Mountainside Skilled Nursing: Abuse Report Delayed 3 Days - NJ
The resident at the center of the complaint had a BIMS cognitive score of 3 out of 15, which placed her in the range of severe impairment. She had suffered a stroke and also carried diagnoses of metabolic encephalopathy, hypotension, muscle weakness, and type 2 diabetes. She needed staff help to complete her daily activities. She was, by any clinical measure, among the most vulnerable people in the building.
The first call came on August 4. A family member, identified in the inspection report only as RR #1, phoned during the facility's morning meeting and asked the social worker to run upstairs and check on the resident. Something had sounded wrong during a phone call. The social worker went up, found the resident in her wheelchair eating lunch, and called RR #1 back from the room. The resident said she was okay. She couldn't remember the social worker's name, but she was eating and appeared calm.
RR #1 mentioned something during that call: a concern about CNA #1 splashing liquid on the resident. The social worker asked whether RR #1 might be referring to washing or bathing. By the end of the conversation, the social worker later told inspectors, RR #1 seemed satisfied with that explanation. The social worker did not report the conversation to any nursing staff that day.
Nobody did anything with it.
The next morning, August 5, RR #1 called again. The family member said they had slept on it and decided it was more than splashing. CNA #1, they said, had bent the resident's hand back. Pulled her hair. Hit her with a chair.
The social worker reported the allegations to the charge nurse and the Director of Nursing. The DON and the administrator, referred to in the report as the LNHA, said they launched an investigation that same day. A nurse did a body assessment on the resident. Staff were interviewed. Witness statements were gathered. The facility held what they described as a customer service in-service. CNA #1 was removed from the resident's care assignment, and the facility arranged for two-person assistance for the resident going forward.
CNA #1 kept working. With other residents.
When inspectors asked the LNHA and DON why they hadn't suspended CNA #1 from all resident care on August 5, the explanation they gave was this: at the end of that day, when they spoke with RR #1, the family member was agreeable with the results of their report. That was enough, in their assessment, to keep the aide on the floor.
The LNHA put it more plainly in a separate interview. On August 5, she told the surveyor, RR #1 was agreeable with the facility's explanation of events. There were no signs of abuse. And the resident was confused and inconsistent with her stories. "So we did not consider it as abuse."
A woman with a BIMS score of 3, who had suffered a stroke and whose brain function was clinically documented as severely impaired, gave an inconsistent account of what had happened to her. The facility used that inconsistency as a reason not to act.
Three days passed.
On August 8, RR #1 sent an email. The family member escalated their concerns in writing. That same day, the facility suspended CNA #1, called police, and phoned the New Jersey Department of Health to report the incident. The formal written report, an AAS-45 form, was submitted to the state three days after that, on August 11.
The LNHA acknowledged to inspectors that she knew incidents involving abuse and neglect have to be reported immediately to NJDOH. She knew this. The facility's own written policy, which the LNHA had initialed with a handwritten date of August 7, one day after the allegations were first reported up the chain of command, stated that all reports of abuse are thoroughly investigated by facility management and that suspicion of abuse must be reported immediately to the administrator and to other officials according to state law.
The LNHA signed that policy on August 7. The state was not notified until August 8, when a family email forced the issue.
What happened between August 4 and August 8 follows a pattern that inspectors and advocates have documented at nursing homes across the country: a family raises an alarm, the facility offers a reassuring explanation, the family momentarily accepts it, and the facility treats that acceptance as permission to stand down. The clock on mandatory reporting stops running. The accused employee keeps working. The investigation proceeds at whatever pace management finds convenient.
Here, the pace was set by RR #1's inbox.
The social worker's decision on August 4 not to report the liquid-splashing concern to nursing staff matters too, even if that first conversation was ambiguous. By the time RR #1 called back on August 5 with specific allegations of physical abuse, a full day had already elapsed since the initial contact. The social worker told inspectors they waited because RR #1 had seemed satisfied. Satisfied with what turned out, by the family's own account the next morning, to be an incomplete picture.
The resident herself, eating lunch in her wheelchair when the social worker came to check on her, said she was okay. She couldn't remember the social worker's name. She had a BIMS score of 3. What she could or could not communicate about what had happened to her body the previous day was never going to be a reliable basis for closing an inquiry.
The inspection was triggered by a complaint and conducted on August 19 and 21, 2025. Inspectors cited the facility for failing to ensure that an alleged perpetrator was removed from contact with residents during the investigation, and for failing to report the allegation to the state immediately upon suspicion of abuse. CMS classified the violation as causing minimal harm or potential for actual harm, affecting a small number of residents.
CNA #1's name does not appear in the inspection report. Whether the police investigation resulted in any action is not addressed in the document. Whether the resident, whose cognition was so impaired she could not recall the name of a staff member she apparently knew, was ever able to give a full account of what happened to her is not recorded.
RR #1 had to send an email to get the aide suspended.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountainside Skilled Nursing and Rehab from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 11, 2026 · Our methodology
MOUNTAINSIDE SKILLED NURSING AND REHAB in MOUNTAINSIDE, NJ was cited for abuse-related violations during a health inspection on August 21, 2025.
The resident at the center of the complaint had a BIMS cognitive score of 3 out of 15, which placed her in the range of severe impairment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.