Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montclair Care Center during CMS and state inspections, most recent first.
A facility failed to complete and transmit MDS assessments within the required timeframe for multiple residents. The MDSC/RN stated he was aware the assessments were late and was catching up, and records showed delayed transmission of admission, discharge return not anticipated, and quarterly MDSs after completion.
Missing DEA Form-222 Record: The facility failed to maintain consistent record keeping for DEA Form-222 used to track ordered and received controlled substances. During survey review with the DON, one DEA order form was found missing from the records, and the DON stated the form could not be located and the timeline for its disappearance could not be determined.
An LPN was observed preparing medications for a resident and made two medication errors, resulting in an 8.0% error rate during the med pass. The LPN gave the wrong dose of Colace and selected the wrong drug, Vitamin B12, instead of the ordered Vitamin B1, and later confirmed the errors during review of the eMAR.
A survey identified deficiencies in the storage and maintenance of potentially hazardous foods. The FSD confirmed the presence of black and white build-up in the ice machine, soiled sprinkler heads and pipes above the stove, dirty grill knobs and oven handles, and expired milk in the refrigerator. Additionally, dented cans of diced peaches were found in the dry storage room, contrary to the facility's policies on food safety and dented can management.
The facility failed to complete and submit MDS assessments for 14 residents within the required 14-day timeframe due to staffing issues, including the resignation of the MDS Coordinator. The delay resulted in some assessments being over 120 days old, and the facility's administrative team acknowledged the backlog but provided no further documentation to address the issue.
The facility failed to ensure timely signing and dating of monthly physician orders and progress notes for multiple residents, resulting in missing and unsigned documentation despite regular physician visits.
The facility failed to ensure that 5 licensed nurses were assessed for required competencies to meet resident care needs. The DON provided appraisals that did not address specific nursing tasks, and both the DON and Administrator confirmed that nurse competencies were not performed, except for Medication Pass Observation by the Consultant Pharmacist.
A resident with dementia and adult failure to thrive was observed with an inaccessible call light on two occasions. The call light cord was tied to the hand rail and resting on the floor, making it difficult for the resident to reach. CNAs confirmed that the call bell should be within reach, and the regular CNA stated she always places it in the resident's hand. The issue was acknowledged by the DON and Administrator.
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS assessment for a resident who was readmitted after a gastrostomy tube insertion. The MDS Coordinator admitted the oversight, which was confirmed during an interview and discussed with the Administrator and DON.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in their assessments. One resident's mood interview was conducted outside the required lookback period, and another resident's immunization status was not properly documented.
The facility failed to consistently assess a resident's vital signs and dialysis access site before and after dialysis visits. The resident reported that nurses did not perform these assessments, and observations and medical record reviews confirmed inconsistent documentation. The facility's policy required these assessments, but they were not consistently followed.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications by not following the Consultant Pharmacist's recommendations and lacking adequate documentation for the use of Linzess. The attending physician did not provide a rationale for the PRN use of Linzess and did not document any progress notes addressing the CP's recommendation. The resident's admission record did not reflect the necessary diagnoses for the medication's indicated use.
Late MDS Transmission for Multiple Residents
Penalty
Summary
The facility failed to complete and transmit MDS assessments in accordance with federal guidelines for 4 of 15 residents reviewed. The report identified that the MDS, a federally mandated assessment tool used to facilitate care management, must be electronically transmitted within 14 days of completion, but the facility did not meet that requirement for Resident #1, Resident #3, Resident #4, and Resident #55. The surveyor reviewed the resident assessment records and requested the final validation reports from CMS after being informed that three residents had not had an MDS completed and transmitted within the required timeframe. The MDS Coordinator/RN stated that he started in January of that year and was aware the MDS assessments were late and that he was catching up. The records showed that Resident #1’s admission MDS was completed on 10/14/25 for an ARD of 10/7/25 but was not transmitted until 11/11/25; Resident #3’s discharge return not anticipated MDS was completed on 10/8/25 for an ARD of 9/24/25 but was not transmitted until 11/21/25; Resident #4’s admission MDS was completed on 8/26/25 for an ARD of 8/19/25 but was not transmitted until 9/18/25; and Resident #55’s quarterly MDS was completed on 9/4/25 for an ARD of 8/21/25 but was not transmitted until 10/8/25. The surveyor also met with the DON regarding the concern.
Missing DEA Form-222 Record
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not maintaining a consistent system of record keeping for DEA Form-222, the federal narcotic requisition form used to track ordered and received controlled-dangerous substances. During review of the DEA Form-222 with the DON, surveyors observed that DEA order form number 221312108 was missing from the facility’s records. At the time of the survey, the DON stated she would continue to search, investigate, and contact the provider pharmacy. Later, the DON stated she was relatively new to the facility and had been keeping the DEA Form-222 with her and double checking that all forms were present. She also stated that the missing DEA order form number 221312108 could not be located and the timeline for when it went missing could not be determined. The facility policy reviewed stated that the facility complied with laws and regulations related to handling, storage, disposal, and documentation of Schedule II controlled substances.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that medications were administered without an error rate of 5% or greater. During a medication administration observation, two nurses were observed administering medications to five residents, with 25 opportunities for error and two observed errors, resulting in an 8.0% medication error rate. The deficient practice involved Resident #55 and one of the nurses who prepared medications for the resident. For Resident #55, the LPN prepared Colace 100 mg and Vitamin B1 100 mg for administration. While preparing the medications, the LPN stated she could not find all of the medications due that morning and went to check the supply room downstairs. She then returned with a bottle of Vitamin B12 500 mcg and later poured one capsule of Colace 100 mg instead of the ordered two capsules, and two tablets of Vitamin B12 500 mcg instead of one tablet of Vitamin B1 100 mg. During review of the eMAR, the LPN acknowledged that she poured the wrong dose of Colace and obtained the wrong drug, Vitamin B12 500 mcg, which was not part of the physician's order.
Deficiencies in Food Storage and Maintenance Practices
Penalty
Summary
The facility was found to have deficiencies related to the storage and maintenance of potentially hazardous foods, as observed during a survey on 4/3/24. The Food Service Director (FSD) confirmed that the ice machine had black and white build-up, the sprinkler heads and pipes above the stove were soiled, grill knobs and oven handles were dirty, and expired milk was found in the refrigerator. Additionally, dented cans of diced peaches were observed in the dry storage room, contrary to the facility's policies on food safety and dented can management.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments for 14 residents within the required 14-day timeframe as mandated by the Centers for Medicare and Medicaid Services (CMS). The survey team identified that the MDS assessments for these residents were significantly overdue, with some assessments being over 120 days old. The residents affected included those with Annual MDS, Quarterly MDS, Significant Change MDS, and Admission/5 Day MDS assessments that were either still in progress or in export-ready status but not submitted to CMS within the required timeframe. The survey team conducted interviews and reviewed medical records, revealing that the delays were due to staffing issues, including the resignation of the previous MDS Coordinator and the use of an agency to handle MDS submissions. The facility's administrative team, including the License Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Operations (RDO), acknowledged the backlog and attributed it to the absence and eventual resignation of the MDS Coordinator. The RDO admitted to not realizing the extent of the delay in MDS submissions. The survey team noted that the facility's policy and procedure for the timely completion of MDS assessments, revised in June 2023, was not followed. Despite the facility's acknowledgment of the issue and the stated reasons for the delays, no further documentation or information was provided to address the late submissions. The deficiency was identified as a failure to comply with federal and state regulatory requirements for the timely submission of MDS assessments.
Failure to Ensure Timely Physician Orders and Progress Notes
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficiency was observed for three residents. For Resident #41, the physician did not sign and date the monthly Order Summary Report for several months, despite the physician visiting the facility every other day. Similarly, Resident #58's medical record revealed that the physician had not signed monthly orders for February and March 2024, and the April 2024 Clinical Physician Orders were overdue for review by 63 days. The facility administrator confirmed the lack of signed monthly orders but did not provide a reason for the oversight. Resident #45's medical record showed that monthly physician orders were only signed for two months, and there was a significant gap in the physician's progress notes, with the latest entry being a late entry dated 2/12/24 and the previous one dated 12/22/22. The Regional Director of Operations (RDO) stated that physicians documented electronically and transferred their reports to the facility's electronic progress notes but was unaware of the missing entries. For Resident #28, the attending physician's progress notes were missing for several months, with the latest entry being a late entry dated 11/19/2023. The Director of Nursing (DON) was unaware of the missing progress notes and stated that the attending physician visited the facility monthly. The facility's policy required physician orders and progress notes to be signed and dated every thirty days, with the possibility of extending to every sixty days after the first ninety days of the resident's admission. However, the facility failed to adhere to this policy, resulting in missing and unsigned physician orders and progress notes for multiple residents. The administrative team acknowledged the issue and stated that physicians had their own logins to the electronic system but had not consistently documented their visits and orders.
Failure to Assess Nurse Competencies
Penalty
Summary
The facility failed to ensure that 5 of 5 licensed nurses were assessed to have the required competencies to meet the care needs of residents. The surveyor requested annual nurse competencies for 5 randomly selected nurses, but the Director of Nursing (DON) provided Nursing Performance Appraisals that did not address specific nursing tasks. The appraisals covered non-care areas such as knowledge of the resident's bill of rights, maintaining residents' dignity, and infection control techniques, but failed to list the specific required steps to complete nursing tasks competently. The DON confirmed that nurse competencies were not done for any of the nurses employed at the facility. The Administrator also confirmed that no nurse competencies were performed by facility administration, except for the Medication Pass Observation conducted by the facility's Consultant Pharmacist. The facility's Staff Performance Evaluation Policy indicated that an employee should receive a performance evaluation that includes satisfactory demonstration of applicable competencies, but this was not adhered to.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible. The deficiency was identified for a resident with dementia and adult failure to thrive, who was observed on two separate occasions with the call light cord tied to the right hand rail and resting on the floor, making it inaccessible. The resident was alert but had garbled speech, long and short-term memory deficits, and impaired decision-making skills. Interviews with CNAs confirmed that the call bell should be within reach of the resident, and the regular CNA for the resident stated she always places the call bell in the resident's hand. The issue was discussed with the Director of Nursing and the Administrator, who acknowledged the problem.
Failure to Complete SCSA MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment for one resident. The resident, who had diagnoses of gastrostomy and adult failure to thrive, was observed receiving a feeding through a gastrostomy tube. The resident was transferred to the hospital for a planned insertion of a gastrostomy feeding tube and was readmitted to the facility after the procedure. The MDS Coordinator admitted that a SCSA assessment should have been completed upon the resident's readmission but was not, due to an oversight. This omission was confirmed during an interview with the MDS Coordinator and discussed with the Administrator and the Director of Nursing.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in their assessments. For Resident #41, the Annual MDS (AMDS) assessment dated 11/24/23 showed a severe cognitive impairment with a BIMS score of 3 out of 15. However, the Resident Mood Interview (PHQ-9) was conducted five days before the Assessment Reference Date (ARD), which is outside the required 7-14 day lookback period. The MDS Coordinator (MDSC)/Registered Nurse (RN) and the Social Worker (SW) were involved in this process, with the SW admitting to conducting the assessment earlier than allowed due to a misunderstanding of the timing requirements. For Resident #116, the most recent AMDS assessment dated 9/1/23 indicated a moderately impaired cognition with a BIMS score of 9 out of 15. However, the assessment failed to capture the resident's immunization status accurately. The electronic immunization record showed that the resident had received the Influenza vaccine on 10/14/22 and the Pneumovax on 10/28/21, but this information was not documented in Section O of the AMDS assessment. The director of operations acknowledged that the MDSC/RN did not capture the immunization data because it was not yet in the electronic medical record, despite being available as historical data.
Failure to Consistently Assess Dialysis Resident's Vital Signs and Access Site
Penalty
Summary
The facility failed to consistently assess a resident's vital signs and dialysis access site prior to leaving and upon returning from the dialysis clinic. This deficiency was identified for one resident who required dialysis care and services. The resident, who has diagnoses including end-stage renal disease and type 2 diabetes mellitus, reported that the nurse did not assess them before leaving or when returning from the dialysis clinic. Observations confirmed that the Licensed Practical Nurse (LPN) did not assess the resident's vital signs or the access site before the resident left for dialysis. Additionally, a review of the medical records showed that out of 30 days of dialysis visits, nurses documented both pre and post-dialysis assessments on only one day and post-dialysis assessments on five days. The facility's policy and procedure for dialysis care, reviewed in June 2023, instructed staff to assess the access site before transport to the dialysis facility and upon return. However, the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that nurses should document these assessments in the electronic Nursing Progress Notes, which was not consistently done. The Administrator acknowledged the concern and stated that nursing staff were educated to perform and document pre and post-dialysis vital signs and access site checks.
Failure to Follow Consultant Pharmacist Recommendations and Provide Adequate Documentation for Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not following the Consultant Pharmacist (CP) recommendations and lacking adequate diagnosis, indications, and documentation supporting the use of Linzess. The resident had a physician's order for Linzess as needed (PRN) for constipation, but there was no documentation in the electronic medical record (EMR) to support the effectiveness or clinical rationale for its PRN use. The CP had recommended clarifying the use of Linzess, but the attending physician did not provide a rationale for continuing the medication as PRN and did not document any progress notes addressing the CP's recommendation between 1/2/2024 and 4/1/2024. The attending physician stated that the resident had a diagnosis of constipation and had been using Linzess at home but could not recall changing the order to PRN or seeing the CP's recommendation. The CP confirmed that she had made the recommendation and usually the facility addresses such concerns promptly. However, the resident's admission record did not reflect diagnoses of irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC), which are the indicated uses for Linzess. The manufacturer's prescribing information also did not support the PRN use of Linzess for these conditions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montclair
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Family Of Caring Healthcare At Montclair | 1 mi | ★★★★★ | 0 | 0 |
| Green Hill | 1.9 mi | ★★★★★ | 6 | 0 |
| Job Haines Home For Aged People | 2.2 mi | ★★★★★ | 0 | 0 |
| Park Crescent Healthcare & Rehabilitation Center | 2.5 mi | ★★★★★ | 12 | 0 |
| Alaris Health At St Marys | 2.8 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.