That scene on February 26 was one of four instances federal inspectors documented during an early morning incontinence tour at Mountainside Skilled Nursing and Rehab, where residents were found sitting in saturated diapers for hours due to chronic understaffing that violated New Jersey state law.
The facility failed to meet minimum staffing requirements on 8 of 14 day shifts in the two weeks before inspection, leaving certified nursing assistants responsible for up to 19 residents each during overnight shifts when the state requires no more than 14.
At 8 a.m. that February morning, inspectors accompanied CNA #1 to check on Resident 103 in bed. When the aide exposed the resident's incontinence brief, inspectors observed it was saturated with urine. The CNA confirmed the brief was soaked.
Fifteen minutes later, CNA #2 showed inspectors Resident 113's condition. The brief was saturated with urine. But when the aide exposed it, inspectors discovered another incontinence brief underneath, also saturated with urine. The CNA acknowledged both briefs were soaked and confirmed facility policy prohibited residents from wearing two briefs at once.
The worst case involved Resident 76, who told inspectors staff provided incontinence care only once per shift. The resident explained that because transfers required a mechanical lift, staff said it was too difficult to provide proper care before the next shift arrived, forcing the resident to remain in soiled briefs for hours.
At 8:30 a.m., CNA #3 exposed Resident 105's brief, which was saturated with urine. The aide acknowledged the brief was soaked and confirmed all residents should receive incontinence care every two hours and should never be left saturated.
The overnight shift on February 25-26 was particularly understaffed. Unit 1 had 47 residents with three assigned aides, giving one CNA responsibility for 17 residents. Unit 2 had 58 residents with three aides, leaving one CNA with 19 residents. Two CNAs had called out sick that night.
The Staffing Coordinator confirmed during a March 4 interview that she was aware of the state requirement limiting night shift CNAs to 14 residents each, but acknowledged the facility regularly exceeded that ratio.
New Jersey law requires nursing homes to maintain specific minimum staffing ratios: one certified nursing aide for every eight residents during day shifts, and one direct care staff member for every 14 residents during night shifts. The law took effect February 1, 2021.
State records show Mountainside violated these requirements repeatedly. During the two weeks before the March inspection, the facility was short-staffed on more than half of all day shifts. On February 20 and 21, only 16 CNAs worked day shifts serving 142 and 141 residents respectively, when state law required at least 18.
The pattern extended back months. During a two-week period in October 2024, the facility failed to meet minimum CNA requirements on two day shifts, with only 16 aides serving 133 residents when 17 were required.
Director of Nursing confirmed during a February 27 interview that incontinence rounds should occur every two to three hours during night shifts and that residents should never have two briefs in place. The DON acknowledged the state-mandated ratio of one CNA to 14 residents for overnight shifts.
When surveyors attempted to interview the overnight CNAs responsible for the residents found in saturated briefs, the aides did not return calls.
The facility's own policy, revised in July 2024, states that residents unable to carry out activities of daily living independently will receive necessary services to maintain good nutrition, grooming, and personal hygiene.
On February 27, the survey team discussed their findings with the Director of Nursing and Licensed Nursing Home Administrator. The violations resulted in a citation for minimal harm with potential for actual harm affecting some residents.
The inspection was conducted as part of a complaint investigation, suggesting someone reported concerns about conditions at the 145-bed facility on US Highway 22.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountainside Skilled Nursing and Rehab from 2025-03-04 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Mountainside Skilled Nursing and Rehab
- Browse all NJ nursing home inspections