MOUNTAINSIDE, NJ - Federal inspectors documented serious medication safety failures and inadequate staffing levels at Manor Care Mountainside during a March 2025 inspection, finding expired medications in active inventory and residents experiencing prolonged periods without proper incontinence care.
Expired Medications Put Residents at Risk
Inspectors discovered multiple instances of expired medications being stored with active inventory, including a tuberculosis diagnostic medication that had been expired for 24 days and an injectable anxiety medication expired for six months.
The most concerning finding involved Lorazepam Injectable, a controlled substance used to treat anxiety symptoms and prevent seizures. The medication had been expired for six months, yet remained in the facility's active inventory with a completely blank accountability log. Staff could not account for who administered the medication, when it was given, or to which residents.
Medical Significance of Expired Medications
When medications expire, their chemical composition can change, potentially reducing effectiveness or creating harmful byproducts. For tuberculosis diagnostic tests, expired medication can produce false results, compromising infection control measures. Expired injectable medications pose additional risks, as degraded compounds can cause adverse reactions or fail to provide intended therapeutic effects.
The facility also stored an intravenous sodium chloride bag without proper tamper-proof packaging, violating contamination prevention protocols essential for patient safety.
Controlled Substance Management Failures
Inspectors identified systematic failures in controlled substance tracking across multiple medication carts. Staff discovered discrepancies between actual medication counts and official records for five different residents receiving controlled substances including Tramadol, Methylphenidate, Lorazepam, and Oxycodone.
Licensed practical nurses acknowledged administering medications without immediately documenting the removal on required accountability logs, creating gaps in the chain of custody for controlled substances. These record-keeping failures make it impossible to track medication usage accurately or identify potential diversion.
Staffing Shortages Affect Direct Care
The facility violated New Jersey state staffing requirements on multiple occasions, falling short of the mandated one certified nursing assistant per eight residents during day shifts. During a two-week period in February 2025, the facility was understaffed for eight of 14 day shifts.
On February 20th and 21st, the facility operated with only 16 CNAs for 142 and 141 residents respectively, requiring at least 18 CNAs to meet state requirements. These shortages directly impacted resident care quality and staff workload distribution.
Inadequate Incontinence Care
During early morning inspections, surveyors documented residents left in saturated incontinence briefs for extended periods. Multiple residents were found with urine-saturated briefs during 8 AM rounds, indicating they had not received proper toileting assistance during overnight hours.
One resident was discovered wearing two incontinence briefs, both saturated with urine - a practice the facility's own staff acknowledged violated policy. Another resident reported receiving incontinence care only once per shift and being told by staff that mechanical lift requirements made it "too difficult" to provide more frequent care.
Health Consequences of Delayed Incontinence Care
Prolonged exposure to urine and feces can cause skin breakdown, urinary tract infections, and pressure ulcers. Elderly residents with limited mobility face heightened risks of developing serious skin conditions when left in saturated briefs. Proper incontinence care requires checks every 2-3 hours to prevent these complications.
Nursing Unit Understaffing Patterns
Inspection records revealed that overnight shifts operated with CNAs responsible for up to 19 residents each, significantly exceeding the facility's stated 1:14 ratio. Unit 2 on the second floor, with 58 residents and only three assigned aides, created assignments well above manageable levels for quality care delivery.
The staffing coordinator acknowledged two CNA call-outs during the inspection period but confirmed that replacement staff were not secured, leaving remaining CNAs with excessive patient loads.
Industry Standards and Required Practices
New Jersey nursing home regulations require facilities to maintain specific CNA-to-resident ratios: one CNA per eight residents during day shifts, one direct care staff per 10 residents during evening shifts, and one direct care staff per 14 residents during night shifts.
Medication management standards require facilities to remove expired drugs from active inventory, maintain detailed controlled substance records, and store intravenous medications in tamper-proof packaging. These requirements protect residents from medication errors and ensure proper oversight of controlled substances.
Facility Response and Corrective Actions
During meetings with the survey team, facility administrators acknowledged the violations and stated they would implement corrective measures. The Director of Nursing confirmed that expired medications should be removed from inventory and presented evidence of in-service training for proper intravenous packaging and narcotic documentation procedures.
However, the facility could not provide explanations for how the six-month-old expired Lorazepam remained undetected despite daily shift-to-shift counts between nurses, raising questions about the effectiveness of existing oversight systems.
Regulatory Context
These violations occurred during a routine federal inspection conducted by the Centers for Medicare & Medicaid Services. The facility received citations under multiple federal regulations governing pharmaceutical services, staffing requirements, and resident care standards.
Manor Care Mountainside must submit a plan of correction addressing each cited violation and demonstrate sustained compliance with federal and state regulations to maintain its certification for Medicare and Medicaid participation.
The inspection findings highlight ongoing challenges in nursing home operations, where adequate staffing levels and medication safety protocols are essential for resident wellbeing and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manor Care Mountainside from 2025-03-04 including all violations, facility responses, and corrective action plans.
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