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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-28 | 2023-05-12 | 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 | 2023-03-28 | 2023-05-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-28 | 2023-05-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-03 | 2023-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-03 | 2023-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-03 | 2023-04-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-03 | 2023-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-03 | 2023-04-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-04-03 | 2023-04-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-03 | 2023-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-03 | 2023-04-21 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-04-03 | 2023-04-21 | 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 | 2023-04-03 | 2023-04-21 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-04-03 | 2023-04-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-03 | 2023-04-21 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-04-03 | 2023-04-21 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-11 | 2023-02-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-14 | 2023-02-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-14 | 2023-02-01 | 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 | 2022-11-14 | 2022-12-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-11-14 | 2022-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-14 | 2022-12-15 | 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 | 2022-11-14 | 2022-12-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-14 | 2022-12-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-14 | 2022-12-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-14 | 2022-12-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-14 | 2022-12-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-11-14 | 2022-12-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-14 | 2022-12-13 | 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 | 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 |
| 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 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-11 | 2020-02-29 | 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 | N |
| 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 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-11 | 2020-02-19 | N |
| 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 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-11 | 2020-02-19 | 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 | 2019-12-11 | 2020-02-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-11 | 2020-02-19 | N |
| 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 | N |
| 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 | N |
| Keep all essential equipment working safely. | Health | 2019-12-11 | 2020-02-19 | 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 | 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 |
