Inspection Reports for Montclair Care Center
111-115 Gates Avenue, NJ, 07042
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Inspection Report
Original Licensing
Deficiencies: 0
Sep 30, 2024
Visit Reason
Initial inspection for licensure of renovated long term care facilities, specifically the renovated lobby and resident sitting parlor.
Findings
No deficiencies were noted during the inspection of the renovated lobby and resident sitting parlor. The facility was in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Inspection Report
Annual Inspection
Census: 47
Capacity: 64
Deficiencies: 11
Apr 5, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to reasonable accommodations, comprehensive assessments, MDS submissions and accuracy, dialysis care, physician visits and documentation, nursing staff competencies, unnecessary drug use, food safety, and electrical system maintenance.
Complaint Details
Complaint investigations were completed during this survey for complaint numbers NJ160655, NJ168170, NJ171858, NJ172270. Substantiation status not explicitly stated.
Severity Breakdown
SS=D: 5
SS=E: 4
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to ensure resident's call light was readily accessible. | SS=D |
| Facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for 1 of 12 residents reviewed. | SS=D |
| Facility failed to complete and submit electronically the Minimum Data Set (MDS) within 14 days for 14 residents. | SS=E |
| Facility failed to code the Minimum Data Set (MDS) accurately for 2 of 12 residents reviewed. | SS=D |
| Facility failed to consistently assess a resident's vital signs and access site prior to leaving and upon returning from dialysis. | SS=D |
| Facility failed to assure physician monthly medication reviews were signed and dated, and failed to document physician progress notes at required intervals. | SS=E |
| Facility failed to ensure licensed nurses were assessed for required competencies. | SS=E |
| Facility failed to ensure a resident was free from unnecessary medication and failed to follow Consultant Pharmacist recommendations. | SS=D |
| Facility failed to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner. | SS=F |
| Facility failed to ensure documentation of receptacle testing in patient care rooms in accordance with NFPA 99. | SS=E |
| Facility failed to ensure newly hired employees received required two-step Mantoux tuberculin skin test. | SS=D |
Report Facts
Census: 47
Total Capacity: 64
Sample Size: 15
Deficiency Count: 14
Dent Size: 1.5
Dent Size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding call bell placement for Resident #34 |
| Certified Nursing Assistant #2 | CNA | Regular CNA for Resident #34, interviewed about call bell placement |
| Director of Nursing | DON | Interviewed regarding call light accessibility, MDS omissions, dialysis assessments, nurse competencies, and physician documentation |
| Administrator | Responded to call bell placement education, MDS submission delays, dialysis assessment concerns, and food safety issues | |
| MDS Coordinator | MDSC | Interviewed about omitted Significant Change in Status Assessment and late MDS submissions |
| Regional Director of Operations | RDO | Discussed MDS submission backlog and physician documentation issues |
| Licensed Practical Nurse | LPN | Observed not assessing resident vital signs before dialysis transport |
| Attending Physician | MD | Interviewed about medication order and Consultant Pharmacist recommendations |
| Consultant Pharmacist | CP | Interviewed about medication recommendations and facility responsiveness |
| Food Service Director | FSD | Interviewed and observed during food safety inspection |
| Director of Maintenance | DOM | Interviewed about electrical receptacle testing and documentation |
Inspection Report
Routine
Census: 53
Capacity: 64
Deficiencies: 6
Mar 3, 2022
Visit Reason
Routine standard survey to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with requirements related to psychotropic medication use, food safety and sanitation, life safety code compliance including emergency lighting, smoke barrier doors, emergency electrical system maintenance, and oxygen cylinder storage. Deficiencies included improper documentation and use of psychotropic PRN medications, unsanitary kitchen conditions with outdated and improperly stored food, missing emergency lighting at the generator transfer switch, smoke barrier doors not fully closing, incomplete generator transfer time certification and testing, and unsecured oxygen cylinders.
Severity Breakdown
SS=D: 2
SS=E: 3
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure psychotropic PRN medications had documented rationale, non-pharmacological interventions trialed, and re-evaluation within 14 days. | SS=D |
| Failure to maintain proper kitchen sanitation and safe storage of potentially hazardous foods, including outdated items and unsanitary equipment. | SS=F |
| Emergency battery backup light missing above emergency generator transfer switches. | SS=D |
| Smoke barrier doors near resident rooms 224/225 and 108/109 did not fully close, allowing passage of smoke, flame, or gases. | SS=E |
| Failure to certify emergency generator transfer time within 10 seconds and failure to exercise generator 12 times annually as required. | SS=E |
| Oxygen cylinders in basement storage room were unsecured and at risk of tipping, rupture, or damage. | SS=E |
Report Facts
Census: 53
Total licensed capacity: 64
Psychotropic medication PRN orders exceeding 14 days: 1
Outdated food items: 7
Generator load tests missing: 3
Oxygen cylinders unsecured: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN#2) | Named in relation to deficient documentation and administration of psychotropic medications | |
| Director of Nursing (DON) | Involved in review and corrective actions for psychotropic medication deficiencies | |
| Maintenance Director | Responsible for checking emergency lighting and smoke door closures | |
| Food Service Director (FSD) | Responsible for kitchen sanitation and food safety corrective actions | |
| Pharmacist Consultant | Reviewed residents on psychotropic medications |
Inspection Report
Routine
Census: 46
Deficiencies: 0
Sep 7, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 47
Deficiencies: 0
Jan 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Notice
Deficiencies: 0
Apr 15, 2011
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and describing their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, legal duties of NJDHSS, and contact information for privacy concerns.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | Listed as NJDHSS Privacy Officer and contact person for privacy practices. |
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