Cycle 1
Health 2024-08-19 · Fire 2024-08-19
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hillsborough, NJ
Bridgeway Care And Rehab Center At Hillsborough
2-star overall rating with 2-star inspections with $17,192 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
395 Amwell Road, Hillsborough, NJ
(908) 281-4400
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
121
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-05-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,350
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.58% · Performance 22.16% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.25
Baseline 5.22% · Performance 7.46% · Measure score 1.25 · Achievement 1.25 · Improvement 0
Total nurse turnover
5.31
Baseline 39.64% · Performance 41.98% · Measure score 5.31 · Achievement 5.31 · Improvement 0
Adjusted total nurse staffing
3
Baseline 4.03 hours · Performance 3.93 hours · Measure score 3 · Achievement 3 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 372 · Observed rate 9.14% · Lower 95% interval 7.59% |
| Discharge to community | 59.26% |
50.57%
8.7 pts better
|
Better than the National Rate · Eligible stays 389 · Observed rate 53.73% · Lower 95% interval 53.63% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 283 · Denominator 283 |
| Falls with major injury | 0.35% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 283 |
| Discharge self-care score | 46.54% |
53.69%
7.1 pts worse
|
Numerator 101 · Denominator 217 |
| Discharge mobility score | 46.08% |
50.94%
4.9 pts worse
|
Numerator 100 · Denominator 217 |
| Pressure ulcers or injuries, new or worsened | 3.89% |
2.29%
1.6 pts worse
|
Numerator 11 · Denominator 283 · Adjusted rate 3.87% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 247 · Observed rate 7.29% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 209 |
| Staff flu vaccination coverage | 98.78% |
42%
56.8 pts better
|
Numerator 243 · Denominator 246 |
| Discharge function score | 40.55% |
56.45%
15.9 pts worse
|
Numerator 88 · Denominator 217 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 64 · Denominator 64 |
| Transfer of health information to patient | 99.43% |
96.28%
3.2 pts better
|
Numerator 173 · Denominator 174 |
| Resident COVID-19 vaccinations up to date | 17.61% |
25.2%
7.6 pts worse
|
Numerator 28 · Denominator 159 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.1
1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.8% |
93.0%
9.2 pts worse
|
93.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 87.6% · Q3 80.9% · Q4 76.8% · 4Q avg 83.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
97.2%
0.2 pts worse
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.9% |
2.4%
6.5 pts worse
|
3.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.0% · Q3 8.5% · Q4 8.4% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
11.4%
8.3 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 7.4% · Q3 1.2% · Q4 2.4% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
4.6%
3 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 2.6% · Q4 1.3% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.8% |
19.0%
5.8 pts worse
|
19.6%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 24.1% · Q3 27.8% · Q4 26.6% · 4Q avg 24.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
13.5%
5.6 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 18.2% · Q3 20.3% · Q4 17.7% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.2% |
9.8%
4.4 pts worse
|
16.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.4% · Q3 10.9% · Q4 25.6% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
9.7%
4.3 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.0% · Q3 4.2% · Q4 8.2% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.7%
1.1 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.3% · Q3 2.2% · Q4 0.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.8% |
15.9%
4.1 pts better
|
19.8%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 11.0% · Q3 13.5% · Q4 16.6% · 4Q avg 11.8% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.0%
0.5 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.5% · Q3 5.3% · Q4 3.6% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.5% |
78.7%
6.2 pts worse
|
81.7%
9.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.5% · Q2 74.8% · Q3 68.0% · Q4 69.2% · 4Q avg 72.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
8.2%
0.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 2.0% · Q4 2.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.3% |
80.1%
10.8 pts worse
|
79.7%
10.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
25.4%
1.5 pts better
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 23.2% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-07 · Fire 2022-11-07
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2020-03-09 · Fire 2020-03-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-08-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-20
F · Potential for more than minimal harm
2022-11-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-11-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-11-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-23
F · Potential for more than minimal harm
2022-11-07
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-11-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
G · Actual harm
2025-11-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-30
G · Actual harm
2025-11-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-11-30
E · Potential for more than minimal harm
2024-08-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-08-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-08-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-08-19
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-19
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-08-30
D · Potential for more than minimal harm
2023-07-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-17
E · Potential for more than minimal harm
2022-11-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-11-07
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-11-07
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-11-07
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-11-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-23
D · Potential for more than minimal harm
2020-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-20
Penalties and ownership
What sits behind the stars
$17,192
2025-11-05
Fine
Fine · fine $17,192
Fine
Ownership
Pelligrino, Donald
5% Or Greater Direct Ownership Interest · Individual
Manego, Rossana
Operational/Managerial Control · Individual
Pelligrino, Donald
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Foothill Acres Rehabilitation & Nursing Center
Hillsborough, NJ
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Bridgeway Care And Rehab Center At Bridgewater
Bridgewater, NJ
2-star overall rating with 2-star inspections with abuse icon flag with $7,901 in total fines with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Waterfront Rehabilitation And Healthcare Center
Raritan, NJ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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