Inspection Reports for
Montclair Care Center
111-115 Gates Avenue, Montclair, NJ, 07042
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
73% occupied
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 3
Date: Nov 26, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, pharmaceutical services, and medication administration in the nursing home.
Findings
The facility failed to timely complete and transmit Minimum Data Set (MDS) assessments for 4 residents, maintain accurate DEA Form-222 records for controlled substances, and ensure medication administration errors were below 5%, with an observed error rate of 8%.
Deficiencies (3)
Failure to complete and transmit Minimum Data Set (MDS) assessments within 14 days for 4 residents.
Failure to maintain consistent record keeping of DEA Form-222, with one form missing and unaccounted for.
Medication administration errors resulting in an 8% error rate, exceeding the 5% threshold.
Report Facts
Residents with late MDS assessments: 4
DEA Form-222 missing: 1
Medication administration error rate: 8
Medication administration opportunities observed: 25
Medication administration errors observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator/Registered Nurse | Interviewed regarding late MDS assessments and catching up on transmissions. | |
| Director of Nursing (DON) | Discussed concerns about late MDS transmissions, missing DEA Form-222, and medication errors; provided in-service training to nursing staff. | |
| Licensed Practical Nurse (LPN) | Observed administering medications with errors to Resident #55. | |
| Regional Director of Operations (RDO) | Present during discussions of DEA Form-222 record keeping and medication pass errors. | |
| Licensed Nursing Home Administrator (LNHA) | Present during discussions of DEA Form-222 record keeping and medication pass errors. | |
| Licensed Practical Nurse/Infection Preventionist | Present during discussion of medication pass errors and DON's in-service training. |
Inspection Report
Original Licensing
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint investigations were completed during this survey for complaint numbers NJ160655, NJ168170, NJ171858, NJ172270. Substantiation status not explicitly stated.
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.
Deficiencies (11)
Facility failed to ensure resident's call light was readily accessible.
Facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for 1 of 12 residents reviewed.
Facility failed to complete and submit electronically the Minimum Data Set (MDS) within 14 days for 14 residents.
Facility failed to code the Minimum Data Set (MDS) accurately for 2 of 12 residents reviewed.
Facility failed to consistently assess a resident's vital signs and access site prior to leaving and upon returning from dialysis.
Facility failed to assure physician monthly medication reviews were signed and dated, and failed to document physician progress notes at required intervals.
Facility failed to ensure licensed nurses were assessed for required competencies.
Facility failed to ensure a resident was free from unnecessary medication and failed to follow Consultant Pharmacist recommendations.
Facility failed to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner.
Facility failed to ensure documentation of receptacle testing in patient care rooms in accordance with NFPA 99.
Facility failed to ensure newly hired employees received required two-step Mantoux tuberculin skin test.
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
Deficiencies: 9
Date: Apr 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, assessment, medication management, physician documentation, nurse competencies, dialysis care, and food safety at Montclair Care Center.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility, incomplete resident assessments, late and inaccurate Minimum Data Set (MDS) submissions, inconsistent dialysis assessments, missing physician order signatures and progress notes, lack of nurse competency evaluations, inappropriate medication use without proper documentation, and unsanitary food storage and preparation conditions.
Deficiencies (9)
Failed to ensure the resident's call light was readily accessible for 1 resident (#34).
Failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for 1 of 12 residents (#34).
Failed to complete and submit electronically the Minimum Data Set (MDS) within 14 days for 14 residents.
Failed to code the Minimum Data Set (MDS) accurately for 2 residents (#41 and #116).
Failed to consistently assess a resident's vital signs and dialysis access site prior to leaving and when returning from dialysis for 1 resident (#117).
Failed to assure physician signed and dated monthly orders and documented progress notes for 3 residents (#41, #58, #45).
Failed to assess competencies of 5 licensed nurses to meet care needs.
Failed to ensure 1 resident (#28) was free from unnecessary medication; Linzess was prescribed PRN without adequate diagnosis or documentation.
Failed to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner, including dirty ice machine, soiled grill knobs and oven handles, expired milk, and dented cans.
Report Facts
Residents reviewed for MDS submission: 14
Residents reviewed for dialysis care: 1
Nurses assessed for competencies: 5
Residents reviewed for unnecessary medications: 5
Days overdue for MDS submissions: 33
Days overdue for MDS submissions: 41
Physician order review overdue days: 63
Linzess dosage: 290
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Confirmed call bell should be within reach of resident #34 |
| Certified Nursing Assistant #2 | CNA | Regular CNA for resident #34, stated she always puts call bell in resident's hand |
| MDS Coordinator | MDSC | Admitted mistake in omitting Significant Change in Status Assessment for resident #34 |
| Director of Nursing | DON | Discussed deficiencies and concerns with surveyors; confirmed dialysis policy and nurse competency issues |
| Administrator | Administrator | Responded to education on call bell placement and dialysis assessments; confirmed no nurse competencies performed |
| Regional Director of Operations | RDO | Discussed MDS submission delays and physician documentation issues |
| Infection Preventionist | IP | Stated nurses should document pre and post dialysis assessments |
| Attending Physician | MD | Could not provide rationale for PRN use of Linzess or recall CP recommendation |
| Consultant Pharmacist | CP | Made recommendations regarding Linzess use; stated facility usually responsive |
| Social Worker | SW | Performed PHQ-9 assessment early, before ARD date, causing inaccurate MDS coding |
Inspection Report
Routine
Census: 53
Capacity: 64
Deficiencies: 6
Date: 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.
Deficiencies (6)
Failure to ensure psychotropic PRN medications had documented rationale, non-pharmacological interventions trialed, and re-evaluation within 14 days.
Failure to maintain proper kitchen sanitation and safe storage of potentially hazardous foods, including outdated items and unsanitary equipment.
Emergency battery backup light missing above emergency generator transfer switches.
Smoke barrier doors near resident rooms 224/225 and 108/109 did not fully close, allowing passage of smoke, flame, or gases.
Failure to certify emergency generator transfer time within 10 seconds and failure to exercise generator 12 times annually as required.
Oxygen cylinders in basement storage room were unsecured and at risk of tipping, rupture, or damage.
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
Deficiencies: 2
Date: Mar 3, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the use of psychotropic medications and kitchen sanitation practices at Montclair Care Center.
Findings
The facility failed to ensure proper documentation and clinical rationale for the use of PRN anti-anxiety medications beyond 14 days for one resident, including lack of documentation of target behaviors and non-pharmacological interventions. Additionally, the kitchen sanitation was inadequate, with issues including outdated food items, rust and debris in refrigerators, unclean kitchen equipment, and improper food storage practices.
Deficiencies (2)
Failure to document rationale and non-pharmacological interventions prior to administering PRN anti-anxiety medications and lack of clinical rationale for use beyond 14 days for Resident #50.
Failure to maintain proper kitchen sanitation practices including rusted and dirty refrigerator shelves, outdated food items, mold or black substance on refrigerator walls, unclean kitchen equipment, and improper food storage.
Report Facts
Dates medication administered without documented rationale: 13
Dates medication administered without documented rationale: 5
Outdated food items: 7
Years cook worked at facility: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN#2 | Licensed Practical Nurse | Administered Alprazolam and Lorazepam IM without documenting non-pharmacological interventions or target behaviors. |
| Director of Nursing | Director of Nursing | Acknowledged deficiencies in medication administration documentation and physician orders. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Examined resident and acknowledged PRN anti-anxiety medications should be ordered for 14 days with re-evaluation. |
| Food Service Director | Food Service Director | Acknowledged kitchen sanitation issues including rust, debris, and outdated food items. |
| Certified Nursing Aide | Certified Nursing Aide | Interviewed regarding resident's behavior and care refusal. |
| Consultant Pharmacist | Consultant Pharmacist | Reviewed drug regimen and commented on PRN medication use and documentation. |
Inspection Report
Routine
Census: 46
Deficiencies: 0
Date: 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
Date: 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
Date: 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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