Community Extended Care Hospital of Montclair

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program to prevent the transmission of infectious organisms when staff failed to properly maintain urinary catheter drainage systems and ensure resident care equipment was stored in a manner that prevented contamination.1. Urinary catheter drainage bags for four residents were observed resting on the floor, creating risk for contamination of the closed urinary drainage system.2. Resident care equipment (bedpans and urinals) in shared bathrooms were not labeled, creating potential for cross-use between residents. These failures created conditions conducive to the transmission of multidrug-resistant organisms and catheter-associated urinary tract infections and had the potential to place residents at risk for acquiring infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored and used within labeled use-by dates when one opened food container dated 2/20/26 was found in the walk-in refrigerator on 2/22/26. This failure had the potential for food borne illnesses for residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received medications as clinically indicated and free from unnecessary medications for two out of four sampled residents (Residents 1 and 2) when:1. Resident 1 did not receive prescribed medication that was intended to treat his medical condition.2. Resident 2 received a medication that was not intended for her and for which she had no clinical indication. These failures had the potential to cause harm when Resident 1 did not receive a prescribed medication, placing him at risk for an untreated medical condition and Resident 2 was exposed to unnecessary medication and possible adverse effects.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was able to exercise the right to access personal and medical records for one of three residents (Resident 1), when medical records for Resident 1 were requested by Resident 1 Power of Attorney (POA) but were not delivered within two working days of the request as per the facility ' s policy. This failure resulted in a violation of Resident 1 ' s right to have access to medical records as requested by POA.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect the rights of one of the three sampled residents (Resident 1) when a Certified Nurse Assistant (CNA 1) turned on the light in Resident 1 ' s room without her permission on September 28, 2024. This failure had the potential compromise Resident 1 ' s sense of safety and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care for one of three sampled residents (Resident 1), who required two - person assistance for repositioning and care, when Certified Nursing Assistant (CNA 1) provided care to Resident 1 on two separate occasions (September 28, 2024, and September 29, 2024.) This failure has the potential to compromise Resident 1 ' s physical safety, emotional well-being and trust in care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of three sampled residents (Resident 1) was not adequately supervised following two prior falls within the facility. This failure resulted in Resident 1 falling for the third time and sustaining a red/purple discoloration in the left head area, left hip swelling (abnormal enlargement), and pain in the left hip/leg

Inspectors wroteF689 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the facility's policy regarding safety and supervision of residents was implemented, when one of the four sampled residents (Resident 1) was not supervised during lunchtime, which potentially resulted to a change of condition leading to Resident 1 being transferred to a general acute hospital for evaluation and treatment. This failure had the potential to place a clinically compromised resident (Resident 1) at risk for aspirating when resident was not supervised by the staff during mealtime.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Food and Nutrition Services staff had appropriate competencies to prepare puree diets (food prepared with a smooth and moist consistency for residents who have difficulty chewing and/or swallowing) when a [NAME] (Cook 1) used an immersion mixer (a hand-held blender usually used to mix or blend single serving food portions in the container they are being prepared) to puree meat, rice, and soup from the Korean Diet menu which resulted in puree that was not smooth and did not hold its shape for four residents receiving a physician-ordered puree Korean Diet. This failure had the potential to result in choking or unpalatable texture that could potentially alter the nutrition status for medically compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The ice machine cooling compartment (where the ice is made) had a black colored residue that could be wiped away with a paper towel, which had the potential to contaminate the ice and cause foodborne illness (illness caused by ingestion of contaminated food or beverages). 2. The food preparation sink did not have an air gap (a separation in the drain pipe that ensures prevention of contaminated drain and wastewater from contaminating the sink) which had the potential to cause foodborne illness. 3. The middle sink of the three-compartment sink (three sinks used for manual dishwashing, one for washing, one for rinsing, and one for sanitizing dishes) had rust which had the potential to contaminate the water being used to rinse the dishes. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube - a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) was implemented in accordance with the facility's policy and procedure, for three of four residents (Resident 84, 29 and 42) reviewed for G-tube when: 1. For Resident 84, a license nurse did not check for G-tube placement (listening to gurgling sound when flushing air through the G-tube to confirm the correct position) before administering medications. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise Resident 84's health. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the approved menus when: 1. Four residents receiving a Korean puree diet (food prepared with a smooth and moist consistency for residents who have difficulty chewing and/or swallowing) were served the incorrect portion size on their lunch tray for the following items: 1.a. ½ cup of pureed rice was served on February 7, 2023, and February 8, 2023. (The spreadsheet indicated to serve ¾ cup.) 1.b. ¼ cup of pureed beef/tofu was served on February 8, 2023. (The spreadsheet indicated to serve ½ cup.) 2. The recipe for pureed rice was not followed when the cook used water to puree rice. (The recipe indicated to use milk.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the advance directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions), were completed and available for one of four residents (Resident 112) reviewed for advance directives. This failure had the potential to result in a delay of treatment for Resident 112 as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services in the skin conditions under Section M for one of three residents (Resident 116) reviewed for pressure injury (an open wound on the skin caused by a long period of constant pressure). This failure had the potential to cause inaccuracy in identifying Resident 116's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services to ensure resident's abilities in activities of daily living was provided for two of eight residents (Residents 77 and 123) reviewed for position and mobility, when: 1. For Resident 77, the physician's order for Speech Therapy evaluation (an assessment to evaluate a resident's ability to swallow) was not carried out. 2. For Resident 123, the physician's order for a brace (a material used to support, align, or hold a bodily part in the correct position) for the right-hand contracture (a condition of shortening and hardening of muscle, tendons, or other tissues, often leading to deformity of joints) was not carried out. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment was maintained for three of nine residents (Residents 34, 112, and 104) reviewed for accidents, when: 1. There was no oxygen sign posted outside Resident 34's room. (Resident 34 had an order to receive oxygen therapy.) 2. There was no oxygen sign posted outside Resident 112's room. (Resident 112 had an order to receive oxygen therapy.) 3. The facility's own smoking policy was not implemented for Resident 104, who was a smoker. These failures have the potential to increase the risk of injuries, which could threaten the welfare, health, and safety of Residents 34, 104, and 112.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication destruction policy was followed for one of eleven residents (Resident 24) reviewed for medication administration, when two licensed nurses disposed a controlled medication (medication or substances that is controlled by the government because it may be abused or cause addiction) in a pharmaceutical waste container (container used by facility to discard medications). This failure has the potential for diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure medications and medication carts (used to transport resident's medication) were properly secured when one of six medication carts was found unlocked and unattended by a licensed nurse. This failure had the potential to compromise the security of the medications, for potentially unauthorized staff and residents could access it in a highly vulnerable population of 128 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights systems were easily accessible to 128 residents, in two of four shower rooms (West Shower rooms A and B). This failure had the potential for harm, as residents left unattended in the shower would be unable to call for help, or alert staff in the event of an incident.