MOUNTAINSIDE, NJ - Federal inspectors documented multiple medication safety failures at Manor Care Mountainside during a March 2025 inspection, including a concerning 10% medication error rate that placed vulnerable residents at risk of serious complications.
Critical Insulin Administration Failures
The most serious violations involved improper administration of insulin to diabetic residents. On February 26, 2025, inspectors observed a Licensed Practical Nurse (LPN) administer 2 units of Humalog insulin to a resident in a public hallway, violating both medication safety protocols and patient privacy rights.
The resident had a blood sugar reading of 158, prompting the insulin injection according to sliding scale orders. However, the nurse administered the medication despite the resident having an early morning medical appointment and no breakfast. Insulin administered without food can cause dangerous hypoglycemia (low blood sugar), a potentially life-threatening condition.
According to manufacturer guidelines, Humalog must be given within 15 minutes before a meal or immediately after eating. The medication's warning label specifically states that hypoglycemia "may be life-threatening" and requires careful blood glucose monitoring, particularly when meal patterns change.
When the resident returned from the appointment, they confirmed they had not received breakfast or a snack bag from the facility. "Prior to an appointment breakfast does not happen," the resident told inspectors. The resident's blood sugar had dropped to 101 by 11:30 AM, indicating the insulin had lowered glucose levels without nutritional support.
Systemic Medication Management Problems
The facility's medication error rate of 10% was double the federal threshold of 5%. During two days of observation, inspectors documented three medication errors out of 30 opportunities across four nurses and four residents.
Additional medication errors included: - Preparing double doses of Tylenol (two tablets instead of one) - Failing to check blood pressure before administering blood pressure medication with hold parameters - Administering duplicate phosphate binder medications to a dialysis patient
Medication errors in nursing homes can lead to hospitalizations, adverse drug reactions, and in severe cases, death. For elderly residents with multiple health conditions, even minor dosing mistakes can have cascading effects on their health.
Pharmacy Oversight Failures
The facility's consultant pharmacist failed to identify duplicate therapy involving two phosphate binders prescribed to a dialysis patient. Both Sevelamer and Velphoro serve the same function - controlling phosphorus levels in patients with kidney disease.
During interviews, the pharmacist admitted to not reviewing admission medication records and stated he "did not think to question the prescriber" about the duplicate medications. Federal regulations require pharmacists to conduct thorough medication regimen reviews to identify and report irregularities, including duplicative therapies.
Duplicate medications can increase the risk of side effects and drug interactions, particularly problematic for dialysis patients whose kidney function cannot filter excess substances from their blood.
Privacy and Infection Control Violations
Beyond medication errors, inspectors observed significant lapses in basic care standards. The insulin administration in a public hallway violated patient privacy rights and professional nursing standards. Proper medication administration requires a private setting to protect patient dignity and confidentiality.
Multiple staff members violated infection control protocols during meal service. Inspectors observed: - Certified nursing assistants applying hand sanitizer to residents without cleaning their own hands between patients - Kitchen staff serving multiple meal trays without hand hygiene - Licensed nurses assisting residents with hand washing while failing to sanitize their own hands
Proper hand hygiene prevents the spread of infectious diseases, particularly important in nursing home settings where residents often have compromised immune systems.
Meal Service Deficiencies
The facility failed to provide required evening snacks despite meal gaps exceeding 14 hours. Five residents reported being unaware that evening snacks were available, with dinner served at 5 PM and breakfast not arriving until 9 AM the following day.
Federal regulations require facilities to offer nourishing snacks when more than 14 hours pass between meals. Extended fasting periods can be particularly problematic for diabetic residents who need consistent nutrition to maintain stable blood sugar levels.
Regulatory Standards and Required Improvements
Federal nursing home regulations mandate specific protocols for medication administration, including: - Verifying the right patient, medication, dose, route, and time - Following manufacturer guidelines for timing and food requirements - Maintaining patient privacy during all medical procedures - Conducting comprehensive medication reviews to prevent errors
The facility's policy manual correctly outlined these requirements but staff implementation fell short of standards, indicating a gap between written procedures and actual practice.
Manor Care Mountainside must implement immediate corrective measures including enhanced staff training on medication safety, strengthened pharmacy oversight, and improved infection control practices. The facility's plan of correction will be subject to follow-up inspections to ensure compliance with federal care standards.
The violations highlight systemic issues that extend beyond individual staff errors to encompass training, supervision, and quality assurance processes essential for resident safety and well-being.
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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