Mountainside Skilled Nursing And Rehab
MOUNTAINSIDE SKILLED NURSING AND REHAB in MOUNTAINSIDE, NJ — inspection on August 21, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
as follows: -8/4/25 - Unit 2, 7:00 AM to 3:00 PM (7-3) shift, CNA #1 was assigned to Post 4 with 9
#1 was assigned to Post 5 with 12 room assignments.-8/6/25 - Unit 1, 7-3 shift, CNA #1 was
Post 5 with 9 room assignments, and-8/8/25 - Unit 2, 7-3 and 3-11 shifts, CNA #1 was assigned to Post 5 with 10 room assignments. On 8/19/25 at 12:59 PM, the surveyor interviewed the SW, who stated that on 8/4/25, RR #1 called them around 10:00 AM during morning meeting. RR #1 asked the SW if they could run upstairs and check on [the resident] because they did not sound right when RR #1 was talking to the resident on the phone.
The SW stated they went upstairs and saw the resident in their room in their wheelchair and eating their lunch.
The SW stated that they asked the resident how they were, and the resident stated they could not remember the SW's name and said they were ok.
The SW further stated the resident was pleasant and appeared to be in no distress, so the SW called RR #1 while they were in the resident's room and gave them updates on the resident.
The SW said the RR #1 frequently called them and asked to check on [the resident].
The SW stated at that time, RR #1 reported they had a concern with CNA #1 splashing liquid on the resident.
The SW stated they told RR #1 that the resident was sitting in their wheelchair and eating lunch and there was no liquid anywhere else in the room.
The SW stated they then asked RR #1 if they were referring to when CNA #1 was washing or bathing the resident? The SW reported that at the end of the conversation, RR #1 was ok after the SW explained the splashing could have been during care.
The SW stated they did not report that conversation with RR #1 to any of the nursing staff until 8/5/25, when RR #1 called again and said after sleeping on it, I felt like it was more than the splashing of liquid and [RR #1] further said that [CNA #1] was bending the resident's hand back, pulled [the resident's] hair, and hit [the resident] with a chair.
The SW stated they then reported RR #1's concerns to RNUM #1 and the DON, who went upstairs and spoke to the resident and CNA #1. On 8/19/25 at 1:21 PM, the surveyor interviewed the LNHA and the DON.
The LNHA and the DON stated that when they knew of RR #1's concerns on 8/5/25, they started the investigation; RNUM #1 did a body assessment on the resident, they interviewed and gathered witness statements, and conducted a customer service in-service.
They further stated they removed CNA #1 from the resident's care and assigned a two-person assistance for [the resident's] care.
They stated that they started the investigation, but did not suspend CNA #1 from other residents' care assignments because at the end of the day on 8/5/25, when they spoke to RR #1, RR #1 was agreeable with the result of their report.
The LNHA and DON stated they suspended CNA #1 and called police on 8/8/25, when RR #1 emailed and escalated their concerns. N.J.A.C. 8:39-4.1(a)5
315259 08/21/2025
Mountainside Skilled Nursing and Rehab 1180 US Highway 22 Mountainside, NJ 07092
diagnoses which included but were not limited to: metabolic encephalopathy (a condition where the
diabetes mellitus without complications. A review of the Minimum Data Set (MDS), an assessment
of 15, which indicated a severely impaired cognition.
The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs).On 8/19/25 at 12:59 PM, the surveyor interviewed the SW, who stated that on 8/4/25, RR #1 called them around 10:00 AM during morning meeting. RR #1 asked the SW if they could run upstairs and check on [the resident] because they did not sound right when RR #1 was talking to the resident on the phone.
The SW stated they went upstairs and saw the resident in their room in their wheelchair and eating their lunch.
The SW stated that they asked the resident how they were, and the resident stated they could not remember the SW's name and said they were ok.
The SW further stated the resident was pleasant and appeared to be in no distress, so the SW called RR #1 while they were in the resident's room and gave them updates on the resident.
The SW said the RR #1 frequently called them and asked to check on [the resident].
The SW stated at that time, RR #1 reported they had a concern with CNA #1 splashing liquid on the resident.
The SW stated they told RR #1 that the resident was sitting in their wheelchair and eating lunch and there was no liquid anywhere else in the room.
The SW stated they then asked RR #1 if they were referring to when CNA #1 was washing or bathing the resident? The SW reported that at the end of the conversation, RR #1 was ok after the SW explained the splashing could have been during care.
The SW stated they did not report that conversation with RR #1 to any of the nursing staff until 8/5/25, when RR #1 called again and said after sleeping on it, I felt like it was more than the splashing of liquid and [RR #1] further said that [CNA #1] was bending the resident's hand back, pulled [the resident's] hair, and hit [the resident] with a chair.
The SW stated they then reported RR #1's concerns to RNUM #1 and the DON, who went upstairs and spoke to the resident and CNA #1. On 8/19/25 at 1:21 PM, the surveyor interviewed the LNHA and the DON.
The LNHA and the DON stated that when they knew of RR #1's concerns on 8/5/25, they started the investigation; RNUM #1 did a body assessment on the resident, they interviewed and gathered witness statements and conducted a customer service in-service.
They further stated they removed CNA #1 from the resident's care and assigned a two-person assistance for [the resident's] care.
They stated that they started the investigation, but did not suspend CNA #1 from other residents' care assignments because at the end of the day on 8/5/25, when they spoke to RR #1, RR #1 was agreeable with the result of their report.
The LNHA and DON stated they suspended CNA #1 and called police on 8/8/25, when RR #1 emailed and escalated their concerns.
They further stated they called in the event to NJDOH on that day 8/8/25 but submitted the FRE [AAS-45] to NJDOH on 8/11/25.
The LNHA and DON stated that they were aware that incidents involving abuse and neglect have to be reported immediately to NJDOH. On 8/19/25 at 3:49 PM, the surveyor interviewed the LNHA regarding the facility's policy and procedure on Abuse allegations and reporting.
The LNHA stated that on 8/5/25, RR #1 was agreeable with the facility's explanation of events and there were no signs of abuse and the resident was confused and inconsistent with their stories so we did not consider it as abuse. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy initialed by the LNHA with a handwritten date of 8/7/2025, included Policy Statement: All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are [.] thoroughly investigated by facility management.Reporting Allegations to the Administrator and Authorities:1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .N.J.A.C 8:39-9.4(f)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.