Manor Care Mountainside

F-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: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21.

1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq. ) shall maintain the following minimum direct care staff -to-resident ratios:

(1) one certified nurse aide to every eight residents for the day shift.

(2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties, and

(3) one direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties

b. Upon any expansion of resident census by the nursing home, the nursing home shall be exempt from any increase in direct care staffing ratios for a period of nine consecutive shifts from the date of the expansion of

the resident census.

c. (1) The computation of minimum direct care staffing ratios shall be carried to the hundredth place.

(2) If the application of the ratios listed in subsection a. of this section results in other than a whole number of direct care staff, including certified nurse aides, for a shift, the number of required direct care staff members shall be rounded to the next higher whole number when the resulting ratio, carried to the hundredth place, is fifty-one hundredths or higher.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 315259 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315259 B. Wing 03/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountainside Skilled Nursing and Rehab 1180 US Highway 22 Mountainside, NJ 07092

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 (3) All computations shall be based on the midnight census for the day in which the shift begins.

Level of Harm - Minimal harm or d. Nothing in this section shall be construed to affect any minimum staffing requirements for nursing homes potential for actual harm as may be required by the Commissioner of Health for staff other than direct care staff, including certified nurse aides, or to restrict the ability of a nursing home to increase staffing levels, at any time, beyond the Residents Affected - Some established minimum .

A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks of staffing from 2/9/25 through 2/22/25 prior to the Standard survey of 3/4/25 revealed the facility was deficient in staffing hours as evidenced by the following:

For the 2 weeks of staffing prior to survey from 02/09/2025 to 02/22/2025, the facility was deficient in CNA staffing for residents on 8 of 14 day shifts as follows:

-02/14/25 had 17 CNAs for 145 residents on the day shift, required at least 18 CNAs.

-02/15/25 had 17 CNAs for 145 residents on the day shift, required at least 18 CNAs.

-02/16/25 had 17 CNAs for 143 residents on the day shift, required at least 18 CNAs.

-02/17/25 had 17 CNAs for 143 residents on the day shift, required at least 18 CNAs.

-02/19/25 had 17 CNAs for 142 residents on the day shift, required at least 18 CNAs.

-02/20/25 had 16 CNAs for 142 residents on the day shift, required at least 18 CNAs.

-02/21/25 had 16 CNAs for 141 residents on the day shift, required at least 18 CNAs.

For the 2 weeks of Complaint staffing from 10/13/2024 to 10/26/2024, the facility was deficient in CNA staffing for residents on 2 of 14 day shifts as follows:

-10/13/24 had 16 CNAs for 133 residents on the day shift, required at least 17 CNAs.

-10/21/24 had 16 CNAs for 133 residents on the day shift, required at least 17 CNAs.

The surveyor observed postings of daily nursing staffing reports on each day of the survey.

On 3/4/25 at 10 am the survey team discussed the shortages of nursing staffing hours with the Licensed Nursing Home Administrator.

36419

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 315259 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315259 B. Wing 03/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountainside Skilled Nursing and Rehab 1180 US Highway 22 Mountainside, NJ 07092

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Review of the 11-7:00 AM CNA assignment sheet revealed that unit 2 on the second floor nursing unit had a census of 58 Residents with 3 assigned aides.The CNA (CNA # 4 ) had an assignment of 19 residents on Level of Harm - Minimal harm or that 11-7AM shift. potential for actual harm 2. On 2/26/25 at 8:15 AM, the surveyor accompanied by CNA #2 observed Resident #113 in bed. CNA #2 Residents Affected - Some exposed Resident #113's incontinence brief, which was saturated with urine. At that time, when CNA #2 exposed the incontinence brief, another incontinence brief was observed, which was also saturated with urine. CNA #2 acknowledged the two briefs were saturated with urine and confirmed that the facility policy was that residents should not have two incontinence briefs in place.

Review of the CNA assignment sheet revealed the unit 2 second floor had a census of 58 Residents with 3 assigned aides. The CNA (CNA #5) had an assignment of 19 residents on that 11-7AM shift.

3. On 2/26/25 at 8:20 AM, the surveyor, accompanied by CNA #2, observed Resident #76 in their room seated in a wheelchair with the mechanical lift pad positioned underneath them. Resident #76 stated that she/he was only provided incontinence care once per shift and was informed by staff that since she/he required the use of a mechanical lift during transfers, it was too difficult to get him/her back into bed before

the evening shift arrived at 3:00 PM, therefore she/he had to stay in a saturated brief, which at times was saturated with urine and feces.

Review of the CNA assignment sheet revealed the unit 2 second floor had a census of 58 Residents with 3 assigned aides. The CNA (CNA #5) had an assignment of 19 residents on that 11-7AM shift.

4. On 2/26/25 at 8:30 AM, the surveyor, accompanied by CNA #3, observed Resident #105 seated on the side of his/her bed. CNA #3 exposed Resident #105's incontinence brief, and the surveyor observed it was saturated with urine. CNA #3 acknowledged the brief was saturated with urine. CNA #3 confirmed that all residents should be provided incontinence care every 2 hours and should not be left saturated.

Review of the CNA assignment sheet revealed that unit 1 second floor nursing unit had a census of 47 Residents with 3 assigned aides. The CNA (CNA# 6 ) had an assignment of 17 residents on that 11-7AM shift.

During an interview with the surveyor on 2/27/25 at 12:48 PM, the Director of Nursing (DON) confirmed that incontinence rounds should be done every 2-3 hours on the night shift and that residents should not have two incontinence briefs in place. The DON confirmed that the ratio for the 11:00 PM-7:00 AM, shift was 1 CNA to 14 Residents.

During an interview with the surveyor on 3/4/25 at 10:21 AM, the Staffing Coordinator confirmed that on 2/25/25 during the 11:00 PM-7:00 AM, shift the census on Unit 1 (second floor) was 47 and Unit 2 (second floor) was 58. The Staffing Coordinator stated that there were two CNA call outs for that shift and confirmed that the CNAs had 17 and 19 residents on each of their assignments. The Staffing coordinator stated that

she was aware of the 1 CNA to 14 resident ratio for the night shift.

The surveyor attempted phone interviews with the 11:00 PM-7:00 AM CNAs assigned to the above residents. The CNAs did not return the call.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 315259 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315259 B. Wing 03/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountainside Skilled Nursing and Rehab 1180 US Highway 22 Mountainside, NJ 07092

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 2/27/25 at 2:40 PM, the survey team discussed the above observations and concerns with the DON and Licensed Nursing Home Administrator (LNHA). Level of Harm - Minimal harm or potential for actual harm A review of the facility's Activities of Daily Living (ADL), Supporting policy dated as revised July 2024 reflected that residents who are unable to carry out activities of daily living independently will receive the Residents Affected - Some services necessary to maintain good nutrition, grooming and personal and oral hygiene.

NJAC 8:39-5.1(a), 27.1 (a), 27.2 (h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 315259