Cycle 1
Health 2025-11-26 · Fire 2025-11-26
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Montclair, NJ
Montclair Care Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
111-115 Gates Avenue, Montclair, NJ
(973) 746-4616
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Highbridge Healthcare
Operator or chain grouping
Approved since
1996-12-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
4.28
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,117
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.50% · Performance 23.94% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.88% · Performance 10.46% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.09
Performance 34.69% · Measure score 7.09 · Achievement 7.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.01
Baseline 3.86 hours · Performance 4.22 hours · Measure score 4.01 · Achievement 4.01 · Improvement 1.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.46% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 14.13% · Lower 95% interval 8.23% |
| Discharge to community | 44.9% |
50.57%
5.7 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 37.11% · Lower 95% interval 35.85% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98.36% |
95.27%
3.1 pts better
|
Numerator 60 · Denominator 61 |
| Falls with major injury | 3.28% |
0.77%
2.5 pts worse
|
Numerator 2 · Denominator 61 |
| Discharge self-care score | 81.58% |
53.69%
27.9 pts better
|
Numerator 31 · Denominator 38 |
| Discharge mobility score | 68.42% |
50.94%
17.5 pts better
|
Numerator 26 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 4.92% |
2.29%
2.6 pts worse
|
Numerator 3 · Denominator 61 · Adjusted rate 3.68% |
| Healthcare-associated infections requiring hospitalization | 10.46% |
7.12%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 17.91% · Lower 95% interval 6.14% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 91 |
| Staff flu vaccination coverage | 83.81% |
42%
41.8 pts better
|
Numerator 88 · Denominator 105 |
| Discharge function score | 68.42% |
56.45%
12 pts better
|
Numerator 26 · Denominator 38 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 18 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 17.24% |
25.2%
8 pts worse
|
Numerator 5 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.1
0.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
93.0%
3.2 pts better
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 94.7% · Q3 100.0% · Q4 100.0% · 4Q avg 96.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.4%
2.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
11.4%
7.9 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 5.6% · Q4 5.7% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
4.6%
0.2 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 8.8% · Q3 2.8% · Q4 2.9% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
19.0%
0.4 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.1% · Q3 21.6% · Q4 19.4% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
13.5%
3.1 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 8.7% · Q3 9.4% · Q4 9.4% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.6% |
9.8%
4.8 pts worse
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
9.7%
6.1 pts worse
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 3.6% · Q3 10.3% · Q4 14.8% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.8%
0.5 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
15.9%
5 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 29.4% · Q3 22.1% · Q4 17.9% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
6.0%
0.8 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 4.1% · Q3 6.4% · Q4 5.6% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
78.7%
9.5 pts better
|
81.7%
6.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 83.8% · Q3 92.9% · Q4 93.1% · 4Q avg 88.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
8.2%
0.1 pts worse
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.6% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.2% |
80.1%
4.1 pts better
|
79.7%
4.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
25.4%
2.8 pts better
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 24.3% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-03-03 · Fire 2022-03-03
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-01-07
F · Potential for more than minimal harm
2025-11-26
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2026-01-07
F · Potential for more than minimal harm
2025-11-26
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-26
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2026-02-09
F · Potential for more than minimal harm
2025-11-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-12-24
E · Potential for more than minimal harm
2024-04-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-10
E · Potential for more than minimal harm
2022-03-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-04-03
E · Potential for more than minimal harm
2022-03-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-03
E · Potential for more than minimal harm
2022-03-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-04-03
D · Potential for more than minimal harm
2022-03-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-04-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-26
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-24
F · Potential for more than minimal harm
2024-04-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-05
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-05
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-05
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-05-10
F · Potential for more than minimal harm
2022-03-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-03
D · Potential for more than minimal harm
2022-03-03
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-04-03
Penalties and ownership
What sits behind the stars
Ownership
Natanov, Brian
5% Or Greater Direct Ownership Interest · Individual
Egert, Debbie
5% Or Greater Direct Ownership Interest · Individual
Egert, Usher
5% Or Greater Direct Ownership Interest · Individual
Egert, Usher
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Family of Caring Healthcare at Montclair
Montclair, NJ
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Green Hill
West Orange, NJ
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Job Haines Home For Aged People
Bloomfield, NJ
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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