Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montclair Manor Care Center during CMS and state inspections, most recent first.
A resident's responsible party requested medical records, but the facility did not provide all requested records within the required 72-hour timeframe, as confirmed by the Medical Records Director, DON, and administrator. This failure was not in accordance with facility policy and had the potential to compromise the resident's rights.
Surveyors identified unsanitary conditions in the kitchen, including grime on the ice machine chute, debris under the reach-in freezer, and improper thawing of raw meats in the refrigerator, leading to potential cross-contamination. Staff interviews and policy reviews confirmed these practices did not meet required standards.
Surveyors found a hole in the kitchen storage area wall, covered only by metal wire mesh with 1/2 inch openings, in a closet used for storing paper goods. The Registered Dietician acknowledged that pests could enter through the mesh, and facility policy requires all surfaces to be intact. This deficiency created a potential for pest entry and food contamination for 54 medically compromised residents.
Three residents did not receive their prescribed therapeutic diets, including two who were not given the ordered cardiac diet and one whose tray card did not reflect a physician-ordered fortified diet for diabetes and hypertension. Dietary staff and supervisors acknowledged the discrepancies, and facility policies for updating diet orders and tray cards were not followed.
Staff did not follow the approved menu and portion sizes for residents on puree, large portion, and mechanical soft diets. Cooks served incorrect amounts of lasagna and roast turkey, and substituted extra lasagna for garlic bread, contrary to menu requirements. These actions affected multiple medically compromised residents and were confirmed by dietary staff and the Registered Dietician.
A resident's electronic health record (EHR) was left open and visible on a computer at the nursing station, unattended and facing the hallway, making private health information accessible to unauthorized individuals. The ADON acknowledged the error, and the DON confirmed that facility policy requiring EHRs to be shielded from public view and logged off when unattended was not followed.
A resident with diabetes and hypertension experienced significant weight loss, leading to new dietary interventions and physician orders. Despite these changes, the care plan was not updated to reflect the new interventions, as confirmed by the DON, due to an oversight by nursing staff.
A resident with a suprapubic catheter did not receive catheter care as ordered and required by facility policy, with multiple shifts lacking documentation of care. The DON confirmed that catheter care was not performed or recorded as required, resulting in noncompliance with established procedures.
A resident with end stage renal disease and diabetes missed a scheduled extra dialysis session due to the facility's failure to arrange transportation as required by physician order and facility policy. The Social Services Designee did not coordinate the necessary transportation, and the required steps outlined in the dialysis services policy were not followed.
A resident with multiple medical conditions was served a meal containing green beans, despite this item being listed as a dislike on her meal ticket. The DON and Administrator confirmed the error after reviewing the tray and ticket, and the facility's policy requiring staff to check tray cards for preferences was not followed.
Staff failed to follow infection control protocols when a CNA did not wear a gown while providing care to a resident on Enhanced Barrier Precautions for a wound, and when oxygen tubing for another resident with hypoxia and COPD was not changed according to facility policy. Both lapses were acknowledged by staff and leadership as not following established procedures.
Two sinks in the kitchen were found to be in unsafe condition: the handwashing sink had a disconnected drainpipe causing turbid water to leak onto the floor, and the dishwashing machine waterline was leaking, creating a puddle. These issues were observed by staff, confirmed by the RD and maintenance, and were not in compliance with facility policy or the FDA Food Code.
Ten rooms were found to be below the required 80 square feet per resident, with measurements ranging from 77 to 79.1 square feet per resident. The Administrator confirmed these rooms had waivers for being under the required size, and residents interviewed reported no complaints or safety concerns related to room size.
The facility failed to ensure that pharmacy recommendations were communicated to the physician and documented for a resident with chronic kidney disease. The resident's hydroxyzine order lacked a stop date and informed consent, and there was no evidence that the physician was informed of the pharmacist's recommendations.
A resident was found with two individual-use packets of topical medications at their bedside, which were not listed in their active orders. Staff confirmed that medications should not be kept at the bedside and should be stored in a locked medication or treatment cart.
The facility failed to ensure accurate completion and dating of a POLST form for a resident with serious medical conditions. The form was not signed or dated by the provider, and the signature was found on the plastic sleeve instead. The Nurse Practitioner later backdated the form, which was against facility policy.
The facility did not meet the required 80 square feet per resident for 12 of 18 rooms. Despite a waiver request and no reported complaints, the deficiency was confirmed through a Client Accommodations Analysis and staff interviews.
Failure to Provide Complete Medical Records Within Required Timeframe
Penalty
Summary
The facility failed to provide complete medical records to the responsible party for one resident in a timely manner, as required by facility policy. On March 19, 2025, the responsible party requested medical records, and while some current records were provided after three days, not all requested records were given. This was confirmed by the Medical Records Director during interviews and record reviews. The facility's policy, dated May 2017, specifies that access to personal and medical records must be provided within 72 hours of the request, excluding weekends and holidays. Interviews with the Medical Records Director, DON, and administrator all confirmed the expectation that records should be released within the 72-hour timeframe. However, there was inconsistency in the responses regarding whether the policy was fully followed, particularly since not all records were provided as requested. The failure to provide the complete set of records as required by policy had the potential to compromise the resident's rights and could have resulted in psychosocial harm to the responsible party.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food safety and sanitation. The ice machine was found to have yellow grime on the ice chute, which was confirmed by wiping with a paper towel. The Maintenance Supervisor acknowledged that more frequent cleaning might be necessary, and the Registered Dietician confirmed that the ice chute should be kept clean, especially since the ice is used for residents' drinks and water pitchers. Review of the ice machine manual and FDA Food Code indicated that cleaning should occur routinely to prevent microorganism buildup. Additionally, the floor under the reach-in freezer was found to have black grime, trash, and a fork, which was acknowledged by the Registered Dietician as not meeting cleanliness expectations. Inside the refrigerator, chicken was observed thawing in a metal pan with packages hanging over the side, directly above raw turkey and near raw beef, creating a risk of cross-contamination. Staff interviews confirmed that the chicken should not have been stored in this manner, and facility policy requires the use of drip pans to prevent contamination. The FDA Food Code also requires separation of different types of raw animal foods during storage to prevent cross-contamination.
Failure to Maintain Effective Pest Control in Kitchen Storage Area
Penalty
Summary
A deficiency was identified when surveyors observed a hole in the wall of the kitchen's storage area, specifically in a closet used to store paper goods such as cups, plates, and napkins. The hole, resulting from missing drywall, was covered with a metal wire mesh that had openings approximately 1/2 inch wide. This condition was directly observed during a facility visit, and the Registered Dietician confirmed that the expectation was for all walls to be intact, acknowledging that pests could potentially enter through the mesh covering. A review of the facility's sanitation policy indicated that all surfaces and equipment should be maintained in good repair and free from breaks or open seams. Additionally, the FDA Federal Food Code requires nonfood-contact surfaces to be free of unnecessary openings to prevent pest harborage. The failure to maintain an intact wall in the kitchen storage area created a potential entry point for pests, which could lead to food contamination for 54 medically compromised residents who receive food from the kitchen.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to provide physician-ordered therapeutic diets to three residents as observed during dining and record review. Two residents with orders for a cardiac diet, which includes low fat and low sodium requirements, were instead provided with a No Added Salt (NAS) diet because the Dietary Services Supervisor stated the facility does not offer a cardiac diet. The Registered Dietitian acknowledged that the residents' diet orders were not updated to reflect what the facility could provide, and the dietary staff did not ensure the electronic health record matched the actual diet being served. Facility policy required the use of approved, standardized recipes to meet resident needs, but this was not followed for these residents. Another resident with diagnoses of type 2 diabetes and hypertension had a physician order for a fortified regular diet with NAS and consistent carbohydrate (CCHO) requirements. However, during lunch observation, the resident's tray card did not indicate the fortified component as ordered by the physician. The Treatment Nurse confirmed the tray card did not match the physician's order, and the Registered Dietitian stated the correct diet should have been followed. Review of the facility's tray card policy showed that dietary staff were required to update tray cards upon receipt of new or changed diet orders, but this procedure was not followed.
Failure to Follow Approved Menu and Portion Sizes for Special Diets
Penalty
Summary
The facility failed to follow its approved daily menu for multiple residents on special diets, as observed during meal service on two consecutive days. Specifically, for residents on puree diets, the cook served only 1/2 cup of lasagna using a #8 scoop, instead of the required 1 cup portion as indicated on the menu. For residents ordered large portions, the cook served 1 1/2 servings of lasagna instead of the correct menu portion of 1 serving of lasagna and 1 1/2 slices of garlic bread. For residents on mechanical soft diets, the cook used a #16 scoop (1/4 cup) to serve roast turkey, rather than the required #10 scoop (3/8 cup) as specified by the menu. These actions were confirmed through trayline observations and staff interviews, where both the cooks and the Dietary Service Supervisor acknowledged the menu was not followed. The deficiencies affected 18 out of 55 medically compromised residents who required puree, large portion, or mechanical soft diets. The facility's own policy and procedure on food preparation requires the use of approved recipes and standardized portions to meet the nutritional needs of residents. The Registered Dietician and Dietary Service Supervisor both stated that the expectation was for menu portions to be followed, and recognized that a review of portion sizes with the cooks might be necessary. The failure to adhere to the prescribed menu portions had the potential to compromise the nutritional status of these residents.
Resident EHR Left Unattended and Visible at Nursing Station
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's electronic health record (EHR) when the Assistant Director of Nursing (ADON) left a computer terminal at the nursing station unattended, with the EHR open and visible from the hallway. During an observation, it was noted that the computer screen, which displayed the resident's weights, was accessible to public view while no nurse was present at the station. The ADON, upon returning, acknowledged that the EHR should not have been left open and visible. Review of the facility's policy confirmed that computer terminals must be shielded from public view and users are required to log off or clear the screen when leaving a workstation unattended. The Director of Nursing (DON) confirmed that this policy was not followed in this instance.
Failure to Update Care Plan Following Significant Weight Loss and Diet Change
Penalty
Summary
The facility failed to update the care plan for a resident with significant weight loss, despite changes in the resident's condition and new physician orders. The resident, who had diagnoses of type 2 diabetes and hypertension, experienced a 16-pound (13.3%) weight loss over three months. Nursing staff noted the weight loss and recommended weekly weights and a fortified diet to encourage weight gain. A physician order was placed for a fortified regular diet with specific restrictions and consistent carbohydrate intake. However, the resident's care plan for nutrition was not updated to reflect these new interventions and dietary orders. The Director of Nursing confirmed during interviews and record reviews that the care plan was not revised as required by facility policy, which mandates care plan updates when there is a significant change in a resident's condition. The delay in updating the care plan was attributed to an oversight by the nurse who received the order.
Failure to Provide and Document Required Catheter Care
Penalty
Summary
The facility failed to implement its catheter care policy and procedure for a resident with a suprapubic catheter. The resident, who was admitted with diagnoses including hydroureter, chronic kidney disease, and obstructive reflux uropathy, had a physician's order for catheter care to be performed with soap and water every shift and as needed. Review of the Treatment Administration Record (TAR) for the month of March revealed multiple shifts where catheter care was not documented as completed, specifically on several day and evening shifts throughout the month. During interviews and record reviews, the Director of Nursing (DON) confirmed that staff are required to perform and document catheter care every shift, in accordance with both the physician's order and the facility's policy. The facility's policy, which aims to improve hygiene and reduce infection, was not followed as evidenced by the missing documentation and unperformed catheter care on the identified dates.
Failure to Arrange Dialysis Transportation
Penalty
Summary
The facility failed to coordinate and arrange a dialysis appointment for a resident with end stage renal disease and diabetes who required an extra dialysis session due to fluid overload. The physician's order specified the need for an additional dialysis treatment, but the appointment was missed because transportation was not arranged. The Social Services Designee acknowledged that arranging transportation was her responsibility and that she failed to do so, resulting in the resident missing the scheduled dialysis. Review of the facility's policy and procedure for dialysis services indicated that nursing staff are responsible for arranging outside appointments and notifying social services, while social services are responsible for coordinating transportation and notifying family or responsible parties. Additionally, licensed personnel are required to confirm transportation one hour prior to the appointment. The Director of Nursing confirmed that these procedures were not followed in this instance.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
A deficiency occurred when a resident with chronic systolic heart failure, depression, and muscle wasting was served a meal that did not accommodate her documented food preferences. The resident's admission record indicated her dislikes, including green beans, yet she was served green beans for lunch. During interviews and observation, the resident stated she often receives food that does not match her preferences and expressed frustration about the lack of control over her meal options. Upon review of the resident's meal ticket and food tray, both the DON and the Administrator confirmed that green beans, listed as a dislike, were served to the resident. The facility's policy requires staff to check tray cards to ensure correct meals are served according to resident preferences, but this procedure was not followed in this instance. The DON acknowledged that the policy was not adhered to, resulting in the resident receiving a meal inconsistent with her documented preferences.
Failure to Follow Infection Control Protocols for Enhanced Barrier Precautions and Oxygen Tubing
Penalty
Summary
The facility failed to follow proper infection prevention and control practices in two separate instances. In the first case, a Certified Nursing Assistant (CNA) provided care to a resident with diagnoses including cardiomegaly, type 2 diabetes with neuropathy, and chronic mastoiditis, who was under Enhanced Barrier Precautions (EBP) due to a wound. Despite a physician's order and signage indicating EBP, the CNA did not wear a protective gown during high-contact care activities. The CNA stated she was unaware the resident remained on EBP, and the facility's policy required gown and glove use for such residents, which was not followed. In the second instance, a resident with hypoxia and chronic obstructive pulmonary disease was receiving continuous oxygen therapy via nasal cannula. Observation revealed that the oxygen tubing had not been changed in accordance with the facility's policy, which required weekly replacement. The Treatment Nurse acknowledged the tubing should have been changed, and the Director of Nursing and Administrator confirmed the policy was not followed. Both failures had the potential to result in cross-contamination among highly vulnerable residents.
Unsafe Kitchen Sink Conditions Due to Leaks and Disconnected Drainpipe
Penalty
Summary
Two sinks in the facility's kitchen were found to be in unsafe operating condition. The handwashing sink had a disconnected drainpipe, resulting in turbid water leaking onto the kitchen floor and creating a pool of water. This issue was observed during a kitchen inspection with a Dietary Aid, and the Registered Dietician confirmed that the sink should not be leaking and that any such issue should be reported to maintenance immediately. The facility's policy and procedures require all equipment to be maintained and kept in working order, and the FDA Federal Food Code specifies that handwashing sinks must be maintained for proper employee use to prevent contamination. Additionally, a waterline under the dishwashing machine was leaking, causing a puddle of water on the kitchen floor. The Maintenance Employee indicated that the waterline seal likely needed replacement to stop the leak. The Registered Dietician, responsible for kitchen inspections, also stated that the waterline should not be leaking and needed to be fixed. Both deficiencies were observed and confirmed through interviews and a review of facility policies, which emphasize the importance of maintaining equipment in safe working condition.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that ten resident rooms met the required minimum of 80 square feet per resident for multiple occupancy rooms. During an environmental tour and review of facility records, it was confirmed that Rooms 4, 5, 7, 8, 10, 11, 12, 14, 16, and 18 all measured less than the required square footage per resident, with each room ranging from 77 to 79.1 square feet per resident. The Administrator acknowledged that these rooms had existing waivers for being under the required size. Interviews with the residents occupying these rooms revealed that none had complaints regarding the size or space of their rooms, and there were no observed safety hazards or issues with crowding. The deficiency was identified through direct measurement and observation, as well as confirmation from facility leadership that the rooms did not meet the regulatory standard for square footage per resident.
Failure to Document Pharmacy Recommendations and Physician Response
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were communicated to the physician and that the physician's response was documented for a resident with a diagnosis of stage 3 chronic kidney disease. The resident was admitted with an order for hydroxyzine, an antihistamine, without a stop date. The consultant pharmacist recommended clarifying the stop date and obtaining informed consent for the medication, but there was no evidence that these recommendations were communicated to the physician or documented in the resident's medical record. The resident's progress notes and electronic health record showed no documentation of the physician being informed of the pharmacist's recommendations or providing consent for the continued use of hydroxyzine. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the pharmacy consultant's recommendations were received and expected to be acted upon in a timely manner. However, there was no designated person responsible for ensuring that the recommendations were communicated to the physician and documented. The DON confirmed that there was no stop date for the hydroxyzine order and no informed consent documented in the resident's medical record. The Assistant Administrator (AA) also stated that staff were expected to notify the physician and document their response in the resident's medical record when there was a pharmacist recommendation.
Improper Storage of Topical Medications at Bedside
Penalty
Summary
The facility failed to ensure that single-use packets of topical medications were not stored at the bedside for Resident #14. The resident, who was cognitively intact with a BIMS score of 14, was observed with two individual-use packets of topical medications (A&D ointment and hydrocortisone cream) at their bedside. These medications were not listed in the resident's active orders. LVN #3 confirmed that medications should not be kept at the bedside, and LVN #5, who was assigned to the resident during the overnight shift, was unaware that the medications had been left there. CNA #4 also did not know about the medications being left at the bedside. During the survey, LVN #1 acknowledged that Resident #14 did not have an order for the observed medications and admitted to not removing them when she saw them at the bedside. Instead, she informed another nurse about their presence. The medications should have been stored in a locked medication or treatment cart, as per facility protocol. The failure to properly store these medications was confirmed through observations, interviews, and record reviews.
Failure to Accurately Complete and Date POLST Form
Penalty
Summary
The facility failed to ensure documentation was completed and dated accurately for a resident's advance directives. Specifically, the Physician Orders for Life-Sustaining Treatment (POLST) form for a resident with multiple serious diagnoses, including chronic obstructive pulmonary disease (COPD) and chronic kidney disease, was not signed or dated by the provider. The form indicated that the resident wished to attempt resuscitation/CPR, but the signature was found on the plastic sleeve containing the form rather than on the form itself. This discrepancy was identified during a review of the resident's records and interviews with facility staff, including the Medical Records staff and the Director of Nursing (DON), who were unaware of the incomplete documentation. Further investigation revealed that the Nurse Practitioner (NP) responsible for signing the form had initially signed the plastic sleeve and later backdated the form based on a date when she thought she had seen the resident. This practice was not in line with the facility's policy, which required real-time documentation. The Assistant Administrator confirmed that backdating was not standard practice and that all documentation should be completed in real-time. The deficiency was identified during a survey, highlighting a lapse in the facility's adherence to its policies regarding advance directives and proper documentation.
Failure to Meet Required Room Size
Penalty
Summary
The facility failed to ensure the required 80 square feet per resident was met for 12 of 18 resident rooms. A review of facility documents revealed that rooms 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, and 18 did not provide each resident with the mandated space. Despite a waiver request for nine rooms, interviews with the Director of Nursing, Assistant Administrator, and Administrator indicated that they believed the room sizes did not affect resident care and reported no complaints from residents regarding room size. The facility's Client Accommodations Analysis confirmed the deficiency in room size.
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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) |
|---|---|---|---|---|
| Community Extended Care Hospital Of Montclair | 1 mi | — | 10 | 0 |
| Inland Christian Home | 2.2 mi | — | 0 | 0 |
| Claremont Heights Post Acute | 2.2 mi | — | 24 | 0 |
| Trellis Chino | 2.7 mi | — | 1 | 0 |
| Ontario Healthcare Center | 2.7 mi | — | 11 | 0 |
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