Family of Caring Healthcare at Montclair

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to assess a resident's capability to self-administer medication and obtain a physician's order for the resident to self-administer a medication. This deficient practice was identified in 1 of 1 resident reviewed for self-administration (Resident #264) and was evidenced by the following: Refer F697 On 4/22/25 at 11:30 AM, during the initial tour, the surveyor observed Resident #264 in bed, the head of the bed was elevated, the ankle and foot were also elevated off the bed with a pillow. The resident informed the surveyor that they experienced pain 24 hours a day, 7 days a week from their hemorrhoids (swollen veins in the lower rectum and anus) and told the nurse on duty. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 3 of 17 residents reviewed for accommodation of needs (Resident #10, 14, and 20), and was evidenced by the following: 1. On 4/22/25 at 11:00 AM, the surveyor heard the resident calling out for assistance. The surveyor entered the room and observed Resident # 20 in bed with Oxygen infusing via a Nasal Cannula at 2 Liters per minute (LPM). The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was affixed to the lower aspect of the bedframe, not within his/her reach. The surveyor reviewed the medical record for Resident #20. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 of 17 residents (# 14 and #49) reviewed. The deficient practice was evidenced by the following: 1. On 4/22/25 at 12:30 PM, in Resident #49's room, the surveyor observed 3 brown colored circle shaped spots along the resident's window sill. The surveyor also observed dark brown and grey colored streaks on the inside of 2 of 2 of the resident's window pans. The surveyor observed multiple 5 inch long scratches along the bottom of the resident's bathroom door and brown colored debris along the residents bathroom floor. The surveyor also observed brown colored debris along the floor inside the resident's bedroom. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 1 of 20 residents reviewed for resident assessment (Resident #47) This deficient practice was evidenced by the following: The surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is federal 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 up to 14 days of the assessment being completed. The surveyor reviewed Resident #47's electronic medical record. The record revealed that the resident discharged to the hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to update and/or revise care plans for 1 of 20 residents reviewed, Resident # 49. The deficient practice was evidenced by the following: The surveyor reviewed an investigation for a fall Resident #49 had. The fall occurred on 2/1/25. The investigation determines that Resident # 49 had new onset of confusion and was weak and attempted to get out of bed unassisted and the resident fell. The facility's Interdisciplinary team determined that the use of bedside mats and a low bed would prevent injury should the resident fall again. A review of the residents' care plan for falls revealed that the interventions from the fall of 2/1/25 were not included in the resident's active care plans. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for a.) 1 of 17 residents reviewed for Activities of Daily Living (ADL) care (Resident #212) and b.) 2 of 3 residents (Resident #20 and #51) observed for incontinence care on 1 of 3 Units (3rd-floor Nursing Unit). This deficient practice was evidenced by the following: 1. On 4/22/25 at 12:00 PM, during a tour of the 3rd floor Nursing Unit, the surveyor observed a strong urine odor in room [ROOM NUMBER]. The surveyor interviewed the Certified Nursing Assistant (CNA #1) assigned to the resident in room [ROOM NUMBER] (Resident #212). CNA #1 stated that it was the first opportunity she had to provide incontinence care to the resident. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to assess, develop an individualized person-centered care plan to address the resident's hearing deficits and consistently provide an assistive device to maintain hearing ability. This deficient practice was identified for 1 of 1 resident reviewed for communication-sensory (Resident #35) and was evidenced by the following: On 4/22/25 at 11:36 AM, during the initial tour, the surveyor observed Resident #35, seated in a wheelchair, in the elevator, escorted by a rehabilitation (rehab) staff and a family representative. Resident #35 was alert, pleasant and not responsive to any questions. The family representative informed the surveyor that the resident could not respond since they did not have their hearing aid on. [...]

Inspectors wrote2. On 4/22/25 at 12:30 PM, the surveyor observed Resident # 49, in bed in their room and the resident was receiving oxygen therapy via nasal cannula (NC). The surveyor observed that the oxygen flow via the oxygen concentrator for the resident, was set to 1.5 LPM. At 12:35 PM, the surveyor interviewed Resident # 49's family who was at the resident's bedside, who stated that the oxygen was often set at different rates when she visited, and she was not sure what the oxygen rate should have been set at. At 12:49 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the oxygen should have been set for 2 LPM and was not sure why the rate was at 1.5 LPM. A review of Resident # 49's Physician's Orders (PO) revealed an order for Administer O2 (oxygen) at 2L/Min (liters per minute) via NC, inhalation as needed every 5 minutes as needed for SOB, dated 4/16/25. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide pain management, consistent with professional standards and develop an individualized comprehensive care plan (ICCP) to address Resident #264's localized pain. This deficient practice was identified for 1 of 1 resident reviewed for pain and was evidenced by the following: Refer F554 On 4/22/25 at 11:30 AM, during the initial tour, the surveyor observed Resident #264 in bed, awake, the head of the bed was elevated, the ankle and foot were also elevated off the bed with a pillow and was on a semi seated position. The resident informed the surveyor that they experienced pain 24 hours a day, 7 days a week from their hemorrhoids (swollen veins in the lower rectum and anus) and told the nurse on duty that day. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to a) maintain infection control standards and procedures during a wound care treatment for 1 of 1 resident (Resident #112) reviewed for care and services for pressure ulcers and b) provide a safe and sanitary environment to prevent the potential spread of infection and cross-contamination to residents and staff by failing to remove personal protective equipment (PPE) when exiting an isolation room. This was observed for 2 of 2 Certified Nursing Assistant (CNA)'s observed. The deficient practice was evidenced by the following. Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; [...]

Inspectors wroteComplaint #: NJ00152419 Based on record review, interviews, and facility policy review, the facility failed to notify the Responsible Party (RP) of a change in medical status and failed to ensure the RP's right to be informed and make decisions regarding medical care for one of one resident (Resident (R) 3) reviewed for resident rights. Specifically, the facility failed to notify the RP of R3's change in medical condition and did not give the RP the opportunity to make decisions regarding invasive medical care related to intravenous and subcutaneous hydration therapy.

Inspectors wroteComplaint #: NJ00160914 Based on interviews, record reviews, and policy review, the facility failed to notify the physician of laboratory results for one of one (Resident (R) 2) residents reviewed for laboratory services. Specifically, the facility failed to notify the physician of R2's abnormal urinalysis results.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) follow a physician's order for parameters before administering blood pressure medication, b.) sign the Electronic Treatment Administration Record (ETAR) to confirm a resident's suprapubic catheter care, placement and patency was done and urine output record was completed, and c.) execute a physician's order for a sleep aid medication for a resident with insomnia. This was found with 3 of 19 residents reviewed for professional standards of practice, Resident # 42, Resident # 271, and Resident # 67. Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to accurately document the administration of controlled medication for one resident (Resident #14). This deficient practice was identified on 1 of 2 medication carts reviewed and evidenced by the following: On 3/9/23 at 10:26 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the third floor Cart Two. The surveyor and the LPN reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic medication inventory was compared to the to the corresponding declining inventory sheet, the surveyor identified Resident #14's oxycodone/apap 5/325 milligram (mg) tablets, a medication used for pain, did not match. The blister pack contained 22 tablets and the declining inventory sheet indicated there should be 23 tablets remaining. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation and The Centers for Disease Control and Prevention (CDC) guidance it was determined that the facility failed to a) follow accepted infection control practices regarding the use of Personal Protective Equipment (PPE) for residents on Transmission Based Precautions (TBP). The deficient practice was identified for 2 Certified Nursing Assistants (CNA) and 1 laboratory technician (LT) employed by an outside vendor and b) failed to clean resident rooms in a sequence that would decrease the possibility of spreading infection, ie. Covid-19. The deficient practice was observed for 1 housekeeper. The deficient practices are as follows: 1. On 05/05/21 at 12:30 PM the surveyor observed a CNA deliver a lunch tray to a resident residing in a room designated as Person Under Investigation (PUI). [...]