Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montello Manor during CMS and state inspections, most recent first.
Incomplete and inaccurate ADL documentation was found for two residents with toileting assistance needs and incontinence. One resident had missing shift documentation for bladder elimination, toilet transfer, and toileting hygiene, while the other had missing entries for bladder and bowel elimination, toilet transfer, toileting hygiene, scheduled toileting every 2 hours, and a requested 4:00 a.m. bedpan intervention; some entries were also charted at the start of the night shift instead of overnight. The DON confirmed the clinical records were not complete and accurate.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to ensure call bells were within reach for four residents, as observed over two days. A resident in a wheelchair and another in a broda chair had call bells placed out of reach, while two others had call bells either not visible or wrapped around the wall. Despite staff observations and adjustments, the issue persisted, with a CNA failing to address a call bell on the floor until another CNA intervened.
The facility failed to maintain a sanitary and comfortable environment in both the North and East Wings, as well as the Laundry Room. Observations included chipped paint, dirty surfaces, broken tiles, unsecured trash, and uncleanable surfaces. These deficiencies were confirmed by the Environmental Services Director.
The facility failed to update and implement comprehensive care plans for residents with specific needs. A resident's care plan lacked updates for COPD management, while another was left unsupervised during meals, contrary to care plan directives. Additionally, a resident used outdated oxygen tubing, and another could not reach the call bell, violating care plan interventions. These issues were confirmed with the administrator.
The facility failed to follow physician orders for three residents, resulting in deficiencies in urinary, dietary, and respiratory care. A resident's Foley catheter was not flushed as ordered, another resident was not supervised during meals as required, and a third resident's oxygen tubing was not changed according to schedule.
The facility failed to secure chemicals and remove metal brackets, creating hazards. Unsecured Ajax detergent bottles were found in shared bathrooms, posing risks as per the Safety Data Sheet. Additionally, metal brackets were observed on the floor in a resident-accessible area, confirmed by the Environmental Services Director.
The facility failed to maintain proper respiratory equipment care, as observed with unbagged and undated oxygen tubing and nasal cannulas for several residents. Equipment was improperly stored, with some items not changed weekly as required by the facility's policy. These deficiencies were confirmed by a surveyor and discussed with the administrator.
The facility's Quality Assurance Committee failed to ensure the effectiveness of corrective plans for deficiencies identified in a previous survey. The same issues were recited, including inadequate housekeeping, failure to issue necessary notices for transfers and bed holds, unsecured chemicals posing hazards, and failure to provide meals accommodating resident preferences.
The facility did not ensure that CNAs received the required 12 hours of annual in-service education, including dementia training, for five CNAs employed for over a year. Employee records lacked evidence of completing the necessary training hours for 2024, as confirmed by the Facility Administrator and surveyors.
The facility failed to ensure licensed staff were trained on the PCC system, leading to medication errors for two residents. One resident received incorrect doses of Bupropion, while another received Reglan beyond the prescribed duration. The DON admitted training varied, with some staff opting out, resulting in errors in medication order entry and administration.
The facility did not complete annual performance evaluations for CNAs employed for over a year, affecting five CNAs. This was confirmed during an interview with the Facility Administrator and surveyors.
Two residents experienced significant medication errors due to incorrect dosing and duration of medications. One resident received both Bupropion ER 300 mg and 450 mg daily for four days, leading to hospitalization with lactic acidemia and a UTI. Another resident received Reglan for six additional days beyond the prescribed duration due to a missing stop date in the electronic charting system. The DON acknowledged the errors, and the surveyor confirmed them with the Administrator.
A facility failed to accommodate a resident's dietary preferences and did not provide alternative meal options for those on minced and moist and puree diets. Despite being cleared for a mechanical soft diet, the resident was limited to two exceptions due to facility constraints. The resident, who is cognitively intact, was not offered a waiver to choose a different diet, and the facility's menu lacked variety, impacting dietary satisfaction.
A facility failed to maintain complete and accurate clinical records for a resident receiving respiratory care. Observations showed the resident using a nasal cannula with tubing dated incorrectly, and discrepancies were found in the documentation of tubing changes. The provider order required regular changes and cleaning, but records did not align with these instructions.
The facility did not ensure that the required members attended the QAA meetings, with the DON missing the February meeting and the Infection Preventionist absent from the June meeting. This was confirmed by the Administrator.
The facility failed to disinfect reusable equipment during medication administration for two residents and did not implement proper infection prevention measures for a room under contact precaution. A CNA-M did not sanitize a blood pressure cuff between uses, and a room with a resident who had Norovirus lacked a contact precaution sign, contrary to facility policy.
The facility failed to regularly inspect bed frames and mattresses, resulting in a deficiency where a resident's bed had a mattress 12 inches too short, creating a potential entrapment risk. This was confirmed by the Maintenance Director and discussed with the Administrator.
The facility failed to ensure that nursing staff maintained active licenses and certifications. The DON worked with an expired RN license for five days, while a CNA worked 20 shifts and another CNA worked approximately 32 hours weekly with expired certifications. These issues were confirmed through interviews with the DON and the Administrator.
Incomplete and inaccurate ADL documentation for two residents
Penalty
Summary
Clinical records were not complete and accurate for two residents reviewed for ADL care. Resident #19 had a care plan identifying an ADL self-care performance deficit related to debility and requiring extensive assistance by one staff for toileting, with episodes of bowel and bladder incontinence. The resident’s March 2026 ADL task documentation included bladder elimination, toilet transfer, and toileting hygiene every shift, but there was no documentation that these interventions were completed, not completed, refused, or that the resident was unavailable on multiple shifts, including night shift on 3/2/26, 3/8/26, 3/21/26, and 3/30/26, and evening shift on 3/26/26. Resident #27’s care plan identified an ADL self-care performance deficit related to immobility, requiring extensive assistance by 1-2 staff for toileting, with occasional bowel and bladder incontinence, use of briefs/pull-ups, toileting every 2 hours and as needed, and a request to be awakened by 4:00 a.m. for a bedpan if the resident did not ring prior. The March 2026 ADL task documentation lacked entries showing completion, non-completion, refusal, or unavailability for bladder elimination, bowel elimination, toilet transfer, and toileting hygiene on several night and evening shifts. It also lacked documentation for scheduled toileting every 2 hours and for the requested 4:00 a.m. bedpan intervention on multiple dates, and some entries were documented at the beginning of the night shift rather than in the overnight hours. The DON confirmed the records were not complete and accurate for the dates identified.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call bells were within reach for four residents during the survey period. On multiple occasions, Resident #24 was observed sitting in a wheelchair beside the bed with the call bell hanging down at the head of the bed, making it inaccessible. Similarly, Resident #7 was seen in a broda chair with the call bell wrapped on the side rail at the head of the bed, and later placed on the bed behind the chair, both times out of reach. Resident #15 was observed in a broda chair with no visible call bell around, and Resident #188 was lying in bed with the call bell wrapped around the call box on the wall behind the bed. On the second day of the survey, further observations confirmed that Residents #7, #15, and #188 still had their call bells out of reach. A Licensed Practical Nurse (LPN) and surveyors noted the issue and adjusted the call bells to be within reach. However, later observations showed that Resident #7's call bell was again on the floor, and a certified nurse's aide (CNA) failed to address it while attending to the resident. It was only after another CNA entered the room that the call bell was handed to the resident, confirming the ongoing issue of call bells being inaccessible to residents.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in both the North and East Wings, as well as the Laundry Room. During an Environmental Tour, several deficiencies were observed. In the North Wing, issues included chipped and gouged paint on a wooden board and metal baseboard heating unit, a dirty wheelchair with a torn armrest, stained and broken floor tiles in a bathroom, and unsecured trash bags in the exit area vestibule. Additionally, a bedpan and wash basin were found on the floor next to a toilet in one of the resident rooms. In the East Wing, the cove base in a resident room was visibly soiled, and a ceiling vent in the hallway was dirty and dusty. There were also cracked and broken floor tiles in a bathroom and a large crack in the sheetrock wall by a window. The Laundry Room had a cement floor with chipped and missing paint, and a large folding table with chipped paint and duct tape on the edges, creating uncleanable surfaces. These findings were confirmed by the Environmental Services Director during an interview.
Failure to Implement and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for residents with specific needs. Resident #8's care plan was not updated to include goals and interventions for managing Chronic Obstructive Pulmonary Disease (COPD) and the use of a nebulizer, despite having physician orders for Ipratropium-Albuterol Inhalation Solution. The administrator confirmed the care plan's lack of updates. Resident #7 was observed without access to a call bell and was left unsupervised while eating, contrary to the care plan's interventions for dementia-related self-care deficits and swallowing problems. The care plan specified the need for supervision during meals and the use of a small plastic spoon, which was not adhered to during the observations. Resident #10 was observed using oxygen tubing that had not been changed since 1/28/25, despite the care plan's directive to change the tubing weekly and as needed. Resident #24 was unable to reach the call bell due to its placement, which contradicted the care plan's intervention to ensure the call bell was within reach to prevent falls and encourage the resident to request assistance. These deficiencies were discussed with the administrator, highlighting the facility's failure to implement and update care plans to meet the residents' needs effectively.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in urinary care, activities of daily living, and respiratory care. For Resident #12, the clinical record showed a physician order to flush the resident's Foley catheter daily with 60 cc of normal saline for obstructive uropathy, but there was no evidence this was being done. The Administrator confirmed the order was not completed daily. Resident #7 had a provider order for a minced and moist diet with nectar consistency, to be fed by staff using a plastic spoon. However, the resident was observed eating breakfast independently with a metal spoon and without staff supervision. A CNA entered the room but did not assist with feeding. For Resident #10, the provider order required changing and dating the O2 and C-pap tubing and cleaning the concentrator filter every Monday night shift. Observations showed the resident using a nasal cannula with tubing dated from several weeks prior, indicating the order was not followed.
Unsecured Chemicals and Metal Brackets Pose Hazards
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards due to improper storage of chemicals. On two separate days of the survey, unsecured bottles of Ajax laundry detergent were observed on the back of toilets in shared resident bathrooms. These observations were confirmed by the Environmental Services Director. The Safety Data Sheet for the detergent indicates potential harm if ingested or if it comes into contact with eyes or skin, highlighting the risk posed by the unsecured chemicals. Additionally, on another day of the survey, metal brackets approximately two feet long were found on the floor in the North wing staff exit vestibule, creating an accident hazard. This area was accessible to residents, and the presence of the metal brackets was confirmed by the Environmental Services Director. These findings indicate a failure to maintain a safe environment for residents, as required by regulations.
Improper Respiratory Equipment Storage and Maintenance
Penalty
Summary
The facility failed to maintain a proper respiratory program to prevent the development and transmission of disease and infection related to respiratory equipment care for four residents over three days of survey. Observations revealed that Resident #19 had unbagged oxygen tubing and a nasal cannula hanging on an oxygen tank attached to their wheelchair, which was stored in the hallway outside their room. The tubing was not dated, indicating a lack of adherence to infection control protocols. Similarly, Resident #7's nebulizer machine was found with an unlabeled mask and tubing stored improperly on a dresser, with no evidence of orders for changing the nebulizer mask and tubing weekly. Further observations showed that Resident #10's oxygen nasal cannula tubing was labeled with an outdated date, and the tubing was draped over personal belongings instead of being properly stored. Resident #187's oxygen nasal cannula tubing was wrapped and stored under the oxygen concentrator handle, which was not in compliance with the facility's policy. The facility's policy, last revised in February 2022, requires oxygen cannula and tubing to be changed every seven days and stored in a plastic bag when not in use. The surveyor discussed these findings with the administrator, confirming the improper storage and availability for use of the respiratory equipment.
Recurrent Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction for deficiencies identified during the Annual Long Term Care Survey Process for Federal Recertification. The deficiencies, which were initially cited on 12/12/23, were recited during the survey on 2/20/25. These included F584 for inadequate housekeeping and maintenance services, F623 for not issuing a written transfer/discharge notice, F625 for not providing a written bed hold notice with cost of care, F689 for not securing chemicals to prevent accident hazards, and F806 for failing to provide food that accommodates resident preferences and a second-choice meal of similar nutritive value. During an interview on 2/20/25, these findings were discussed with the Administrator, highlighting the recurrence of the same issues previously identified.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training, including mandatory dementia training, for five CNAs employed for more than one year. Specifically, the employee records for CNAs hired on various dates from 1991 to 2023 lacked evidence of completing the necessary training hours for the year 2024. This deficiency was confirmed during an interview with the Facility Administrator and two surveyors.
Medication Administration Errors Due to Inadequate Training on PCC System
Penalty
Summary
The facility failed to ensure that licensed staff were adequately trained and assessed for competency in using the electronic clinical documentation program, Point Click Care (PCC), leading to medication administration errors for two residents. Resident #1 was administered Bupropion ER 300 mg and 450 mg daily for four days, despite physician orders to discontinue the 450 mg dose and hold the 300 mg dose due to increased delusions and visual hallucinations. The error was attributed to incorrect entry of the physician's order into the PCC system. Resident #34 received Reglan 5 mg four times daily for 20 days, exceeding the physician's order of 14 days, due to the absence of a stop date in the PCC system. The Director of Nursing acknowledged that training on the PCC system varied among staff, with some opting out of training. The facility's policy requires medications to be administered according to orders, including verifying the right resident, medication, dosage, time, and method before administration. However, the surveyor confirmed that licensed staff were not consistently provided training on the PCC system.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for Certified Nursing Assistants (CNAs) who have been employed for more than one year. This deficiency was identified for five CNAs, all of whom had been employed for over a year without receiving the required annual performance evaluation. Specifically, CNA #1, hired in 2018, CNA #2 and CNA #4, both hired in 2023, CNA #3, hired in 1991, and CNA #5, hired in 2017, all lacked evidence of a completed performance evaluation for the year 2024. This information was confirmed during an interview with the Facility Administrator and two surveyors.
Significant Medication Errors in Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For one resident, a medication error occurred involving the incorrect dosing of the antidepressant Wellbutrin (Bupropion). The resident received both Bupropion ER 300 mg and Bupropion ER 450 mg daily for four days, leading to increased delusions, visual hallucinations, nausea, and vomiting. The resident was evaluated by a provider, and orders were obtained to hold the medications. The resident was subsequently admitted to the hospital with a diagnosis of lactic acidemia with elevated anion gap and a UTI. Another resident received an incorrect duration of the medication Reglan. The physician's order was for Reglan 5 mg to be given four times a day for 14 days, but the resident received the medication for an additional six days due to the absence of a stop date in the electronic clinical charting software. The Director of Nursing acknowledged that the physician's order for Bupropion ER 450 mg was entered incorrectly into the system, and the staff did not review the medication order thoroughly. The surveyor confirmed these significant medication errors with the Administrator.
Failure to Accommodate Resident Dietary Preferences and Provide Alternatives
Penalty
Summary
The facility failed to provide food that accommodates resident preferences and did not offer a second-choice meal or alternative with similar nutritive value for a resident on a minced and moist diet. The resident, who is cognitively intact and responsible for their own decision-making, expressed dissatisfaction with the limited food options and the lack of alternatives. Despite being cleared by a speech therapist for a mechanical soft diet, the facility only allowed two exceptions to the minced and moist diet, citing complexity as a reason for not offering more options. The resident's medical records and care plan indicated that they could feed themselves with supervision for exception foods. However, the facility did not provide a waiver for the resident to choose a different diet, as outlined in the admission contract. The facility's dietary notes revealed that the resident's diet was downgraded from ground meat to minced and moist, and the resident was informed that they could only choose two safe food items. The facility also failed to provide alternative meal options for residents on minced and moist and puree diets, with repetitive menu items like oatmeal and eggs served daily. Interviews with the Director of Food and Dietary and the DON confirmed the lack of food waivers and the facility's reluctance to offer them due to previous Immediate Jeopardy concerns. The DON acknowledged the resident's autonomy in decision-making but did not provide the necessary supervision for consuming restricted foods. The facility's actions and inactions led to the deficiency, impacting the resident's dietary satisfaction and potentially affecting all residents on similar diets.
Incomplete and Inaccurate Documentation of Respiratory Care
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident receiving respiratory care. Observations on February 18, 2025, revealed that the resident was using a nasal cannula for oxygen administration with tubing dated January 28, 2025. A review of the resident's provider order from December 2, 2024, instructed nursing staff to change and date the oxygen and C-PAP tubing and clean the concentrator filter every night shift on Mondays. However, the medication administration record for January 2025 documented the nasal cannula tubing change on January 27, and the February 2025 record showed changes on February 3, 10, and 17. This discrepancy indicates incomplete and inaccurate documentation of the resident's respiratory care.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required members attended the Quality Assessment and Assurance (QAA) meetings. Specifically, the Director of Nursing did not attend the QAA meeting held on February 20, 2024, and an Infection Preventionist was absent from the meeting on June 4, 2024. This was confirmed during an interview with the Administrator on February 20, 2025.
Inadequate Disinfection and Infection Control Measures
Penalty
Summary
The facility failed to properly disinfect reusable resident equipment during medication administration for two residents. On February 19, 2025, a Certified Nursing Assistant - Med Tech was observed taking blood pressure readings for two residents using a blood pressure cuff. After each use, the CNA-M did not sanitize the blood pressure cuff, contrary to the facility's policy which requires decontamination of reusable resident care equipment between residents. During an interview, the CNA-M acknowledged the oversight, stating that equipment should be cleaned with a sanitizing wipe between residents but admitted to forgetting to do so on that day. Additionally, the facility did not implement appropriate infection prevention measures for a room under contact precaution. On February 20, 2025, a surveyor, along with the Maintenance Director, observed that there was no contact precaution sign on the door of a room where a resident with Norovirus had been staying. The Maintenance Director confirmed that the room would not be cleaned until instructed by Nursing administration. The Infection Preventionist later confirmed that the room should remain on precautions with signs on the door, as the resident had been sent to the hospital and the 48-hour precaution period had not yet passed.
Failure to Inspect Bed Frames and Mattresses
Penalty
Summary
The facility failed to conduct regular inspections of bed frames and mattresses as part of a maintenance program, leading to a deficiency involving one of the 37 beds. Specifically, a surveyor observed that a resident's bed had a mattress approximately 12 inches too short for the bed frame, creating a large gap between the mattress and the footboard, which posed a potential entrapment risk. This observation was confirmed by the Maintenance Director during an interview. The deficiency was noted during multiple observations by surveyors on the same day, and the issue was discussed with the facility's Administrator.
Expired Licenses and Certifications Among Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff maintained an active license and/or certification in accordance with state laws, as evidenced by the review of employee personnel records and interviews. The Director of Nursing (DON), a Registered Nurse (RN), worked for five days with an expired license. Additionally, a Certified Nursing Assistant (CNA #2) worked 20 shifts with an expired certification, and another CNA (CNA #3) worked approximately 32 hours weekly with an expired certification. These deficiencies were confirmed through interviews with the DON and the facility Administrator.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Lewiston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Russell Park Rehabilitation & Living Center | 1 mi | ★★★★★ | 0 | 0 |
| St Mary's D'youville Pavilion | 1.3 mi | ★★★★★ | 3 | 1 |
| Marshwood Center | 2 mi | ★★★★★ | 12 | 0 |
| Odd Fellows Health Care Center | 3.4 mi | ★★★★★ | 10 | 0 |
| Clover Health Care | 3.6 mi | ★★★★★ | 7 | 1 |
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