Manor Care Mountainside

F-F658

Based on observation, interview, and record review, it was determined that the facility failed to ensure that

the Consultant Pharmacist (CP) identified and reported a medication irregularity, to the attending physician,

the facility's medical director, and the director of nursing (DON).

This deficient practice was identified for 1 of 5 residents (Resident #13) reviewed for unnecessary medications and was evidenced by the following:

On 2/25/25 at 11:31 AM, during the initial tour of the facility the surveyor observed Resident #13 lying in bed.

The head of the bed was elevated. The resident stated that the breakfast and care were satisfactory.

The surveyor reviewed the medical record of Resident #13.

According to the Admission Record face sheet, an admission summary, reflected that Resident #13 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis.

A review of medication list from the hospital included the following:

-Sevelamer carbonate (Renvela; a phosphate binder to control serum phosphorus levels for those with chronic kidney disease) 800 milligrams (mg). Take 1 tablet by mouth three times a day with meals. Sevelamer was last given to the resident 01/29/25 at 5:01 PM

-Sucroferric Oxyhydroxide (Velphoro; a phosphare bnder for the control of serim phosphorus levels for those with chronic kidney disease on dialysis). Chew one tablet (500 mg) three times a day. The last administered time was not indicated.

A review of the electronic Medication Administration record included the following physician's orders:

-Sevelamer 800 mg. give 1 tablet by mouth three times a day for phosphorus, started on 1/30/25, and discontinued on 2/19/25.

-Velphoro 500 mg, give 1 tablet by mouth three times a day for phosphate binder with meals, started on 1/30/25, and discontinued on 2/19/25.

A review of the Renal Dialysis communication form (RDCF) for February 2024 did not reflect the RD center administered to Resident #13, the Sevelamer and the Velphoro while at the RD center.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 42 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 0756 A review of the CP's Medication Regimen Review (MRR) for January 2025, revealed that the CP failed to identify, obtain a rationale, and report the duplicate therapy of two phosphate binders prescribed to Resident Level of Harm - Minimal harm or #13. potential for actual harm

On 3/3/25 at 12:06 PM, during an interview with the surveyor, the CP stated that he had seen both Residents Affected - Few medications prescribed in the past for different residents and did not think to question the prescriber. The CP acknowledged that MRRs should be individualized. At that time, the CP also stated that he did not review the admission medication record for Resident #13.

On 3/3/25 at 2:07 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator and

the DON, the surveyor asked who was responsible for identifying duplicate therapy. The DON stated that the CP was responsible for the identification of duplicate therapy/irregularity. The CP conducted an MRR review upon admission and monthly thereafter. The concern regarding the failure to identify, obtain a rationale and report the irregularity of two phosphate binders for Resident #13 was discussed with the LNHA and the DON.

A review of the provided facility policy, Medication Regimen Reviews (MRR), dated/revised 3/11/24, included that the MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example . duplicative therapies .

No further information was provided.

NJAC 8:39-29.3

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 42 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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 45449 potential for actual harm Refer 658 Residents Affected - Some Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration

observation on 2/26/25 and 2/27/25, the surveyor observed four (4) nurses administer medications to four (4) residents. There were 30 opportunities, and three errors were observed which resulted in a medication error rate of 10%. This deficient practice was identified for two (2) of four (4) residents (Resident #80 and #115), that was administered by two (2) of four (4) nurses.

This deficient practice was evidenced by the following:

Reference:

A review of the manufacturer's specifications for Humalog under Dosage and Administration: Administer HUMALOG(R) U-100 or U-200 by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal.

Under Warning and Precautions included Hypoglycemia: May be life-threatening. Monitor blood glucose and increase monitoring frequency with changes to insulin dosage, use of glucose lowering medications, meal pattern .

1. On 2/26/25 at 7:48 AM, the surveyors observed Resident #80 seated in a wheelchair, on the hallway speaking with the Licensed Practical Nurse (LPN #1) standing in front of the medication cart. Resident #80 requested for Tramadol (a narcotic pain medication) from LPN #1. LPN #1 asked the resident to rate their pain level from 1 (mild) to 10 (severe). Resident #80 stated their pain level at that time was 1 or 2 (mild).

At that time, the surveyors observed LPN #1 prepare medications for Resident #80. The medications included the following physician's order:

-Humalog 100 units/milliliter (Insulin Lispro; used to control high blood sugar) Inject per sliding scale: 151-200 = 2 units . subcutaneously before meals and at bedtime; was started on 2/12/25.

-Ferrous Sulfate 325 milligram (mg) , give 1 tablet by mouth one time a day for supplement; was started on 8/10/22.

-Tylenol 8 Hour Extended Release (Acetaminophen) give 325 mg (1 tablet) by mouth every 8 hours for pain management. Not to exceed three grams; was started on 9/2/22.

At that time, LPN #1 informed the surveyor, that Resident #80 had an appointment that morning and was preparing to leave. LPN #1 took the resident's blood sugar level in the hallway. The blood sugar monitor reflected a reading of 158. LPN #1 injected, 2 units of the Humalog to Resident #80 in the hallway and failed to provide privacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 42 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 0759 On 2/26/25 at 7:54 AM, LPN #1 confirmed she had three (3) tablets in the medication cup and that it contained one (1) tablet of Ferrous Sulfate, and two (2) tablets of Tylenol 325 mg. LPN #1 stated she Level of Harm - Minimal harm or reviewed the electronic Medication Administration Record (eMAR) and was ready to administer. potential for actual harm At that time, the surveyor and LPN #1 reviewed the eMAR together. The eMAR reflected that the resident did Residents Affected - Some not have an order for two ( 2) tablets of Tylenol for pain. LPN #1 acknowledged and confirmed that she had made an error in preparing two tablets of Tylenol. Further review of the eMAR reflected Tylenol was administered that morning by a different nurse from a prior shift. LPN #1 stated that she looked at the As needed order for Tylenol 325 mg , one (1) tablet every 4 hours for elevated temperature.

Additionally, an order for Tramadol 50 milligram (mg) 1 tablet every 12 hours as needed for pain/severe pain; started on 5/21/24, was observed. LPN #1 stated that Tramadol was indicated for pain level of 0 to 10 and could have administered as needed Tramadol to the resident.

At that time, LPN #1 also acknowledged that she should not have administered insulin to a resident in the hallway to protect patient's privacy rights. At that time, the LPN stated that the resident was given a breakfast bag that they took with them to the appointment.

On 2/26/25 at 8:05 AM, the breakfast truck arrived. The surveyor asked the Certified Nursing Assistant (CNA) for the breakfast tray for Resident #80 . The CNA pulled and showed the surveyor Resident #80's breakfast tray which was untouched.

On 2/26/25 at 11:34 AM, during an interview with the surveyor, the CNA stated that when a resident had an early morning appointment, the nurse on duty would inform her to have the resident ready for their appointment. The nurse on duty would also call dietary services to send the breakfast tray for the resident earlier so they can have breakfast before leaving.

On 2/26/25 at 11:47 AM, during an interview with the surveyor the Registered Nurse (RN) assigned to unit 1 of the second floor, stated that they had a calendar in the electronic Medical Record (eMR). The RN stated that for resident with an early morning appointment were known to the nursing staff through the calendar. When a resident on her unit had an appointment, she would inform the CNA assigned to resident to provide morning care earlier. The RN also stated that she would call dietary to ensure the breakfast tray was provided earlier, this was important for those who were to receive a dose of insulin and/or medications that required to be administered with food.

On 2/26/25 at 12:06 PM, during an interview with the surveyor, Resident #80 stated that prior to an appointment breakfast does not happen. The resident stated that they did not want to bother the nurses as

they were busy and was satisfied that the CNA provided the morning care prior to the appointment. Resident #80 informed the surveyor that they did not receive a snack bag from the facility that morning. The resident stated that the nurse checked their blood sugar level when they returned, and it was about 100. The resident also stated that they bounced along while traveling to their appointment and would have normally received Tramadol for comfort.

A review of the eMAR reflected the resident's blood sugar on 2/26/25 at 11:30 AM was 101.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 42 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 0759 On 2/27/25 at 7:53 AM, during an interview with two surveyors, LPN #2 stated that for residents that required insulin the resident must eat before leaving for their appointment to avoid hypoglycemia (low blood sugar). Level of Harm - Minimal harm or potential for actual harm 2. On 2/27/25 at 8:02 AM, the surveyor observed LPN #2 prepare medications for Resident #115. The medications included a physician's order of Carvedilol 3.125 mg, give 1 tablet twice a day for hypertension Residents Affected - Some (high blood pressure). Hold for systolic blood pressure less than 105, heart rate less than 60. Give with food.

The order was started on 2/24/25.

At 8:14 AM, the LPN #2 finished preparing the medications, and confirmed she was ready to administer the medications to Resident #115.

At 8:17 AM, the surveyor stopped the medication pass observation and asked to speak with LPN #2 outside

the resident's room. The surveyor and LPN #2 reviewed the order for Carvedilol. LPN #2 stated she had taken all the vitals at 7:30 AM. LPN #2 acknowledged blood pressure should be taken prior to administration and stated that she would take the blood pressure prior to administration of the medication.

On 2/27/25 at 2:36 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) , and the Director of Nursing (DON), the surveyor discussed the concerns regarding the failure provide privacy to Resident #80, failure to ensure medication that were required to be administered before meals, received a meal, failure to administer medications in accordance with the physician's order (Resident #80 and #115).

On 3/3/25 at 10:21 AM, during a follow-up meeting with the survey team, and the LNHA, the DON acknowledged and provided education on privacy. The DON stated that breakfast should have been offered earlier. The DON acknowledged and confirmed that an order with parameters should be followed.

A review of the provided facility policy, Administering Medications, dated/revised 9/2024, indicated that medications were to be administered in a safe, timely and as prescribed. Additionally, t under Policy Interpretation and Implementation: Medications were administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times to verify the right resident, the right medication, the right dosage .

NJAC 8:39-11.2(b), 29.2(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 42 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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 19106 Residents Affected - Few Based on interview and record review it was determined that the facility failed to provide a nourishing snack at bedtime when the time between dinner and breakfast exceeded 14 hours. The deficient practice was identified for 5 of 5 residents (Resident #34, 84, 67, 108, 24) in attendance at the resident group meeting and was evidenced by the following:

The surveyor conducted the resident group meeting on 2/27/25 at 10:30 PM. All 5 of 5 residents stated they were not aware that evening snacks were available for residents. All of the residents resided on the second floor nursing units. All of the residents stated they would like to have an evening snack available to them.

Resident #34 stated they eat dinner at 5 pm and eat breakfast at 9 AM.

A review of the Meal Truck Delivery Schedule revealed the time between delivery of dinner and the delivery of breakfast ranged from 14.5 hours to 15.5 hours.

The 7/2024 facility Frequency of Meals policy indicated a nourishing snack will be offered if the time span between evening meal and the next day's breakfast exceeds 14 hours.

NJAC 8:39-17.2(f)1; 17.4(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 42 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 36419 potential for actual harm Based on observation, interview, and review of pertinent facility documents, it was determined that the facility Residents Affected - Few failed to follow appropriate infection control practices and perform hand hygiene as indicated during dining

observation.

This deficient practice was observed in 1 of 2 dining rooms and was evidenced by the following:

According to the CDC Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, last reviewed on January 30, 2020, included that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:

Immediately before touching a patient

Before performing an aseptic task or handling invasive medical devices

Before moving from work on a soiled body site to a clean body site on the same patient

After touching a patient or the patient's immediate environment

After contact with blood, body fluids, or contaminated surfaces

Immediately after glove removal.

On 2/25/25 at 12:30 PM, the surveyor observed nine residents seated in the Second-Floor dining room waiting for their lunch meal.

On 2/25/25 at 12:35 PM, the surveyor observed the Certified Nursing Assistant (CNA) putting clothing protectors on each resident with no observed hand hygiene between residents. The surveyor observed the CNA then applied Alcohol Based Hand Rub (ABHR) to each of the residents' hands, assisted the residents with rubbing their hands together without sanitizing her own hands between the residents.

On 3/3/25 at 12:13 PM, the surveyor observed six residents seated in the Second-Floor dining room waiting for their lunch meal. The surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM) apply ABHR to four residents hands and assisted each of the residents with rubbing their hands together, with no observed hand hygiene between residents.

On 3/3/25 at 12:20 PM, the surveyor observed the Registered Nurse/Minimum Data Set (MDS) coordinator serve lunch to residents in the 2nd floor dining room. The MDS coordinator removed the items from the tray, removed the dome lids, opened foods, and without sanitizing her hands went back into the food truck to remove another tray. The surveyor observed the MDS coordinator served and remove five meal trays without any observed hand hygiene.

On 3/3/25 at 12:50 PM, during an interview, the RN/MDS coordinator confirmed that she should have performed hand hygiene between residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 42 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 0880 On 3/3/25 at 12:55 PM, during an interview, the LPN/UM acknowledged she should have performed hand hygiene between residents. Level of Harm - Minimal harm or potential for actual harm On 3/3/25 at 1:00 PM, during an interview, the CNA stated that she had applied ABHR prior to assisting the residents and then after assising all of them, but was not aware that she should have sanitized her hands Residents Affected - Few between residents.

On 3/3/25 at 2:58 PM, the surveyor discussed the above observations and concerns with the LNHA and DON.

A review of the facility's Handwashing/Hand Hygiene policy and procedure dated as revised July 2024 reflected .the facility considers hand hygiene the primary means to prevent the spread of infection .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors .Use of an ABHR or soap and water should be used before and after direct contact with a resident .before and after handling food and before and after assisting a resident with meals .

NJAC 8:39 - 19.4(a)(m)(n); 27.1 (a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 42 315259

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 28 of 42 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 29 of 42 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 30 of 42 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 31 of 42 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45449

Residents Affected - Some Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a.) expired biologicals were removed from active inventory, b.) consistently implement a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications, and c.) an intravenous bag was stored in a tamper proof and contaminant resistant packaging,

The deficient practices were identified for two (2) of two (2) medication rooms and two (2) of three (3) medication carts inspected during the medication storage and labeling observation and was evidenced by

the following.

Reference:

According to the manufacturer specification of Aplisol, under storage included that vials in use for more that 30 days should be discarded due to possible oxidation and degradation which may affect potency.

According to the Centers for Disease Control and Prevention , for Prevention Unsafe Injection Practices, dated [DATE REDACTED], included the following under key points for multi-dose vials: Once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date.

https://www.cdc.gov/injection-safety/hcp/clinical-safety/

1. On [DATE REDACTED] at 9:47 AM, in the presence of the Registered Nurse/Unit Manager (RN/UM) began the medication room inspection located on the first floor. At that time, the surveyor observed an open vial of Aplisol (an injectable used to detect tuberculosis (TB)). The opened Aplisol vial had a handwritten date of [DATE REDACTED]. At that time, the surveyor asked the RN/UM when did the Aplisol expire. The RN/UM looked at the box and stated that the Aplisol did not expire until ,d+[DATE REDACTED].

2. At that time, the surveyor continued the inspection of the refrigerator and found an opened, punctured Lorazepam Injectable 20 milligram /10 milliliter (a controlled substance used to treat symptoms of anxiety and is also used as an anticonvulsant) . The bottle had a handwritten date of [DATE REDACTED] and a pharmacy label that reflected House Stock dated [DATE REDACTED]. The RN/UM stated the Lorazepam Injectable expired after 60 days from the first date it was opened; She acknowledged the Lorazepam had been expired [for six (6) months].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 42 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 0755 At that time, the surveyor and the RN/UM reviewed the Controlled Substance Record for Lorazepam Injection (an accountability log, that denoted who administered the medication, the date and time of the Level of Harm - Minimal harm or administration, amount on-hand, amount received, amount given, and the amount remaining). The potential for actual harm accountability log was blank, did not indicate who administered the medication to whom, when, the amount removed, the amount given and the remaining quantity. The RN/UM stated that a shift-to-shift count was Residents Affected - Some conducted daily between two nurses and could not explain how in six (6) months, the discrepancy of who opened the controlled substance Lorazepam, and if it was administered to a resident or was diverted was not identified. The RN/UM stated she would inform the Director of Nursing and investigate.

3. On [DATE REDACTED] at 10:56 AM, in the presence of the Licensed Practical Nurse (LPN #1) the surveyor began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart located in unit 1, on the second floor. The surveyor observed Resident #16's bingo card (blister packet which contains the medication) with a pharmacy label for Tramadol 50 mg, and contained 11 tablets. The Individual Patient Controlled Drug Record (IPCDR) for Resident #16's Tramadol reflected a remaining quantity of 12 tablets.

At that time, LPN #1 stated she administered the medication that morning and acknowledged she should have signed the IPCDR immediately upon removal of the narcotic medication.

At that time, the surveyor observed Resident #64's bingo card with a pharmacy label for Methylphenidate 5 mg, that was empty. The IPCDR reflected a remaining quantity of one (1) tablet. LPN #1 stated she administered the medication that morning and did not sign when she removed the Methylphenidate for administration.

4. On [DATE REDACTED] at 11:27 AM, in the presence of LPN #1 began the medication room inspection and observed -one (1) bag of sodium chloride for injection 250 ml, without an outer packaging or seal. At that time, LPN #1 stated she would dispose of the sodium chloride ad inform her supervisor.

5. On [DATE REDACTED] at 12:18 PM, On [DATE REDACTED] at 10:56 AM, in the presence of LPN #2, the surveyor began the narcotic medication inspection, of the medication cart located in unit 2, on the second floor. LPN #2 stated that the previous nurse on the cart had to suddenly leave, and a narcotic count prior to taking over the cart did not occur.

The surveyor observed the following:

-Resident #38's bingo card had a pharmacy label for Tramadol 50 mg and contained 2 tablets. The corresponding IPCDR for reflected a remaining quantity of 3 tablets.

-Resident #75's bingo card had a pharmacy label for Lorazepam 0.5 mg and contained 45 tablets. The corresponding IPCDR reflected a remaining quantity of 46 tablets.

- Resident #63's bingo card had a pharmacy label for Oxycodone Immediate Release 10 mg and contained 19 tablets. The corresponding IPCDR reflected a remaining quantity of 20 tablets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 42 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 0755 On [DATE REDACTED] at 2:36 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) , and the Director of Nursing (DON), the surveyor discussed the concerns regarding the expired TB Level of Harm - Minimal harm or diagnostic [24 days], the expired Lorazepam [6 months], an intravenous bag that was not stored in a tamper potential for actual harm and contaminant resistant packaging, failure to consistently implement a system of records for controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications, the Residents Affected - Some opened Lorazepam's accountability log was blank without evidence of whom it was administered to, or diverted and the multiple discrepancies between the Resident's medication inventory (Resident #16, #64, #38, #75 and #63) and the corresponding IPCDR.

On [DATE REDACTED] at 10:21 AM, during a follow-up meeting with the survey team, and the LNHA, the DON acknowledged that expired medication should be removed from active inventory. The DON could not account to whom the Lorazepam was administered to and presented a blank accountability log. The DON also stated that an in-service for intravenous packaging was provided and for the process of proper narcotic documentation.

A review of the provided facility policy, Controlled Substances dated/revised [DATE REDACTED], included: Upon Administration, the nurse administering he medication is responsible for recording name of the resident receiving the medication, name, strength and dose of the medication, time of administration, method of administration, remaining quantity of the medication, and signature of the nurse administering the medication. At the end of each shift, the nurse on duty and the nurse going off duty, determine the count together.

A review of the provided facility policy, Storage of Medications, dated/reviewed ,d+[DATE REDACTED], included that drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.

No further information was provided.

NJAC 8:,d+[DATE REDACTED].1(a), 29.4 (g)(k), 29.7(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 42 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 45449

Residents Affected - Few Refer