Montclair Care Center

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 4 of 15 residents (Resident #1, 3, 4, and #55) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 11/24/25 at 9:04 AM, the surveyor provided the MDS Coordinator/Registered Nurse (MDSC/RN) with the list of 3 residents who had not completed an MDS in over 14 days. The surveyor also requested a copy of the resident's final validation report (generated after every MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure consistent maintenance of the system of record keeping of the Drug Enforcement Agency (DEA) order Form-222 (a federal narcotic requisition form), that enabled accurate reconciliation of controlled-dangerous substances (narcotic medications, that due to their high potential for abuse, are tracked with a degree of detail and attention) that was ordered and received. The deficient practice was identified for 1of 11 DEA Form-222s reviewed and was evidenced by the following: Reference:21 CFR 1305.16(b) Whenever any used or unused DEA Forms 222 are stolen or lost (other than in the course of transmission) by any purchaser or supplier, the purchaser or supplier must immediately upon discovery of the theft or loss, report the theft or loss to the Special Agent in Charge of the Drug Enforcement Administration in the Divisional Office responsible for the area in which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 11/24/25, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 25 opportunities for error, and two (2) errors were observed which resulted in a medication error rate of 8.0%. This deficient practice was identified for one (1) of five (5) residents (Resident #55), that was administered by one (1) of two (2) nurses and was evidenced by the following:On 11/24/25 at 9:54 AM, from the hallway, the surveyor observed Resident #55 awake, in bed, and well dressed. At 9:56 AM, the surveyor observed the Licensed Practical Nurse prepare medications for Resident #55. The medications prepared included the following physician's order (PO):-Colace (Docusate) oral capsules 100 milligrams (mg), to be given 2 capsules by mouth, one time a day for constipation (two (2) capsules = 200 mg). The PO was started on 11/10/25.-Vitamin B1 oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/3/24 at 9:45 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In the food preparation area, inside the ice machine, the surveyor observed a black colored build up along the seam and white colored matter inside the walls of the ice machine. The FSD stated that the dish machine was last cleaned about one month ago. 2. In the food preparation area, above the stove and grill cook tops, the surveyor observed 3 out of 5 sprinkler head nozzles and the pipes soiled with a brown colored substance. 3. In the food preparation area, the surveyor observed that 3 of 3 grill knobs were soiled with a brown colored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 14 residents sampled (Resident #11, 16, 22, 26, 27, 33, 36, 39, 50, 117, 9, 30, 45, and #41) and reviewed for resident assessment. According to the Long-Term Care RAI 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool and a federally mandated process for clinical assessment of all residents. It must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. This deficient practice was evidenced by the following: On 4/3/24, at 2:35 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to: a.) assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 3 of 12 residents reviewed (Resident #41, #58 and #45), b.) document Physician Progress Notes (PPN) at least every 60 days with alternating Nurse Practitioner (NP) visits for 1 of 12 residents reviewed (Resident #45), and c.) document physician progress notes that reflect the physician's decisions about the continued appropriateness of the resident's current medical regimen for 1 of 12 resident reviewed (Resident #28). The deficient practices were evidenced by the following: 1. On 4/2/24 at 11:14 AM, the surveyor observed Resident #41 sitting in the wheelchair, returning from the activity room, wheeled by the staff. The surveyor reviewed Resident #41's hybrid medical records (paper and electronic). According to the admission Record (an admission summary), Resident #41 was admitted to the facility with diagnoses that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined that the facility failed to ensure that 5 of 5 licensed nurses were assessed to have the required competencies to meet the care needs of residents residing at the facility. The deficient practice is evidenced as follows. On 4/04/24 at 10:44 AM the surveyor requested from the Director of Nursing (DON) 5 randomly selected nurses' annual nurse competencies. Later that day the DON provided 5 Nursing Performance Appraisals for the 5 nurses. The Appraisals did not address specific nursing tasks. Many of the Appraisals covered non-care areas, such as demonstrates knowledge of resident's bill of rights, completing the 24 hour report, maintaining residents' dignity, responding to residents' calls for assistance, ensures safety of personal possessions, willing to work under supervision, knowledge with carrying out daily nursing tasks, applies restraints according to manufacturers instruction and plan of care, and carry out proper infection control techniques. The Appraisals that addressed nursing tasks failed to list the specific required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined that the facility failed to ensure the resident's call light was readily accessible. The deficient pratice was identified for 1 resident (#34) of 9 reviewed for accommodation of need and evidenced by the following. On 4/01/24 at 10:05 AM and 04/02/24 9:20 AM the surveyor observed the resident alert in bed with eyes open. The residents' speech was garbled. On both days the call light cord was tied to the right hand rail, hanging down, and resting on the floor. A review of the medical record revealed the following information. The admission Record indicated the resident had dementia without behavioral disturbance and adult failure to thrive. The Quarterly Minimum Data Set (MDS) assessment tool indicated the resident had long and short term memory deficits and impaired decision making skills. On 4/03/24 at 11:38 AM the surveyor interviewed Certified Nursing Assistant #1 (CNA #1) who confirmed the call bell should be within reach of the resident. On 4/03/24 at 11:39 AM the surveyor interviewed CNA #2 who was the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment for 1 of 12 residents reviewed (Resident #34). The deficient practice was evidenced by the following. On 4/1/24 at 10:05 AM, the surveyor observed the resident in bed receiving a feeding through a gastrostomy tube (a tube placed endoscopically into the stomach). A review of the medical record revealed the following information. The admission Record included diagnoses of gastrostomy and adult failure to thrive. The Nursing Progress Note of 1/11/2024 at 10:01 AM indicated the resident was transferred to the hospital for a planned insertion of a gastrostomy feeding tube. The Nursing Progress Note of 1/16/2024 at 10:39 AM indicated the resident was re-admitted to the facility after having had a gastrostomy inserted. The tracking of completed MDS assessments listed a Discharge Return Anticipated on 1/11/24 (indicating when the resident was transferred to the hospital for gastrostomy placement), an Entry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 2 of 12 residents reviewed (Resident #41, and #116). The deficient practice was evidenced by the following: 1. On 4/2/24 at 11:14 AM, the surveyor observed Resident #41 sitting in the wheelchair, who returned from the activity room, and was wheeled by the staff. The surveyor reviewed Resident #41's hybrid (combination of paper and electronic) medical record as follows: The admission Record (an admission summary) documented that Resident #41 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease (impairment of memory). The resident's most recent Annual MDS (AMDS) assessment, dated 11/24/23, reflected that Resident #41 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognition impairment. The AMDS with an ARD of 11/24/23 Section D Resident Mood Interview (PHQ-9), signed by the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record record review it was determined that the facility failed to consistently assess a resident's vital signs and dialysis access site prior to leaving and when returning from the dialysis clinic. The deficient practice was identified for 1 of 1 resident, #117, reviewed for dialysis care and services and is evidenced by the following. On 4/1/24 at 10:01 AM, the surveyor observed the resident seated in a side chair in their room. The resident stated they go to the dialysis clinic 3 times a week. The resident stated the Certified Nurse Assistant (CNA) gets the resident ready and brings the resident down to meet the transport driver. The resident stated the nurse does not assess the resident before leaving or when returning from the dialysis clinic. 04/2/24 at 1:15 PM, the surveyor observed the resident in their room talking with the CNA. At 1:30 PM the CNA brought the resident out of the room and into the hallway. The Licensed Practical Nurse (LPN) inquired if the resident had their dialysis communication book, the resident replied, and the CNA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, review of the electronic medical record and other pertinent medical records, the facility failed to ensure that 1 of 5 residents reviewed for unnecessary medications (Resident #28) was free of an unnecessary medication by failing to follow the Consultant Pharmacist (CP) recommendations and failing to provide adequate diagnosis, indications and documentation supporting the use of a medication. The deficient practice was evidenced by the following: On 4/2/2024 at 12:30 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #28. The resident's EMR reflected a physician's order dated 12/27/2023 for Linzess Capsule (a medication used to treat irritable bowel syndrome with constipation or chronic idiopathic constipation) two-hundred ninety (290) micrograms (mcg) with directions give one (1) capsule by mouth every twenty-four (24) hours as needed (PRN) for constipation. The resident's EMR reflected documentation from the CP dated 1/2/2024 that reflected a request to clarify Linzess. On 04/2/2024 at 1:17 PM the surveyor interviewed the Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent the development of food-borne illness. This deficient practice was evidenced by the following: During a tour of the kitchen with two surveyors and the Food Service Director (FSD) on 2/25/22 at 11:00 AM, the following was observed: 1. The walk-in refrigerator floor was covered with wet debris and all rusted as identified by the FSD, who also stated that there was a leak and that's why the floor is wet and rusted. There were three wire racks inside the refrigerator. Each rack contained four shelves. All the shelves had evidence of debris build-up which the FSD was able to rub off with a white rag and stated that it was debris. In addition, the FSD acknowledged that all the shelves on the wire racks were rusted. She further stated that she told the Licensed Nursing Home Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) two anti-anxiety medications (Alprazolam [Xanax] and Lorazepam [Ativan]) prescribed to be given as needed (PRN) for anxiety and extreme agitation had a documented rationale for why it was being administered, and any non-pharmacological interventions trialed before administering the medications, and b.) a clinical rationale was documented for why the as needed anti-anxiety medications were prescribed for greater than 14-days. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #50), and was evidenced by the following: On 2/28/22 at 10:42 AM, the surveyor observed Resident # 50 inside his/her room. The resident smiled at the surveyor and spoke some English but mostly Spanish. The resident was observed eating a small candy bar with enjoyment. The surveyor reviewed the medical record for Resident #50. A review of the resident's admission Record reflected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.