Mountainside Skilled Nursing and Rehab

Inspectors wroteCOMPLAINT #: 2723201, 2790272 , 2977831 Based on observations, interviews, record reviews, and review of pertinent facility documents it was determined that the facility failed to a.) obtain, record, and monitor weights monthly per their protocol, b.) implement weekly weights timely after a significant weight loss, and c.) reliably document meal intake for a resident with a known history of adult failure to thrive (syndrome characterized by unintentional weight loss, decreased appetite, poor nutrition, and increasing inactivity) who required intravenous (IV) fluids for dehydration (Resident #4). This deficient practice was identified for 1 of 3 residents (Resident #4) reviewed for nutrition and hydration. [...]

Inspectors wroteComplaint # 2587610 Based on interviews and review of pertinent facility documents on 08/19/25, it was determined that the facility failed to implement their abuse prevention policy to protect a cognitively impaired resident (Resident #1) from physical abuse when Resident #1's Representative (RR #1) reported to the facility's Social Worker (SW) an allegation of abuse. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1). The deficient practice was evidenced as follows: A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy initialed by the LNHA with a handwritten date of 8/7/2025, included Policy Statement: All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are [.] thoroughly investigated by facility management. [...]

Inspectors wroteComplaint # 2587610 Based on interviews and review of pertinent facility documents on 08/19/25, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of physical abuse that occurred on 8/4/25. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1), and was evidenced by the following: A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 8/11/25, included the date and time of event: 8/4/25 at 10:00 AM. The FRE further included under Narrative that on 8/4/25, [RR #1] reported concern to facility's SW that [RR #1] was on the phone with [the] resident while care being rendered by [CNA #1]. [RR #1] stated resident was yelling through the phone. [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner in multiple areas on 2 of 2 floors located throughout the facility. The deficient practice was evidenced by the following: 1. On 2/25/25 at 1:55 PM, in Resident # 236's room located on the 1st floor in room [ROOM NUMBER], the surveyor observed five different areas of peeling and scratched wall paper on the wall, across from the resident's bed, which was exposing the sheet rock underneath. The surveyor also observed an 8 inch area of torn wall paper and a white colored spackle on the wall around it. The surveyor observed that the top drawer on the dresser located near the resident's bed, was observed to be broken and unable to be pushed back into the dresser. [...]

Inspectors wroteComplaint # NJ 00162506, NJ 177359, NJ 183441 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 6 residents (Resident #,76 #103, #105, and #113) observed for incontinence care on 1 of 2 units (2nd-floor Nursing Unit). This deficient practice was evidenced by the following: On 2/26/25 at 7:50 AM, the surveyor completed an incontinence tour on the 2nd floor Nursing Unit and observed the following: 1. On 2/26/25 at 8:00 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1) observed Resident #103 in bed. CNA #1 exposed Resident #103's incontinence brief, and the surveyor observed that it was saturated with urine. CNA #1 confirmed that the brief was saturated with urine. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to assess residents' vital signs and dialysis access site for complications upon return from the renal dialysis (RD) center. This deficient practice was identified for 2 of 2 residents (Resident #3 and #13) reviewed for dialysis and was evidenced by the following: 1. On 2/25/25 at 11:31 AM, during the initial tour of the facility the surveyor observed Resident #13 lying in bed. The head of the bed was elevated. The resident stated that the breakfast and care were satisfactory. The surveyor reviewed the medical record of Resident #13. According to the admission Record face sheet, an admission summary, reflected that Resident #13 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. [...]

Inspectors wroteComplaint # NJ 00162506, NJ 177359, NJ 183441 Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, and b.) failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 4 of 6 residents (Resident #76 #103, #105, and #113) on 2 of 3 units (2nd-floor Nursing Unit 1 and Unit 2). This deficient practice was evidenced by the following: Refer to F677 Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a.) expired biologicals were removed from active inventory, b.) consistently implement a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications, and c.) an intravenous bag was stored in a tamper proof and contaminant resistant packaging, The deficient practices were identified for two (2) of two (2) medication rooms and two (2) of three (3) medication carts inspected during the medication storage and labeling observation and was evidenced by the following. Reference: [...]

Inspectors wroteRefer 658 Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 2/26/25 and 2/27/25, the surveyor observed four (4) nurses administer medications to four (4) residents. There were 30 opportunities, and three errors were observed which resulted in a medication error rate of 10%. This deficient practice was identified for two (2) of four (4) residents (Resident #80 and #115), that was administered by two (2) of four (4) nurses. This deficient practice was evidenced by the following: Reference: A review of the manufacturer's specifications for Humalog under Dosage and Administration: [...]

Inspectors wroteBased on observaton and interview it was determined that the facility failed to interact with residents in a dignified and respectful manner. The deficient practice was noted for 1 resident (Resident #45) during an individual interview, for 5 of 5 residents (#34, 84, 67, 108, 24) in attendance at the resident group meeting, and in 1 of 2 nursing unit dining rooms during lunch meal observations.

Inspectors wroteBased on observation and interview it was determined that the facility failed to provide residents access to the NJ Department of Health (NJDOH) survey results. This deficient practice was identified for 5 of 5 residents in attendance at the resident group meeting (Resident #34, 84, 67, 108, 24) and was evidenced by the following: On 2/25/25 at 9:00 AM, the surveyor observed a binder in the lobby area containing past NJDOH survey results. On 2/27/25 at 10:30 AM, the surveyor conducted the resident group meeting. All 5 of the 5 residents stated they were unaware of how they could access the NJDOH survey reports. The residents stated they do not go into the lobby. They stated they have not seen the survey reports on their nursing units. [...]

Inspectors wroteComplaint #NJ181450 Based on interview and record review it was determined that the facility failed to a.) respond to residents' requests for assistance in a timely manner for 5 of 5 residents in attendance at the resident group meeting (Resident #24, 34, 67, 84, and 108) and b.) ensure the call bell (bell used to summon staff for assistance) was placed within a resident's reach for 1 of 30 Residents (Resident # 74). This deficient practice was evidenced by the following: 1. The surveyor conducted the resident group meeting on 2/27/25 at 10:30 AM. All 5 of 5 residents stated that the call bell response was slow on the 11 PM -7 AM shift. One resident stated one time they had waited from 1:00 AM to 3:00 AM. The resident stated they needed drinking water and I have bilateral contractures and can't do it myself. [...]

Inspectors wroteComplaint #: NJ162370; NJ1162293 Based on interview and record review, it was determined that the facility neglected to provide a resident who required extensive assistance of two or more caregivers for personal care the required amount of assistance who complained of rough care while being repositioned by one caregiver. The deficient practice was identified for 1 of 6 residents reviewed for those requiring assistance with activities of daily living (ADL) (Resident #333), and was evidenced by the following: The surveyor reviewed the closed electronic medical record of Resident #333 which revealed the following information: A review of the Minimum Data Set (MDS), an assessment tool dated 2/25/23, indicated the resident had mild cognitive impairment and required extensive assistance of two or more caregivers with bed mobility and incontinence care. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 3 of 30 residents reviewed (Resident #59, #131, and #132) and was evidenced by the following: 1. The surveyor reviewed Resident # 132's records. The resident was discharged from the facility, and according to the Discharge Return Not Anticipated MDS, dated [DATE], the resident was discharged to the hospital. A review of Resident #132's progress notes dated 12/20/24, revealed the resident was discharged home. On 2/27/25 at 1:06 PM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDS), who stated that the discharge MDS for Resident #132 should have indicated that the resident was discharged to their home. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately develop and implement a person-centered comprehensive care plan for care and service needs. This deficient practice was observed for 1 of 30 residents reviewed, Resident # 236, was evidenced by the following: On 2/25/25 at 1:55 PM, the surveyor observed Resident # 236, in bed in their room and the resident was receiving oxygen therapy via nasal cannula (NC). The surveyor reviewed Resident #236's Electronic Medical Record. Resident #236's face sheet revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic respiratory failure and pulmonary fibrosis. A review of the Physician's Order Sheet dated February 2025, revealed the resident had a physician's order for O2 via NC continuous at 3 LPM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a.) proper administration of Fluticasone nasal spray in accordance with manufacturer's specifications, and b.) administration and availability of prescribed medication(s) in accordance with professional standards of practice. The deficient practice was identified for 1 of 4 nurses who administered medications to 1 of 4 residents (Resident #127) and 1 of 27 Residents reviewed for Medication Record Review. The evidence was as follows: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The nurse practice act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain medical equipment in good working condition to prevent injuries for 1 of 24 residents reviewed (Resident #108). This deficient practice was evidenced by the following: The surveyor interviewed Resident #108 on 2/25/25 at 1:13 PM. The resident stated several months ago they reported to staff that the raised toilet seat had rusted screws which affixed the seat to the metal frame. The raised toilet seat was replaced with another which had similiar rusted screws and also a crack in the seat. The resident stated they would put a paper towel over the crack and lean to the side in order not to get pinched. At that time, the surveyor observed the raised toilet seat which was in place in the resident's bathroom. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) administer oxygen therapy according to the physician's order for 2 of 2 residents reviewed for oxygen therapy (Resident #66 and #236) and b.) ensure respiratory nasal cannula (NC) tubing was stored in accordance with infection control measures for 1 of 1 resident (Resident #52). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteRefer F658 Based on observation, interview, and record review, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) identified and reported a medication irregularity, to the attending physician, the facility's medical director, and the director of nursing (DON). This deficient practice was identified for 1 of 5 residents (Resident #13) reviewed for unnecessary medications and was evidenced by the following: On 2/25/25 at 11:31 AM, during the initial tour of the facility the surveyor observed Resident #13 lying in bed. The head of the bed was elevated. The resident stated that the breakfast and care were satisfactory. The surveyor reviewed the medical record of Resident #13. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to provide a nourishing snack at bedtime when the time between dinner and breakfast exceeded 14 hours. The deficient practice was identified for 5 of 5 residents (Resident #34, 84, 67, 108, 24) in attendance at the resident group meeting and was evidenced by the following: The surveyor conducted the resident group meeting on 2/27/25 at 10:30 PM. All 5 of 5 residents stated they were not aware that evening snacks were available for residents. All of the residents resided on the second floor nursing units. All of the residents stated they would like to have an evening snack available to them. Resident #34 stated they eat dinner at 5 pm and eat breakfast at 9 AM. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated during dining observation. This deficient practice was observed in 1 of 2 dining rooms and was evidenced by the following: According to the CDC Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, last reviewed on January 30, 2020, included that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: [...]

Inspectors wroteCOMPLAINT: # NJ00179522 Based on interviews, record review, and review of pertinent facility documents on 11/14/2024, it was determined that the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #1 and Resident #2) reviewed for medication administration, follow the facility's Licensed Practical Nurse (LPN) job description, and follow the facility policy titled Administering Medications. This deficient practice is evidenced by the following: 1. According to the admission Record (AR) Resident #1 was admitted to the facility with diagnoses that included but were not limited to encephalopathy, unspecified (a syndrome of overall brain dysfunction); hepatitis A without hepatic coma (an infectious disease of the liver); type 2 diabetes mellitus with hyperglycemia; legal blindness; and chronic pain syndrome. [...]

Inspectors wroteComplaint #: NJ172131, NJ175519 Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to obtain a physician's order for the care of an indwelling Foley catheter (a catheter that is inserted through the urethra to allow for bladder drainage), for Resident #2. This deficient practice was identified for 1 of 4 residents (Resident #2) reviewed for the use of an indwelling Foley catheters and was evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, record reviews, document review, and facility policy review, it was determined that the facility failed to follow the planned, written menu and ensure residents were notified in advance of menu changes for 1 of 1 meal observed. The facility identified 86 residents who received meals from the kitchen (total census 118). Review of a facility policy titled, Menu Overview and Changes, dated 11/2020, revealed the suggested steps to follow when changing the menu included, 4. The registered/licensed dietician approves the changes and signs the diet spreadsheet where changes were made. The food service director makes the approved changes on the following menu components: week at a glance, diet spreadsheet, posting menus, and selective menus. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to cover a urinary drainage bag to provide privacy and dignity for 1 (Resident #108) of 1 resident who had an indwelling urinary catheter.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to obtain an order and assess a resident's ability to self-administer medications for 1 (Resident #13) of 1 sampled resident observed with prescription medications at the bedside.

Inspectors wroteBased on observations, interviews, record review, document review, and facility policy review, it was determined that the facility failed to ensure reasonable accommodations were provided to meet resident needs and functional ability for 2 (Resident #36 and Resident #108) of 2 residents reviewed for accommodations of needs. Specifically, the facility failed to: 1. Ensure Resident #108 was provided with a modified call light that the resident was able to use. 2. Ensure Resident #36's call light was placed within the resident's reach.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' status to facilitate appropriate care planning for 2 (Resident #71 and Resident #85) of 24 sampled residents reviewed for MDS accuracy.

Inspectors wroteBased on interviews, record reviews, and facility policy review, it was determined the facility failed to ensure residents with a new mental illness diagnosis were referred to the state-designated authority for a level two pre-admission screening and resident review (PASRR) for 2 (Resident #74 and Resident #71) of 3 sampled residents reviewed for PASRR.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide treatment and services to prevent potential complications related to the use of an indwelling urinary catheter for 1 (Resident #108) of 1 sampled resident reviewed for urinary catheter care. Specifically, the facility failed to secure Resident #108's catheter to prevent excessive tension on the catheter which could cause dislodgement of the catheter or injury to the bladder/urethra; failed to ensure the catheter's drainage bag was maintained below the level of the bladder to facilitate bladder emptying; and failed to avoid application of creams/ointments to the catheter tubing to prevent potential urinary tract infection.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to: 1. Ensure staff donned proper personal protective equipment (PPE) when entering a room where a resident was on contact isolation for 1 (Resident #12) of 2 residents observed on isolation precautions. 2. Ensure staff properly cleaned a glucometer following manufacturer's instructions during 1 of 1 fingerstick blood sugar observation.

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/6/20 at 9:19 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. The surveyor observed a four-pound jar of grape jelly opened and more than half empty stored on a shelf next to a tub of peanut butter in the sandwich prep area. The jelly had an expiration date of 3/11/22 and an open date of 11/30/20. When interviewed at the time, the FSD said jelly should be stored in the refrigerator when not in use, however, a Food Service Worker (FSW) was, Just using it. The surveyor felt the jar which felt room temperature. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to consistently maintain communication with the dialysis center and coordinate medication administration according to the dialysis schedule. This deficient practice was observed for 1 of 3 residents (Resident #84) reviewed for dialysis services. The deficient practice was evidenced by the following: On 12/17/20 at 12:47 PM, the surveyor observed the resident in bed awake with oxygen in place. The resident informed the surveyor that they go to dialysis Tuesday, Thursday and Saturday. The resident gets picked up approximately 2:30 PM and returns at approximately 7 PM. The surveyor reviewed Resident #84's medical records which revealed the following: According to the admission record, Resident #84 was admitted [DATE] with diagnoses that included End Stage Renal Disease. [...]