Montello Manor

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 2 wings (North and East), a common area, a dining/sitting room and the Laundry room for 1 of 1 facility tour.

Inspectors wroteBased on record review and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 16 sampled residents reviewed for care planning (Residents #1, #3, #14, #21, #27).

Inspectors wroteBased on record review, observations, facility policy, and interviews, the facility failed to provided care in accordance with professional standards of practice, based on the comprehensive person-centered care plan, and the residents' choices for 1 of 2 resident reviewed for activities of daily living (Resident #4). Additionally, the facility failed to follow physician orders for 2 of 17 resident's reviewed (Resident #7 and #14) and failed to notify a resident representative of a fall for 1 of 1 resident reviewed for falls. (Resident #7)

Inspectors wroteBased on observations, facility policy, record review, and interviews, the facility failed to ensure that the resident's environment was free of accident hazards relating to a commode for 3 of 3 observations for 2 of 3 days of survey (5/5/26 and 5/6/26). Furthermore, the facility failed to ensure that a resident's smoking assessment was adequately completed for 1 of 1 resident reviewed for smoking. (Resident #18)

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for 2 of 2 units reviewed for medication storage (East and North Units).

Inspectors wroteBased on record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely manner for 2 of 5 sampled residents reviewed for unnecessary medications (Resident's #14 and #26).

Inspectors wroteBased on record review, observation, interviews, and guidance from Centers for Disease Control and Prevention (CDC), the facility failed to ensure medications were stored properly in medication storage refrigerator for 1 of 1 medication refrigerator observed. Additionally, the facility failed to monitor temperature controls for 1 of 1 medication refrigerator observed for 2 of 2 months reviewed.

Inspectors wroteBased on observations, interview, and the facility's Food Storage and Protection policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the hood systems, the floor, a wall mounted air conditioning unit, and a food slicer; failed to ensure foods in the kitchen, the dry storage room, the walk-in refrigerator and the walk-in freezer were dated and/or labeled; and failed to ensure that kitchen staff with facial hair wore facial hair protection for 2 of 2 tours on 1 of 3 days of survey.(5/4/26)

Inspectors wroteBased on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for multiple dates for 2 of 2 residents reviewed for Activities of Daily Living (ADLs) (Residents #19, #27).

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to hand hygiene during a dining service observation on 1 of 3 days of survey (5/5/26). Additionally, the facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP).

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program so that the facility is free of pests for 2 of 2 units(North and East), the sitting area near the front door, and the conference room.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (NOMNC) form was provided at least two days prior to end of Skilled services for 1 of 3 residents whose Medicare Part A Skilled services were discontinued (Residents #40). In addition, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form 10055, which included appeal rights and liability of payment was provided at least two days prior to a resident's last covered day for 2 of 2 residents whose Medicare Part A services were discontinued and remained in the facility (#40 and #41).

Inspectors wroteBased on facility policy, record review, and interviews, the facility failed to investigate a complaint/grievance for 1 of 1 resident reviewed for personal property (Resident #6).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident received timely Activities of Daily Living (ADL) care for a resident who is dependent for ADL care for 1 of 1 resident reviewed for toileting (Resident #4).

Inspectors wroteBased on record review and interview, the facility failed to provide evidence of documentation to justify the continued use of psychotropic medication and failed to ensure an as needed (PRN) psychotropic medication met the required 14-day limit for 1 of 5 residents reviewed for unnecessary medications. (#26)

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a discharge summary, including a recapitulation of stay and medication reconciliation, was provided to 1 of 1 resident reviewed for discharge planning (Resident #39).

Inspectors wroteBased on facility policy, record review, and interview's, the facility failed to ensure that a care plan was adequately developed/followed in the areas of bowel and bladder care for 1 of 1 resident's reviewed for ADL (activities of daily living) care (Resident #4) and smoking for 1 of 1 resident reviewed for smoking (Resident #18). 1. Resident #4 has diagnosis to include senile dementia and is receiving hospice services for end of life care. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating he/she is not cognitively intact. He/she is dependent on staff for all toileting needs. Review of Resident #4's care plan updated 3/5/26 states [Resident #4] has bladder and bowel incontinence r/t dementia. Incontinent: check and change every 2 hours and as required for incontinence. [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain respiratory equipment for 1 of 3 residents reviewed for respiratory (Resident #15).

Inspectors wroteBased on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 trash dumpsters for 1 of 3 days of survey (5/6/26).

Inspectors wroteBased on record reviews and interviews, the facility failed to complete performance reviews at least once every twelve months for 3 of 5 Certified Nursing Assistants selected for review (Certified Nursing Assistant's (CNA) (CNA's #, #8 and #9).

Inspectors wroteBased on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for Medication Administration Record (MAR) and Treatment Administration Record (TAR) (Resident #1) and 1 of 3 residents reviewed for wound care (Resident #2).

Inspectors wroteBased on observations and interviews, the facility failed to ensure a residents call bell was within reach for 4 of 15 sampled residents for 2 of 3 days of survey with multiple observations. (Resident #24, #7, #15, #188)

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 2 wings (North and East) and the Laundry room for 1 of 1 facility tour.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Chronic Obstructive Pulmonary Disease (COPD) and failed to implement the care plan in the area of ADL (Activities of Living) and oxygen maintenance for 4 of 15 residents care plans reviewed ( #8, #7, #10 and #24)

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow physician orders in the area of urinary care, activities of daily living, and respiratory care for 3 of 15 residents sampled (Resident #12, #7, and #10). 1. Review of Resident #12's clinical record contained a physician order dated 1/8/25 instructing nursing to flush resident's foley catheter with 60 cc (cubic centimeter) of normal saline every day for obstructive uropathy. The clinical record lacked evidence of this was being completed. On 2/19/25 at 9:59 a.m., during an interview, the Administrator confirmed the above physician order was not completed daily by staff. 2. Review of Resident #7's provider order, dated 9/14/24 instructs nursing to provide, Minced and Moist diet, minced texture, Nectar consistency, Fed by Staff, use plastic spoon. [...]

Inspectors wroteBased on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 4 of 4 observations for 2 of 3 days of survey (2/18/25 and 2/20/25).

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a respiratory program to help prevent the development and transmission of disease and infection related to respiratory equipment care for 4 of 4 residents reviewed for respiratory care (Resident #19, #7, #10, and #187) for 3 of 3 days of survey. (2/18/25, 2/19/25 and 2/20/25)

Inspectors wroteBased on record review, interviews, and the facilities Medication Administration Policy, the facility failed to ensure that licensed staff are provided with training and are assessed for competency which includes transcription of physician orders in the facilities electronic clinical documentation program Point Click Care (PCC) the facility utilizes for 2 of 7 residents reviewed for medications. (Resident #1 & Resident #34)

Inspectors wroteBased on the review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year. (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5 )

Inspectors wroteBased on reviews of facility report sent to the Division of Licensing and Certification, record reviews, and interviews, the facility failed to ensure that 2 of 5 sampled residents reviewed for medications was free of significant medication errors. (Resident #1 & Resident #34)

Inspectors wroteBased on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 12/12/23, were effective. The Federal citations F584, F623, F625, F689, and F806 were cited again during the annual Long Term Care Recertification Survey dated 2/20/25.

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 5 of 5 randomly selected CNAs employed greater than 1 year. Furthermore the facility failed to ensure that the CNA attended the mandatory yearly dementia trainings for 3 of 5 CNA's employed greater than 1 year. (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5). On 2/20/25 a surveyor reviewed the following employee files: 1. CNA #1 was hired on 11/26/2018. Review of CNA #1 Employee In-service/attendance Records lacked evidence of dementia training along with the required 12 hours for continuing education for the year of 2024. 2. CNA #2 was hired on 7/31/2023. [...]

Inspectors wroteBased on record review and interview, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 1 of 2 Resident's reviewed for hospitalization (Resident #11).

Inspectors wroteBased on record review and interview, the facility failed to issue a written bed hold notice to include cost of care to the Resident and/or resident representative for 1 of 2 sampled Resident's reviewed for transfer to an acute care hospital (Residents #11).

Inspectors wroteBased on interviews and record reviews, the facility failed to provide food that accommodates the resident preferences and failed to provide a second-choice meal/alternative that is similar in nutritive value as the first-choice meal for 1 of 1 resident reviewed for food choices (Residents #10), this has the potential to affect all residents who have a Minced and moist diet and Puree diet.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the clinical records were complete and contained accurate documentation for 1 of 4 residents review for respiratory care. (Resident #10)

Inspectors wroteBased on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that an Infection Preventionist and the Director of Nursing attended 1 of 4 quarterly QAA meetings.

Inspectors wroteBased on observation, record review, and interview, the facility failed to disinfect reusable resident equipment during medication administration for 2 of 4 residents observed during medication administration. In addition, the facility failed to implement infection prevention measures for 1 of 3 days of survey (2/20/25).

Inspectors wroteBased on interviews, the facility failed to conduct regular inspection of all bed frames and mattresses as part of a regular maintenance program to ensure that the mattresses and bed frames are compatible and identify areas of possible entrapment for 1 of 37 beds.(Resident #11's)

Inspectors wroteBased on Employee Personnel Records, review of the Maine State Board of Nursing Regulatory Licensing and Certified Nursing Assistants (CNA) Registry and interviews, the facility failed to ensure that all nursing staff maintained an active license and/or Certification and was in good standing with the Maine State Board of Nursing for 3 of 9 nursing staff reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide supervision and assistance to a resident who was identified with swallowing issues and requiring assistance with meals. This failure to provide supervision and assistance at the supper meal on 12/1/2023 resulted in the death of one resident and placed the remaining 11 residents, who had been identified as having swallowing issues at risk; thus it was determined an immediate jeopardy situation existed. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements. [...]

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 2 Units (North and East) and common areas for 2 of 2 environmental tours (11/28/23 and 11/30/23)

Inspectors wroteBased on observations, interview, the facility's Resident Food Storage policy and procedure, Food Storage policy and Refrigerator and Freezer Temperature policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the walk-in freezer, the ice machine, an exhaust vent, a ceiling air intake vent, a food slicer and fans four one of one kitchen tour ( 28/23). In addition, the facility failed to ensure that the dish machine was maintaining proper temperature ranges for proper cleaning and sanitizing. Further, the facility failed to monitor and document refrigerator and freezer temperatures for the resident food refrigerator kept in the medication room.

Inspectors wroteBased on record review and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the annual Long Term Care Recertification Survey, dated 12/12/23, was effective. The Federal citation F655 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 2/1/24.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents that was reviewed for baseline care plans. (Resident #188).

Inspectors wroteBased on observation, interview, and record review, the facility lacked evidence to support the monitoring of medication storage room refrigerator temperatures per facility policy to ensure proper medication and vaccine storage temperatures for 1 of 1 medication storage rooms.

Inspectors wroteBased on interviews, it was determined that the facility failed to provide food that accommodated preferences for 1 out of 1 resident receiving Hospice services. (#8) On 11/30/23 at 12:31 PM, during an interview with Resident #8, it was revealed that he/she was told to purchase his/her own ice cream because he/she ate too much of it (6 individual containers/day). Confirmed findings with Dietary Manager and the Director of Nursing (DON). The DON agreed that ice cream was a reasonable request impacting the resident's quality of life and the facility should be providing ice cream.

Inspectors wroteBased on record review and interview, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative of a resident transfer/discharge for a facility initiated transfer/discharge for 2 of 3 residents whose discharge records were review (Resident #22, #35).

Inspectors wroteBased on record review and interview, the facility failed to issue a written bed hold notice to a resident and/or legal representative for 2 of 3 sampled residents who was discharged to the hospital (Resident #22, #35).