MONTCLAIR NURSING AND REHABILITATION CENTER NE DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/18/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
11/18/2009	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
11/18/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
11/18/2009	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
11/18/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/18/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
11/18/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
11/18/2009	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
11/18/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/18/2009	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
11/18/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
11/18/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
11/18/2009	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
11/18/2009	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
11/18/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
11/18/2009	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
11/18/2009	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
11/18/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
11/18/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
11/18/2009	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
11/18/2009	restrictions on the use of portable space heaters.	Widespread	Minimal harm or potential for actual harm
11/18/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
11/18/2009	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
11/18/2009	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
11/18/2009	no-smoking signs where oxygen is used.	Widespread	Minimal harm or potential for actual harm
11/18/2009	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
11/20/2008	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
11/20/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
11/20/2008	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
11/20/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
11/20/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
11/20/2008	proper backup exit lighting.	Widespread	Minimal harm or potential for actual harm
11/20/2008	properly located and lighted "Exit" signs.	Widespread	Minimal harm or potential for actual harm
11/20/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
11/20/2008	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
11/20/2008	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
11/20/2008	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
11/04/2008	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
11/04/2008	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
11/04/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
11/04/2008	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
11/04/2008	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
11/04/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Actual harm
11/04/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
11/04/2008	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
11/04/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
11/04/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
11/04/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
11/04/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
11/04/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
11/04/2008	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
01/04/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
01/04/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
01/04/2008	restrictions on the use of portable space heaters.	Widespread	Minimal harm or potential for actual harm
01/04/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
01/04/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
01/04/2008	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
01/04/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
11/08/2007	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
11/08/2007	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
11/08/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/08/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
11/08/2007	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death