Inspection Reports for Family Of Caring Healthcare At Montclair
42 North Mountain Ave, NJ, 07042
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Nov 15, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on complaints NJ00152419, NJ00160914, and NJ00162197 to investigate compliance with federal and state regulations.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities. Deficiencies included failure to notify responsible parties of changes in medical status and treatment decisions, failure to notify physicians of abnormal lab results, and failure to maintain required minimum staffing ratios.
Complaint Details
The survey was complaint-driven based on complaints NJ00152419, NJ00160914, and NJ00162197. The facility was found not in substantial compliance with federal and state regulations related to resident rights and care, laboratory services, and staffing.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the Responsible Party of a resident's change in medical status and to ensure informed treatment decisions. | SS=D |
| Failure to notify the physician of laboratory results for a resident. | SS=D |
| Failure to maintain required minimum Certified Nurse Aide (CNA) staffing ratios for day shifts as mandated by New Jersey state law. | — |
Report Facts
Survey Census: 62
Sample Size: 12
Deficient CNA staffing day shifts: 7
CNA staffing counts: 5
Required minimum CNAs: 8
Inspection Report
Routine
Census: 55
Deficiencies: 0
Aug 9, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 64
Capacity: 70
Deficiencies: 4
Mar 13, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to failure to follow physician's orders for medication administration and failure to accurately document administration of controlled substances. Life safety code deficiencies were also noted related to emergency lighting and fire alarm system testing and maintenance.
Severity Breakdown
SS=D: 2
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to follow a physician's order for parameters before administering medication and failed to sign the Electronic Treatment Administration Record (ETAR) to confirm placement and patency for medication administration. | SS=D |
| Facility failed to accurately document the administration of controlled substances, including discrepancies in narcotic medication inventory and declining inventory sheets. | SS=D |
| Facility failed to ensure emergency lighting was provided at the emergency generator transfer switch in accordance with NFPA 110 Standard. | SS=F |
| Facility failed to ensure smoke detection sensitivity was checked every alternate year of the facility smoke detectors in accordance with NFPA 72 National Fire Alarm and Signaling Code. | SS=F |
Report Facts
Census: 64
Total Capacity: 70
Deficiencies cited: 4
Dates of cited deficiencies completion: Mar 31, 2023
Dates of cited deficiencies completion: Mar 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in medication administration deficiency for failing to follow physician's orders |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding medication orders and resident care |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding resident care and medication orders |
| Director of Nursing (DON) | Director of Nursing | Interviewed and involved in medication order and administration process |
| Unit Manager (UM) | Unit Manager | Supervised Licensed Practical Nurse #1 and involved in medication administration process |
| Regional Nurse | Regional Nurse | Interviewed about policy and procedure for medication parameters |
| Pharmacy Consultant | Pharmacy Consultant | Responsible for observing licensed nurses monthly for medication administration competency |
| Maintenance Director | Maintenance Director | Responsible for emergency lighting and fire alarm system maintenance and testing |
| Licensed Nursing Home Administrator (LNHA) | Licensed Nursing Home Administrator | Interviewed regarding medication administration concerns |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Dec 30, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health. Additionally, a complaint investigation was conducted regarding failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Findings
The facility was found in compliance with COVID-19 infection control regulations. However, the facility failed to maintain the required minimum direct care staff-to-resident ratios on multiple shifts between 12/11/22 and 12/24/22, specifically deficient in Certified Nursing Assistant (CNA) staffing on 2 of 14 day shifts and 1 of 14 overnight shifts. The facility administration acknowledged the staffing shortages and implemented corrective actions.
Complaint Details
The complaint investigation found substantiated staffing deficiencies with the facility failing to meet minimum CNA staffing requirements on specified dates. The facility's Licensed Nursing Home Administrator and Director of Nursing were made aware of the staffing shortages.
Deficiencies (1)
| Description |
|---|
| Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey, deficient in CNA staffing on 12/11/22, 12/16/22, and 12/19/22 shifts. |
Report Facts
Census: 64
Deficient CNA staffing shifts: 3
Required CNAs on 12/11/22 and 12/16/22 day shifts: 8
Actual CNAs on 12/11/22 and 12/16/22 day shifts: 7
Required total staff on 12/19/22 overnight shift: 5
Actual total staff on 12/19/22 overnight shift: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Named as aware of staffing shortages | |
| Director of Nursing | Named as aware of staffing shortages and involved in corrective action | |
| Staffing Coordinator | Interviewed and acknowledged staffing shortages |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Feb 22, 2022
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: NJ150465) to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with all applicable requirements, including infection control regulations related to COVID-19, and had implemented CMS and CDC recommended practices.
Complaint Details
Complaint #: NJ150465; the complaint investigation found the facility in compliance with all regulatory requirements.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 58
Deficiencies: 0
Oct 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19 practices.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 53
Deficiencies: 0
Sep 14, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 5
May 11, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
The facility was found not in compliance with infection control regulations related to COVID-19 practices, including improper use of PPE by staff and vendors, improper sequencing of room cleaning, and inadequate policies for PPE disposal and meal tray passing between cohorts. Additionally, the facility failed to report a fire incident to the New Jersey Department of Health as required.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to follow accepted infection control practices regarding the use of Personal Protective Equipment (PPE) for residents on Transmission Based Precautions (TBP) by Certified Nursing Assistants and a laboratory technician. | SS=D |
| Failure to clean resident rooms in a sequence that would decrease the possibility of spreading infection, observed in housekeeping staff. | SS=D |
| Failure to have proper disposal bins for soiled gowns in resident rooms and improper handling of PPE disposal. | SS=D |
| Failure to have policies addressing cleaning sequence for COVID-19 cohorts and passing meal trays between cohorts. | SS=D |
| Failure to report a fire incident to the New Jersey Department of Health and provide required documentation. | — |
Report Facts
Census: 53
Sample Size: 17
Date of Fire Incident: Jan 12, 2021
Completion Date for Plan of Correction: May 31, 2021
Date Survey Completed: May 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in infection control PPE deficiency for not wearing full PPE in PUI room |
| Lab Technician | Laboratory Technician | Named in infection control PPE deficiency for improper gown use and disposal |
| Director of Nursing | Director of Nursing | Provided re-education to staff and commented on PPE practices |
| Infection Preventionist | Infection Preventionist | Provided re-education and guidance on infection control practices |
| Unit Manager | Licensed Practical Nurse / Registered Nurse Unit Manager | Observed and intervened in PPE practices and provided information on cohorts |
| Housekeeper | Housekeeper | Named in infection control deficiency for improper cleaning sequence and PPE handling |
| Maintenance Director | Maintenance Director | Interviewed regarding fire incident and reporting |
| Administrator | Facility Administrator | Interviewed regarding fire incident reporting |
Inspection Report
Life Safety
Deficiencies: 4
May 6, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/06/2021 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found noncompliant with several Life Safety Code requirements including improper installation and signage of delayed-egress locking systems on exit doors, unsealed vertical openings in ceilings allowing fire and smoke spread, lack of alarm occupant notification devices in the enclosed courtyard, and failure to conduct required quarterly fire drills or staff training for fire response procedures.
Severity Breakdown
SS=E: 2
SS=D: 1
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Delayed-egress locking systems on exit doors lacked required signage and one door failed to open when tested. | SS=E |
| Vertical openings in ceilings caused by penetrating electrical wires were not sealed with fire rated material, compromising fire and smoke containment. | SS=E |
| The enclosed courtyard was not equipped with alarm occupant notification devices connected to the fire alarm system. | SS=D |
| Fire drills or staff training for fire response procedures were not conducted quarterly for each shift as required. | SS=C |
Report Facts
Deficiency completion date: May 31, 2021
Deficiency completion date: Jul 13, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and interviews related to deficiencies in delayed-egress locking systems, vertical openings, fire alarm system, and fire drills. | |
| Licensed Nursing Home Administrator | Responsible for re-educating Maintenance Director and auditing compliance with fire safety requirements. |
Inspection Report
Abbreviated Survey
Census: 48
Deficiencies: 3
Dec 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to implement Transmission Based Precautions for a new or re-admitted resident and improper use of Personal Protective Equipment by licensed practical nurses and a staff member's hand hygiene technique.
Severity Breakdown
E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement Transmission Based Precautions for 1 of 12 new or re-admission residents as persons under observation for COVID-19. | E |
| Improper use of Personal Protective Equipment by 2 of 3 Licensed Practical Nurses. | E |
| Inadequate handwashing/hand hygiene technique by 1 of 6 staff members (Housekeeper #1). | E |
Report Facts
Census: 48
Sample size: 7
Duration of observation for new admissions: 14
Handwashing duration: 20
Director of Nursing rounding frequency: 5
Director of Nursing rounding frequency: 1
Handwashing competency frequency: 3
N95/surgical mask observation frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in improper PPE use finding |
| LPN #2 | Licensed Practical Nurse | Named in improper PPE use finding |
| Housekeeper #1 | Housekeeper | Named in inadequate hand hygiene finding |
| RN/UM #1 | Registered Nurse Unit Manager | Interviewed regarding resident cohorting and PPE use |
| Admissions Director | Responsible for cohort placement of new and re-admitted residents | |
| Infection Preventionist | Provided re-education and conducted observations on infection control practices | |
| Director of Nursing | Responsible for rounding and auditing infection control compliance |
Inspection Report
Abbreviated Survey
Census: 48
Deficiencies: 1
Dec 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure appropriate infection control practices for donning and doffing PPE to prevent COVID-19 spread. Multiple observations showed improper PPE use by staff, including reuse of gowns across different cohorts and failure to wear required masks and eye protection.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure appropriate infection control practices were followed in accordance with CDC guidance for donning and doffing PPE to prevent COVID-19 spread. | E |
Report Facts
Census: 48
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Observed not wearing required PPE and confirmed PPE protocol errors during survey | |
| Certified Nursing Assistant | Observed improper PPE use including wearing COVID-19 unit gown outside the unit | |
| Director of Nursing | Director of Nursing | Interviewed and confirmed PPE protocol violations and staff education requirements |
| Infection Preventionist | Infection Preventionist | Interviewed regarding PPE requirements and facility policies |
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