stated that a resident who had a psychiatric episode would be allowed to return to the facility when they were cleared to return to the facility. A psychological assessment would show that they were not a danger to themselves or others, and that their treatment was managed. The DON stated that a resident would be radmitted as long as the facility had the medications and could meet the resident's needs. The DON continued that according to the Psychiatric NP's assessment on [DATE] in the hospital, the resident should have been readmitted .
The facility policy, Transfer and Discharge dated [DATE] indicated under the, Policy Section, To permit each resident to remain the facility, and not transfer or discharge the resident from the facility unless: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; The health of individuals in the facility would otherwise be endangered [ .]. The facility policy continued, Residents who are sent emergently to the hospital are considered facility-initiated transfers because their return is generally expected, and will be permitted to return to the facility, unless they meet one of the criteria under which the facility can initiate discharge.
The facility polices, Admissions Policies, and admission Criteria failed to address readmission to the facility following hospitalization.
The undated Notice of Bed Hold Policy and Return to Facility, sent to Resident #3's resident representative indicated, If Medicaid or Managed Medicaid, Bridgeway will reserve the resident's accommodations for up to ten (10) days, with Day 1 being the date of discharge. [ .] If the therapeutic leave or transfer exceeds the bed-hold period, and payment for bed hold is not made, the resident will be allowed to return to their previous room, only if available. If the previous room is not available, they will be offered a bed in another semi-private room.
NJAC 8:39 5.1(d)
gbbbbbbbbbbbbbbbbbbbbbbbbm
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00151859
Based on interview, medical records review, and review of other pertinent facility documentation on 09/1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00151859
Based on interview, medical records review, and review of other pertinent facility documentation on 09/19/23 and 09/20/23, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) for a resident with recurrent urinary tract infections (UTI).
The deficient practice was identified for Resident #2, 1 of 3 residents reviewed for CP and was evidenced by the following:
The surveyor reviewed the closed medical record for Resident #2:
According to the admission Record, Resident #2 was admitted on [DATE] with medical diagnoses which included but were not limited to Metabolic Encephalopathy (a problem in the brain caused by an imbalance in the blood), Chronic Kidney Disease, and UTI.
Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/06/21, revealed that Resident #2 had a Brief Interview for Mental Status Score of 13, which indicated the resident was cognitively intact. The MDS further revealed that the resident was incontinent of bowel and bladder and required extensive assistiance of two staff persons for toileting. The MDS also indicated that the resident had a UTI in the last 30 days.
1. Review of Resident #2's Progress Notes (PN) revealed a 10/30/21 Nursing Note-Narrative (NN) that the resident's family member stated that the resident was hallucinating. The NN also indicated that the doctor was made aware and that the resident was sent to the hospital for altered mental status.
Review of Resident #2's PN revealed a 10/30/21 NN that a call was placed to the Emergency Department and that the resident was being admitted for a UTI.
Review of Resident #2's 11/2/21 Discharge Summary from the hospital revealed that the resident's urine cultures came back positive for Salmonella (type of bacterial infection) and that antibiotics were initiated.
Review of Resident #2's PN revealed a 11/2/21 NN that Resident #2 had returned with a physician order (PO) for Keflex (antibiotic) 500 milligrams (MG) and that the Advance Practice Nurse (APN) was informed.
Review of the Order Recap Report (ORR) for November 2021 revealed a 11/03/21 PO for Cephalexin Tablet 500 MG Give 1 tablet by mouth every 12 hours for salmonella UTI for 4 Days.
Review of the November 2021 Medication Administration Record (MAR) revealed that Resident #2 was administered Cephalexin (Keflex) Tablet 500 MG Give 1 tablet by mouth every 12 hours for salmonella UTI for 4 Days from 11/03/21-11/06/21.
2. Review of Resident #2's PN revealed a 11/19/21 NN that the resident was noted to be more confused than at baseline. The physician was made aware and gave an order to send the resident to the hospital.
Review of Resident #2's PN revealed a 11/20/21 NN revealed that the resident was admitted to the hospital for altered mental status.
Review of Resident #2's PN revealed a 11/26/21 NN indicated that Resident #2 was readmitted to the facility from the hospital on [DATE] and that they were receiving Keflex 500 MG for 4 days for a UTI.
Review of the ORR for November 2021 revealed a 11/25/21 PO for Cephalexin Tablet 500 MG Give 1 tablet by mouth every 12 hours for infection for 4 Days.
Review of the November 2021 MAR revealed that Resident #2 was administered Cephalexin Tablet 500 MG every 12 hours for four days, from 11/25/21-11/29/21.
3. Review of Resident #2's PN revealed a 01/11/22 NN which indicated that the resident's temperature was 100.8 (normal temperature is 97.6-99.6°F) and that the resident did not feel well. The note also indicated that the APN was made aware.
Review of the 01/11/22 Physician Note Narrative indicated that the APN discussed with the MD and the nurse arranged for transport to the hospital.
Review of the 1/14/22 Discharge Summary from the hospital Medical Doctor (MD) indicated that Resident #2 presented to the hospital on [DATE] with reports of lethargy. The resident was also found to have evidence of a urinary tract infection. The urine sample grew Proteus (bacteria) and Resident #2 was started on antibiotics for the UTI. The resident would be transitioned to oral antibiotics on discharge.
Review of the Clinical Physician Orders revealed a 01/14/22 PO for Cefuroxime Axetil (antibiotic) 500 MG Give 1 tablet by mouth two times a day for UTI for 7 Days.
Review of the January 2022 MAR revealed that Resident #2 received Cefuroxime Axetil 500 MG two times a day or 7 days, from 01/14/23-01/18/22.
4. Review of Resident #2's PN revealed a 1/19/22 NN that the resident had a temperature of 99.9°F and the resident had a new onset of altered mental status and mumbling. The physician and APN were notified and a new order was given to send the resident to the hospital.
Review of Resident #2's PN revealed a 1/19/22 NN that the emergency department Registered Nurse called and stated that Resident #2 was admitted to the hospital with diagnoses which included acute encephalopathy and cystitis (inflammation of the bladder usually caused by an infection).
Review of the Resident #2's CP failed to address the resident's recurrent UTIs or include interventions to treat or prevent it's recurrence.
During an interview with the surveyor on 09/20/23 at 12:55 PM, the Licensed Practical Nurse (LPN) #1 stated that a CP reflected cooperation between all the different disciplines on how to fully care for a resident. LPN #1 added that actual problems would be included on the CP. LPN #1 continued that a UTI could be added to a care plan and that it would the Unit Manager's responsibility to add it to the care plan.
During an interview with the surveyor on 09/20/23 at 1:53 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that new orders, new procedures, or new resident behaviors would be added to a resident's CP. The LPN/UM stated that a UTI would go on the CP. The LPN/UM continued that the purpose of putting this on the CP was so that everyone could be aware of the issue and put interventions in place to resolve it.
During an interview with the surveyor on 09/20/23 at 2:58 PM, the Director of Nursing (DON) stated that the purpose of a care plan was to provide communication between the nursing team regarding the customized needs of a resident. The DON stated that a resident's UTI would be placed on the CP.
The 11/28/17 facility policy, Baseline and Comprehensive Care Plans indicated under the Procedure section, that The comprehensive care plan must describe the following: A. The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being [ .]. All care plans will be reviewed quarterly by each discipline and interdisciplinary team members, unless needed sooner due to a significant change in condition.
NJAC 8:39-11.2(f).
Feb 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to accurately a.) assess a residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to accurately a.) assess a resident for pressure ulcers, and b.) properly code a resident for contractures in the Minimum Data Set (MDS)assessments. This deficient practice was identified in 2 of 27 residents reviewed for MDS, Residents #7 and #181, and was evidenced by the following:
a.) Review of the admission Record showed that Resident #7 was admitted to the facility on 11/2021. Medical diagnosis included, but were not limited to Parkinson's disease (neurological disease), kidney disease, hypertension (high blood pressure), heart failure, and depression.
Review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 11/21/22, indicated that Resident #7 had a Brief Interview of Mental Status of 7, meaning the resident had severe cognitive impairment.
Review of Section G, Functional Status showed the resident was a two-person assist for mobility, transfers, and toilet use, and was a one-person physical assist for eating and dressing.
On 02/08/22 at 11:15 AM, the surveyor reviewed Resident #7's current care plan which included a focus of Pressure Ulcer, indicating the resident had a sacral pressure ulcer.
On 02/08/23 at 12:00 PM, the surveyor reviewed Resident #7's Treatment Administration Record (TAR) for the months of August 2022 and November 2022.
For the month of August, there were multiple wound care orders to the resident's sacral area, the care was being provided and the nursing staff were signing the orders as completed, meaning the resident did have a wound in the month of August.
The surveyor then reviewed the TAR for the month of November and there were two wound care orders. 1.) cleanse open area to medial right back with normal saline solution, apply hydrogel and cover with a bordered gauze twice daily, and 2.) Cleanse sacral area with wound cleaner, apply Medi honey and over with border gauze twice daily. The nursing staff were signing the TAR as completed, indicating the resident had two pressure wounds that were receiving treatments.
On 02/09/23 at 10:16 AM, the surveyor reviewed the 8/22/22 quarterly MDS, under section M, skin conditions (M0210) it was documented as No unhealed pressure ulcers.
The surveyor then reviewed the 08/18/22 weekly skin evaluation, completed four days before the quarterly MDS was completed and it was documented that the resident had an 11 centimeter (cm) by 6 cm sacral pressure ulcer.
The surveyor then reviewed the Comprehensive MDS dated [DATE], section M, skin conditions, section M0210. It was documented No for unhealed pressure ulcers.
On 02/09/23 at 11:00 AM, the surveyor then reviewed the weekly skin evaluation completed 11/22/22, the same day the comprehensive MDS was completed. It was documented that the resident had two pressure ulcers. One medial back, full thickness skin loss (meaning open wound), and one sacral wound, full thickness skin loss.
On 02/16/23 at 11:23 AM, the surveyor interviewed the MDS coordinator regarding pressure ulcers. The MDS coordinator said she receives information about wounds from the unit manager or the nurse. The surveyor asked the MDS coordinator how the resident had a pressure ulcer on 7/27/22 and then did not have a pressure ulcer on 08/22/22 when the quarterly MDS was done and then the pressure ulcer was again documented as present on 11/04/22, and then the resident did not have a pressure ulcer on 11/21/22, the time the Comprehensive MDS was completed. The MDS Coordinator told the surveyor Sometimes the wounds heal or become moisture associated disorders.
NJAC 8:39-33.2 (d)
b. On 2/07/23 10:32 AM the surveyor observed Resident #181's left hand contracted with a gauze roll in place for positioning. A family member was present.
Review of the admission Record showed that Resident #181 was admitted to the facility with medical diagnosis that included but were not limited to Alzheimer's Disease and muscle weakness.
Review of the quarterly Minimum Data Sets (MDS), an assessment tool dated 7/13/22, 10/12/22, and 1/7/23, indicated that Resident #181 had long and short-term memory deficits. The section for Functional Limitation in Range of Motion was coded as 0 indicating there was no limitation in the range of motion of the upper extremity.
Review of the physician narrative notes dated 7/11/22, 9/15/22, and 1/6/23 reflected that Resident #181 had a left-hand contracture.
During an interview on 2/14/23 at11:58 AM the MDS Coordinator acknowledged that Resident #181 had a contracture of the left hand which should have been coded on the 7/13/22, 10/12/22, and 1/7/23 Quarterly MDSs.
NJAC 8.39-11.1
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice by a.) ensuring a physician order was in place to check fo...
Read full inspector narrative →
Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice by a.) ensuring a physician order was in place to check for proper feeding tube placement and residual stomach contents, and b.) accurately document feeding tube placement and residual stomach content for 1 of 25 residents (Resident #65) reviewed for professional standards of nursing practice.
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
The evidence was as follows:
On 2/7/23 at 10:08 AM, on initial tour of the facility, the surveyor observed Resident #65 in his/her room sitting in a wheelchair having just returned from therapy. The resident was unable to verbally communicate with the surveyor but was able to nod his/her head and use hand gestures to say hello. The surveyor observed that Resident #65 had a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the wall of the abdomen directly into the stomach, used for tube feeding) placed.
On 2/8/23 at 10:08 AM, the surveyor reviewed the medical record for Resident #65.
A review of the Face Sheet (an admission summary) reflected that the resident was originally admitted to the facility in December of 2022 with diagnosis which included but not limited to convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) following cerebral infarction (stroke), and hemiplegia and hemiparesis (a severe or complete loss of strength or a mild or partial weakness leading to paralysis) following cerebral infarction affecting the right dominant side.
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 12/8/2022, reflected a brief interview for mental status (BIMS) score of 99 which indicated the resident was unable to complete the interview. A further review reflected the resident was receiving 51% or more of their nutrition by PEG tube feeding.
A review of the resident's individualized resident-centered Care Plan initiated on 12/2/2022, included a focused care area for tube feeding related to dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), indicating the resident had a PEG tube placed on 11/28/22. This care area had a goal that the resident will remain free of side effects or complications related to tube feeding and will be free of aspiration (when something swallowed enters your airway or lungs). Upon initial review of the resident's care plan, there was no interventions to check PEG tube placement or check for stomach content prior to initiating feeding or instilling medication or fluid.
On 2/13/23, after surveyor inquiry, the facility provided a care plan which included intervention to check Peg tube proper placement, visual inspection of aspirated stomach content prior to instilling medication, initiating feeding when there is an interruption of feeding every shift.
A review of the resident's physician's orders (PO) included an active order started on 12/2/2022 for nothing by mouth (NPO) diet, an active order on 12/2/2022 for enteral feeding every four (4) hours: hydration flush: bolus with 200 milliliters (mL) water (H2O) for a total of 1200 mL per 24 hours, an active order for enteral feeding every shift to start at 10 PM pump feeding: administer Glucerna 1.2 per PEG tube via pump rate 98 mL per hour to provide 1500 mL total in 24 hours, and an active order dated 12/2/2022 to maintain head of bed elevated 90 degrees while feeding and for 1 hour after meals.
On 2/8/23 at 12:23 PM, the surveyor interviewed the Registered Nurse Supervisor (RNS) in the presence of the Licensed Practical Nurse Unit Manager (LPN/UM). The RNS stated nurses should be checking PEG tube placement and residual between feedings, before hanging new feedings, and at the end of each shift. The RNS stated this should be documented on the medication administration record (MAR) or treatment administration record (TAR) but would require a physician order to appear in the MAR or TAR to be signed off. The RNS and the LPN/UM looked through Resident #65's electronic medical record and were unable to locate any documentation from nursing indicating this was being done. The RNS confirmed there was no order in place for checking PEG tube placement or residual stomach content and stated, there should be an order for it.
On 2/15/23 at 12:09 PM, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, the surveyor interviewed the Director of Nursing (DON). The DON stated nurses look at the length of the tube and should aspirate stomach content to check for placement and residual prior to initiating feeding or administering medication or fluids to ensure the PEG tube is in place in the stomach and administered supplements or medication are not going to be administered into the abdominal cavity or cause aspiration. The DON further stated this is part of nursing and had to have an order to show up and be signed on the MAR or TAR, and that there should have been and order to check for placement and residual.
Review of the facility's Tube Feeding policy and procedure updated 11/10/2019 included under the section labeled procedure: .4. Verify that the tube is functioning before beginning a feeding and before administrating medications. Some methods include: patient interview - for alert patients able to report symptoms that indicate a feeding is not well tolerated such as bloating, nausea, abdominal pain. Checking gastric residual volume (GRV). Observing changes in length of tubing if the exit site was marked upon initial placement . 6. Documentation in the medical record includes physician order and implementation and volume of infusion over designated time periods.
NJAC 8:39- 27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory equipment was dated properly. This deficien...
Read full inspector narrative →
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory equipment was dated properly. This deficient practice was identified for 1 of 2 residents (Resident #1) reviewed for respiratory care and the evidence was as follows:
On 2/7/23 at 10:33 AM, the surveyor observed Resident #1 in his/her room. The resident was in bed and had on an oxygen nasal cannula (a device used to deliver supplemental oxygen) which was attached to an oxygen concentrator with a pre-filled humidifier bottle (a medical device that increases the humidity in oxygen while using supplemental oxygen). Neither the nasal cannula nor the bottle of humidifier solution were dated with the date they were changed.
On 2/14/23 at 11:21 AM, the surveyor observed Resident #1 in his/her room resting in a geriatric chair (a large, padded chair that was designed to help seniors with limited mobility). The resident was receiving oxygen therapy via nasal cannula and pre-filled humidifier bottle. Neither the nasal cannula nor the humidifier were dated. At this time, the surveyor found the Licensed Practical Nurse Unit Manager (LPN/UM) to confirm that these devices were not dated.
On 2/14/23 at 11:57 AM, the surveyor interviewed the LPN/UM who stated nasal cannulas were changed every one to two weeks by the 11 PM - 7 AM shift and must be dated. The LPN/UM further stated that properly dating this equipment is important especially with having agency staff which is all the time, to know when and if it was changed. At this time in the presence of the surveyor, the LPN/UM inspected Resident #1's nasal cannula and humidifier bottle and confirmed that they were not dated.
The surveyor reviewed the medical record for Resident #1:
A review of the Face Sheet (an admission summary) reflected that the resident was originally admitted to the facility in October of 2021 with diagnoses which included but were not limited to pneumonia, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm).
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 2/2/2023, reflected a brief interview for mental status (BIMS) score of 10 out of 15, which indicated moderately impaired cognition. A further review reflected the resident utilized oxygen therapy.
A review of the resident's individualized resident-centered Care Plan initiated on 2/7/2023, included a focused care area for shortness of breath (SOB) related to hypoxia (decreased amount of oxygen in the blood).
A review of the resident's physician's orders (PO) included an active order started on 2/7/2023 for oxygen at three (3) liters per minute (L/min) by nasal cannula continuous inhalation every shift for SOB.
Review of the facility's Oxygen Concentrators and Accessories policy and procedure with effective date 4/15/19 included under the section labeled procedure: 1. Nursing is responsible for changing tubing, cannulas, masks, humidification devices in accordance with the following: a. the following accessories should be changed and dated as needed but at least a minimum of weekly on Sundays by the night shift (or as needed); this includes cannula or masks, pre-filled humidifier bottles.
NJAC 8:39 - 25.2(c)4
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 45% turnover. Below New Jersey's 48% average. Good staff retention means consistent care.
Concerns
- • 8 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 73/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Bridgeway Care And Rehab Center At Bridgewater's CMS Rating?
CMS assigns BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within New Jersey, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Bridgeway Care And Rehab Center At Bridgewater Staffed?
CMS rates BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 45%, compared to the New Jersey average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Bridgeway Care And Rehab Center At Bridgewater?
State health inspectors documented 8 deficiencies at BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER during 2023 to 2025. These included: 1 that caused actual resident harm and 7 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Bridgeway Care And Rehab Center At Bridgewater?
BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 151 certified beds and approximately 142 residents (about 94% occupancy), it is a mid-sized facility located in BRIDGEWATER, New Jersey.
How Does Bridgeway Care And Rehab Center At Bridgewater Compare to Other New Jersey Nursing Homes?
Compared to the 100 nursing homes in New Jersey, BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER's overall rating (4 stars) is above the state average of 3.3, staff turnover (45%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Bridgeway Care And Rehab Center At Bridgewater?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Bridgeway Care And Rehab Center At Bridgewater Safe?
Based on CMS inspection data, BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in New Jersey. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Bridgeway Care And Rehab Center At Bridgewater Stick Around?
BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER has a staff turnover rate of 45%, which is about average for New Jersey nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Bridgeway Care And Rehab Center At Bridgewater Ever Fined?
BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER has been fined $7,901 across 1 penalty action. This is below the New Jersey average of $33,158. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Bridgeway Care And Rehab Center At Bridgewater on Any Federal Watch List?
BRIDGEWAY CARE AND REHAB CENTER AT BRIDGEWATER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.