Hearth Record

Hackensack Meridian Mountainside Medical

An acute care hospital in Montclair, New Jersey 07042

1 Bay Avenue, Montclair, New Jersey 07042. (973) 429-6000.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 2 deficiencies in 2 months of the last 36. Last cited Nov 2025. Most serious: Standard-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.

What did inspectors find?

The last inspection on record was on Nov 19, 2025: a complaint inspection.

2 deficiencies cited in the last three years.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

2 deficiencies in 2 months of the last 36. Last cited Nov 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

2 deficiencies by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Nov 19, 2025: complaint inspection1 deficiency

  • Rn Supervision Of Nursing Care

    The inspectors’ words, 299 words

    “RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 51990 Based on one of 11 medical records reviewed [Patient (P)10], staff interview, and a review of facility documents, it was determined the facility failed to ensure that all patients initial comprehensive nursing assessment and re-assessment is completed in accordance with facility policy. Findings include: A review of P10’s medical record revealed the patient was admitted to 5 East, a medical and surgical unit, on 10/22/25 at 6:24 PM. Documented evidence indicated that P10’s initial nursing assessment was performed on 10/23/25 at 8:05 AM. This was 13 hours and 41 minutes after admission. P10’s initial nursing assessment was not completed by the Registered Nurse (RN) upon admission to the unit or during the subsequent 7:00 PM to 7:00 AM shift. During an interview on 11/19/25 at 1:35 PM, Staff (S)2 confirmed that P10 did not have and initial nursing assessment on admission, or on the subsequent shift, documented in EPIC (the facility’s health electronic record). S2 stated that a comprehensive initial nursing assessment is completed upon admission to the unit and that reassessment is performed every shift by the RN. Facility policy titled, “Assessment and Reassessment-[Facility Name],” effective date 10/07/27, stated, “... Policy: ... 1) The RN (Registered Nurse) will perform a comprehensive assessment of the patient’s care needs, health status and response to interventions ... Reassessment are completed at least once during each shift ... Procedure: ... 1) Initial Patient Assessment performed as soon as possible upon arrival: ... 2) Ongoing assessment as appropriate to the patient: ... a) A baseline physical assessment is to be performed by the primary nurse upon assuming care of the patient every shift ...”.”

    Rule A0395. Standard-level. From a complaint.

Aug 23, 2024: complaint inspection1 deficiency

  • Supervision Of Contract Staff

    The inspectors’ words, 471 words

    “SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 39223 Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure vital signs are documented in accordance with facility policy. Findings include: A review of Medical Record (MR) 1 was completed and revealed that Patient (P) 1 arrived to the Emergency Department on 06/20/24 for complaints of shortness of breath and an oxygen saturation (SpO2) reading of 69% without oxygen supplementation. He/She was subsequently admitted to the facility. The Nurse’s admission assessment on 06/21/24 at 01:00 AM found P1 to be alert and oriented. Further review of MR 1 revealed the following: The patient’s last full set of vital signs prior to discharge on 06/23/24 were documented as follows: 8:00 AM - Heart Rate 95; Respiratory Rate 19, Blood Pressure 111/68, and SpO2 95%. There was no documented evidence as to what level of oxygen support the patient was receiving at that time, or if he/she was receiving oxygen support. A physician’s order to discharge the patient was placed on 06/23/24 at 10:00 AM. At 7:46 PM, eleven hours and forty six minutes after the full set of vital signed were documented, P1 left the facility by ambulance transportation. There was no documented evidence that a full set of vital signs was rechecked within four hours of the patient’s discharge, as required by facility policy. Review of the untimed Universal Transfer Form, dated 06/23/24, indicated that the patient was using 3L oxygen by nasal cannula when he/she was discharged. Documented vital signs on the Universal Transfer Form stated, “... BP: 111/68 P [Pulse] 95 R [Respirations] 18 T [Temperature] 98.5 ...” It was unable to be determined when the vital signs were checked. During an interview on 08/23/24, Staff (S)12, the Registered Nurse, stated that on 06/23/24 they took one full set of vital signs the day of discharge at 08:00 AM. S12 stated that they did not check a full set of vital signs within four hours of P1’s discharge from the facility. Review of facility policy titled, “Discharge Planning Policy-UR Corp” (Policy Number 81996.1), effective 04/23/23, stated, “... 6) Nursing Discharge Assessment a) The nursing discharge assessment will be completed prior to discharge. This may include: ... ix) General status information for home health agencies, nursing home, assisted living, etc. (vital signs within 4 hours of discharge) ...””

    Rule A0398. Standard-level. From a complaint.

All 3 inspections in the last three years
Inspections on record
DateVisitWhat the record says
Nov 19, 2025Complaint inspection1 deficiency cited
Oct 9, 2024Complaint inspectionNo deficiencies cited
Aug 23, 2024Complaint inspection1 deficiency cited

How do patients fare?

  • CMS’s overall for it is 4 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 0 better and 0 worse of 7; safety of care, 1 better and 0 worse of 7; readmission, 0 better and 1 worse of 10.
  • Patients rate it 2 of 5 in CMS’s patient survey (683 surveys completed, Oct 1, 2024 to Sep 30, 2025): 61% rated it 9 or 10 out of 10, and 62% would definitely recommend it.
  • Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), better than the national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
  • CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
  • Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 12.5%, heart failure 9.5%, pneumonia 15.3%, COPD 7.6%, stroke 11.6%. CMS gives no comparison with the national rate for them in this release.
  • Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 13.7%, heart failure 22%, pneumonia 18.1%, COPD 20.6%, hip or knee replacement 5.7%. CMS gives no comparison with the national rate for them in this release.
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 229 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
  • 81% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
  • Medicare’s spending per patient here is 1.08 times the national median (Jan 1, 2024 to Dec 31, 2024).
Source:

CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.

CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 54 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 52 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Jul 1, 1966.
  • Ownership: proprietary.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • Proprietary.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
  • 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
  • In CMS’s patient survey, patients rate how well its nurses communicated 2 of 5.
  • 84% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • Montclair Health System LLC owns 80% directly since Jul 1, 2012; Hmh Hospitals Corporation owns an unstated share directly since Feb 20, 2014.
  • Ahs Management Company Inc. runs it.
  • 5 owners or officers are people: Richard Haun (managing employee (on the payroll), 100%); Martin Bonick (corporate officer, 0%); Richard Haun (corporate officer, 0%); Mary A Crabtree (corporate officer, 0%); Stephen C Petrovich (corporate officer, 0%).
  • CMS’s Provider of Services file records 1 change of ownership, the latest on Jun 1, 2007.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
Ahs Management Company Inc.Runs it (operational or managerial control)100%Jan 1, 2019
Lhp Montclair LLCOwns 5% or more through other companies80%Jul 1, 2012
Ardent Health Inc.Owns 5% or more through other companies80%Mar 13, 2017
Lhp Operations Co LLCOwns 5% or more through other companies80%Jul 1, 2012
Montclair Health System LLCOwns 5% or more directly80%Jul 1, 2012
Lhp Hospital Group, Inc.Owns 5% or more through other companies80%Jul 1, 2012
Ardent Legacy Holdings LLCOwns 5% or more through other companies80%Mar 13, 2017
Ahp Health Partners, Inc.Owns 5% or more through other companies80%Mar 13, 2017
Hmh Hospitals CorporationOwns 5% or more directlyFeb 20, 2014

How does it compare nearby?

  • Of the 9 hospitals CMS lists in Essex County, 8 have an overall star rating from CMS: 2 rated 4 of 5, 2 rated 3 of 5, 2 rated 2 of 5, 2 rated 1 of 5.
  • CMS rates this one 4 of 5.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

8 compared
PlaceOverall star rating
Newark Beth Israel Medical Center2
Clara Maass Medical Center3
VA New Jersey Health Care System2
Cooperman Barnabas Medical Center3
Carewell Health Medical Center1
Saint Michael’s Medical Center4
The University Hospital1
Essex County Hospital CenterNot given

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.
  • In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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