Deficiency Records for The Banyan at Montclair
Updated as of November 01, 2022
This is not the most recent data for The Banyan at Montclair. For the most recent information, click here.
A list of the most recent deficiencies for The Banyan at Montclair. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-14 | 2022-08-28 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-14 | 2022-08-28 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-23 | 2022-05-07 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Meet other general requirements. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-11 | 2021-11-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-14 | 2021-11-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-14 | 2021-11-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-14 | 2021-11-25 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-14 | 2021-11-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-14 | 2021-11-25 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-14 | 2021-11-25 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-14 | 2021-11-25 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-14 | 2021-11-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-14 | 2021-11-25 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-14 | 2021-11-25 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-14 | 2021-11-25 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-14 | 2021-11-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-11-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-11-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-14 | 2021-11-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-14 | 2021-11-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-14 | 2021-11-25 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-10-14 | 2021-11-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-14 | 2021-11-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-14 | 2021-11-25 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-14 | 2021-11-25 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-10-14 | 2021-11-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-22 | 2021-03-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-02-22 | 2021-03-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-07 | 2020-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-18 | 2020-08-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-11 | 2020-02-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-11 | 2020-02-29 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-12-11 | 2020-02-19 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-12-11 | 2020-02-19 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-12-11 | 2020-02-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-11 | 2020-02-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-11 | 2020-02-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-11 | 2020-02-19 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-11 | 2020-02-19 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-12-11 | 2020-02-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-11 | 2020-02-19 | Y |
| Keep all essential equipment working safely. | Health | 2019-12-11 | 2020-02-19 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-12-05 | 2020-02-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-12-05 | 2020-02-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-05 | 2020-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-05 | 2020-02-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-05 | 2020-02-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-05 | 2020-02-12 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-12-05 | 2020-02-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-01-06 | 2020-02-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-01-06 | 2020-02-04 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-06 | 2020-02-04 | Y |
| Keep all essential equipment working safely. | Health | 2020-01-06 | 2020-02-04 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-01-06 | 2020-02-04 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-27 | 2020-01-06 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-27 | 2020-01-06 | Y |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-12-27 | 2020-01-06 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2018-09-11 | 2018-12-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-17 | 2018-10-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-17 | 2018-10-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-09-17 | 2018-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-17 | 2018-10-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-09-17 | 2018-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-17 | 2018-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-17 | 2018-10-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-09-17 | 2018-10-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-17 | 2018-10-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-09-17 | 2018-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-17 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-17 | 2018-10-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-17 | 2018-10-31 | N |
| Meet other general requirements. | Fire Safety | 2018-09-11 | 2018-10-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-11 | 2018-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-11 | 2018-10-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-11 | 2018-10-26 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-09-11 | 2018-10-26 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2018-09-11 | 2018-10-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-11 | 2018-10-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-09-11 | 2018-10-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-11 | 2018-10-15 | N |
