Montclair Manor Care Center

Inspectors wroteBased on interviews and record review, the facility failed to provide medical records to the party responsible for one of four residents (Resident 1) in a timely manner, in accordance with the facility policy. This failure had the potential to compromise Resident 1 ' s rights which had the potential for Resident 1 ' s responsible party to experience psychosocial harm (mental harm and suffering). Findings During a concurrent interview and record review, on April 15, 2025, at 2:30 PM, with the Medical Records Director (Director), the facility ' s AUTHORIZATION FOR THE RELEASE OF CLINICAL INFORMATION, the authorization indicated, on March 19, 2025, the responsible party requested medical records. This information is verified and confirmed by the director. Director stated the party responsible was provided with the current records after 3 (three) days upon request; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. The ice machine had yellow grime (dirt clinging to or rubbed into a surface) in the ice chute (a passage, often filled with ice). This had the potential for contribution of microorganism (tiny living things like bacteria, fungi and algae that are too small to be seen with the naked eye) growth. 2. The floor under the reach-in refrigerator had a black grime and trash. This had the potential of pathogenic (something that can make you sick like germs or viruses) microorganisms to accumulate and attract pests. 3. Inside the refrigerator, the chicken was thawing (to unfreeze) over another set of meat. This had the potential of cross-contamination (contamination between two things). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest (insect or animal such as rodents that can spread disease) control program when in the kitchen, a closet, used to store paper goods (paper cups, paper plates, napkins, etc.), had missing drywall. The hole caused by the missing drywall was covered by a metal mesh wire (a net like material that has holes) cover. This failure had the potential of making an entry for pests and causing food contamination for 54 medically compromised residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered therapeutic diets (special meal plans, made for people with health problems) were provided to three of 11 residents (Residents 34, 48, and 41) reviewed for dining observation when: 1. Residents 34 and 48 did not receive their physician ordered cardiac diet (low sodium, low fat diet). 2. Resident 41 did not receive the prescribed therapeutic diet for lunch on April 1, 2025. These failures had the potential to cause nutritional decline and unmet care needs for Residents 41, 34 and 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their daily approved menu for lunch on April 1, 2025, and April 2, 2025, when: 1. On April 1, 2025, Dietary [NAME] 1 (Cook 1), served puree (food that has been blended, pressed or ground to have a creamy texture) lasagna with #8 scoop (1/2 cup). The menu indicated the portion should be 1 cup. 2. On April 1, 2025, [NAME] 1, for the large portion orders served 1 ½ of lasagna. The menu indicated that it should be 1 ½ garlic bread not lasagna. 3. On April 2, 2025, Dietary [NAME] 2 (Cook 2), for the mechanical soft (foods that are easily swallowed) orders served #16 scoop (¼ cup). The menu indicated the portion should be #10 scoop (3/8 cup). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's electronic health records (EHR- medical records kept on a computer system) were kept private and protected from public view for one of nineteen sampled residents (Resident 22) when the Assistant Director of Nursing (ADON) left Resident 22's EHR unattended, visible and viewable to the hallway at the nursing station. This failure had the potential to place Resident 22 at risk for her medical records to be viewed by other residents or healthcare providers who should not have access to Resident 22's medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was updated in accordance with the facility's policy and procedure for one of four residents (Resident 41) reviewed for nutrition. This failure had the potential for Resident 41 to be at risk for continued nutritional decline, delayed interventions and unmet care needs related to weight loss and associated medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure their catheter (tube that is inserted into your bladder, allowing your urine to drain freely) care policy and procedure was implemented for one of two residents (Resident 11) reviewed for catheter. This failure had the potential to place Resident 11 at risk for developing urinary infection (when bacteria enters and infects the urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate and arrange the dialysis (procedure to remove waste products and excess fluid from the blood) appointment for one of one resident (Resident 36) reviewed for dialysis. This failure had the potential to place Resident 36 at risk of complications due to fluid overload (body has too much water).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were accommodated for one of four residents (Resident 11) reviewed for nutrition when Resident 11 was served green beans for lunch on April 1, 2025. This failure had the potential to result in unmet care of needs for Resident 11 which could potentially affect the resident's nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. A Certified Nursing Assistant (CNA 1) did not wear a protective gown while providing care for Resident 31, who was on enhanced barrier precautions (EBP- infection control intervention designed to reduce the transmission of harmful germs by wearing gown and gloves during high-contact care activities). 2. Resident 18's oxygen tubing (tube that contains two open prongs intended to deliver oxygen into the nose) was not changed in accordance with the facility's policy. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 54 highly vulnerable residents whose health conditions were already compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two sinks in the kitchen were in safe operating condition when: 1. The hand washing sink drainpipe (a pipe carrying off dirty water) was not connected and turbid water was leaking on the kitchen floor. 2. The dish washing waterline (a hose that carries water into the sink) under the sink was leaking water onto the kitchen floor. These failures had the potential of causing water damage, mold (a type of fungus that grows in damp, warm places and can look like fuzzy spots or patches) growth, causing staff injury, and contamination compromising the health of the 54 vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ten rooms (Rooms 4, 5, 7, 8, 10, 11, 12, 14, 16 and 18) measured at least 80 square feet per resident. This failure had the potential for the residents housed in Rooms 4, 5, 7, 8, 10, 11, 12, 14, 16, and 18 to not have the ability to move about freely if the square footage limited their personal space.

Inspectors wroteBased on interviews, record reviews, and facility document and policy review, the facility failed to have evidence that pharmacy recommendations were communicated to the physician, and physician response was documented for 1 (Resident #11) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure single-use packets of topical medications were not stored at the bedside for 1 (Resident #14) of 1 sampled resident observed with medications stored in their room.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure documentation was completed and dated accurately for 1 (Resident #12) of 5 sampled residents reviewed for advance directives.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure the required 80 square feet (sq ft) per resident was met for 12 of 18 resident rooms (rooms 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16 and 18).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when two sinks in the kitchen did not have an air gap (separation of the drainpipe on a sink to prevent backflow of contaminated water during negative pressure). This failure had the potential to expose 48 highly vulnerable residents who received food from the kitchen to food-borne illness (food poisoning).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three outside dumpster lids were completely closed. This failure had the potential to attract vermin (pest or animals that spread diseases) in a facility that cares for 49 medically compromised residents.

Inspectors wrote2. During a review of Resident 8's clinical record, the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included, type 2 diabetes mellitus, end stage renal disease (condition in which kidneys are not working), and hyperlipidemia (excessive fat in the blood). During an observation on October 6, 2022, at 7:20 AM, Resident 8 was sitting in her wheelchair, eating breakfast. Resident 8 stated she was leaving for her dialysis treatment (procedure to remove waste products and excess fluid from the blood). A concurrent interview and record review with the Director of Nursing (DON) was conducted on October 6, 2022, at 3:12 PM. The DON reviewed Resident 8's September 2022 Medication Administration Record (MAR), which indicated the following missing documentations: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Staff did not perform proper hand hygiene during medication pass for three residents (Residents 2, 248, 6, and 8). 2. Staff did not follow facility policy and procedure for wound care for Resident 21. 3. Resident 35's foley catheter bag (a bag connected to the catheter to collect urine) was not changed in accordance with facility policy and procedure. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to other residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set Assessment (MDS - a computerized assessment instrument) for one resident (Resident 31) reviewed for communication. This failure had the potential to cause inaccuracy in identifying Resident 31's care and support needs, and cause delay in these needs being met.

Inspectors wroteBased observation, interview, and record review, the facility failed to develop a comprehensive and personalized care plan to address the needs and goals for two of 24 sampled residents (Residents 31 and 150) when: 1. Resident 31 did not have a personalized care plan for communication. 2. Resident 150 did not have a care plan for diagnosis of cataracts (a condition which causes blurry vision). These failures had the potential to prevent the resident's medical and psychosocial needs from being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to increase range of motion (measurement of how far you can move a specific joint or other body part) or to prevent further decrease in range of motion for one of three sampled residents (Resident 38), when the Restorative Nursing Assistance (RNA) active range of motion (A/AROM) program was not being provided to Resident 38, as per physician orders. This failure had the potential to decrease Resident 38's range of motion and could have resulted in worsening of contractures and mobility.

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 for one resident (Resident 39) reviewed for G-tube. This failure had the potential to increase the risk for aspiration (when food or liquids enter the lungs) and compromise Resident 39's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly record and account for a medication removed from one of 12 Emergency Kits (E-kit- secure box kept with medications inside for urgent use). This failure had the potential to cause medications to not be readily available for resident during an urgent situation in a highly vulnerable population of 49 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for nine of 19 resident rooms. This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms.