Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 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.
Housekeeping and maintenance services were not adequately provided in multiple areas, including the North and East wings, a common area, a dining/sitting room, and the laundry room. The surveyor observed broken and cracked floor tiles, chipped and missing paint, dirty surfaces, damaged privacy curtains, rust, dirty equipment, and other disrepair in resident rooms, bathrooms, hallways, and shared spaces; the DSES confirmed the findings.
IDT care plan reviews were not completed within the required timeframe after MDS assessments for multiple residents. Record review showed that several residents had annual, quarterly, or significant change MDS assessments, but the documented IDT meetings were either held more than 7 days after the assessment or, in one case, only before the assessment. The MDS Coordinator confirmed the meetings were not held within 7 days after MDS completion and stated the facility schedules IDT meetings 14 days from the ARD and only on Wednesdays.
A resident with dementia and hospice services was repeatedly observed sitting in the dining room with no meaningful activity, despite a care plan calling for escort to activities, preferred activities, and in-room visits; staff said the resident was usually left there and not routinely checked or brought to activities. Another resident on hospice had physician orders for daily weights and intake monitoring, but the record lacked required weight and intake documentation on multiple shifts. A third resident had an unwitnessed fall with a bruise, but ordered post-fall neuro checks were not completed and the family was not notified.
Accident Hazard From Loose Commode and Incomplete Smoking Assessment: A resident's commode had very loose bilateral arms that would not stay in place and was observed as an accident hazard by surveyors and confirmed by the DON and DES. The resident said the commode was needed because the resident could not get into the bathroom and had been asking for a new one for quite a while. In addition, an RN smoking evaluation for another resident lacked documentation showing whether the resident could smoke independently or needed supervision, which the DON confirmed.
The facility failed to ensure that two authorized medication staff signed the Shift Count page to verify controlled substances were counted at shift change on the East and North Units. Review of the med cart controlled substance logs showed multiple missing incoming and outgoing signatures on both units, and the DON confirmed the findings.
Pharmacist recommendations were not addressed in a timely manner for two residents. One resident with dementia, chronic pain, and Hospice care had a Diclofenac gel order that needed clarification on the amount to apply, but the chart lacked evidence of provider response. Another resident had scheduled and PRN Lorazepam orders for anxiety/agitation, and the pharmacist asked for review of the diagnosis, behaviors, and continued need, but the DON confirmed there was no provider response.
Improper Medication Refrigerator Storage and Temperature Monitoring: A dormitory-style medication refrigerator with ice buildup was observed storing Insulin Lantus, Ativan, and PPD, while the DON stated it would also be used for vaccines. CDC guidance stated dormitory-style refrigerators should not be used, and manufacturer instructions for Lantus required storage between 36 and 46 degrees F. Temperature logs showed missing entries and out-of-range temperatures over the reviewed months.
Kitchen Sanitation, Food Labeling, and Facial Hair Protection Deficiencies: The kitchen was observed with a heavily soiled hood system, dirty floor, dusty wall-mounted AC unit, and food particles on a slicer, along with chipped paint on a hood over a food prep area. Multiple food items in the kitchen, dry storage room, walk-in refrigerator, and walk-in freezer were not labeled and/or dated, and a kitchen staff member with facial hair was seen working without facial hair protection; the DON confirmed the findings.
Infection Control Program and Hand Hygiene Failures: During lunch service, a CNA wiped a resident’s nose with gloves, removed the gloves, and then put on a new pair to feed the resident without sanitizing her hands. The DON acknowledged the hand hygiene issue and stated she was unaware that the facility’s IPCP policies needed annual review, despite policy language requiring review at least annually.
Ineffective pest control program with fruit flies throughout the facility. Residents and staff reported fruit flies in multiple resident rooms, bathrooms, the East Wing meal cart area, the conference room, the MDS Coordinator’s office, and the sitting area near the front door. Surveyors observed fruit flies around residents, on a meal cart carrying 14 trays, and swarming in hallways, and the Administrator confirmed the pest management program was not effective.
The facility failed to provide required Medicare coverage and liability notices before skilled services ended for two residents who remained in the facility. One resident’s NOMNC was signed only one day before skilled services ended, and both residents’ records lacked evidence of an SNFABN when Medicare A coverage for skilled care was discontinued. The DON stated that ABNs had not been given to residents.
The facility failed to investigate a resident grievance involving four missing vintage cameras. The resident was cognitively intact, and the Administrator recalled being told about the missing items but did not investigate or file a grievance. The DON later confirmed with the POA that four cameras had been brought in for the resident.
Failure to Provide Timely Toileting and ADL Care: A resident who was cognitively impaired, totally dependent for toileting, and on hospice was repeatedly observed sitting alone in a wheelchair in the dining room with no activity while the TV was out of view and out of hearing range. The care plan called for toileting checks every 2 hours and 1:1 activities when unable to attend group events, but staff interviews indicated the resident was often left there for long periods and not normally checked or changed.
A resident had an active PRN order for Lorazepam for anxiety/agitation with no stop date, and the clinical record lacked evidence of a clinical rationale to continue the psychotropic medication beyond the required 14-day limit. The issue was reviewed and confirmed with the DON.
A resident with a planned discharge to independent living was discharged without evidence in the clinical record of a discharge summary, recapitulation of stay, or medication reconciliation. The care plan included referrals for PT, OT, HHA services, medication setup/management, and PSS support, and the DON confirmed the required discharge documentation could not be found.
Care plans were not adequately developed or followed for bowel/bladder care and smoking. A resident with dementia and hospice services had a care plan calling for toileting checks and incontinence care every 2 hours, but documentation showed brief assistance was recorded inconsistently and was missing at the time of review. Another resident’s smoking care plan lacked appropriate goals and interventions for smoking safety, despite the facility policy requiring smoking-related privileges, restrictions, and concerns to be included in the care plan.
Respiratory equipment was not maintained for a resident with sleep apnea who used oxygen nightly. Surveyors observed visible debris buildup on the oxygen concentrator filter on multiple occasions, and the resident’s order required weekly tubing changes and regular filter cleaning. An LPN stated she had not been shown how to clean the filter, and the DON said the LPN had not yet been shown how to clean the oxygen concentrator.
Improperly Maintained Dumpster Lid Exposed Trash: A surveyor observed 1 of 2 trash dumpsters with the top front right lid open, exposing trash. The DON of Food and Nutrition confirmed the finding during interview.
The facility failed to complete annual performance reviews for 3 of 5 CNAs reviewed. The personnel files showed the last annual reviews were completed the prior March, but no current-year reviews were documented. The Administrator confirmed the reviews are normally done in March but had not been completed because the DON had not had time yet.
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.
Housekeeping and Maintenance Deficiencies in Multiple Common and Resident Areas
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in multiple areas of the building, including the North and East wings, a common area, a dining/sitting room, and the laundry room. During an environmental tour with the Director of Environmental Services, the surveyor observed chipped and missing paint on the common area double doors, 26 broken floor tiles in the common area hallway, and chipped or missing paint on the laundry room floor. In the North wing, the surveyor observed dusty and dirty items, including a floor fan and a hallway ceiling vent, along with multiple areas of cracked or broken floor tiles, dirty or missing sealant on sliding door sills, rust on a baseboard heater, and damaged privacy curtains with missing hooks, hanging down, or ripped. Additional observations in resident rooms included gouged or chipped room and bathroom doors, a marred closet door, dirty caulking around a toilet base, a cracked ceiling tile, and a wheelchair covered with dust and food. In the East wing, the surveyor observed a white patient lift with chipped and missing paint and torn or missing non-skid surface on the foot plate, a wheelchair with a black cushion covered in black duct tape, and Resident #1's wheelchair with ripped armrests. Other resident room findings included chipped or gouged bathroom doors, a dirty bathroom floor, a high back chair with chipped or missing sealant on the legs, and a shared bathroom with two dirty unlabeled graduated cylinders on top of the toilet. In the dining/sitting room across from the nurse's station, the floor was dirty, the ceiling grid was dirty and stained, and a tan high back rocker was dirty with bolts that were loose and coming out. The Director of Environmental Services confirmed all of the observed conditions during interview.
IDT Care Plan Reviews Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team (IDT), including resident and/or representative participation to the extent possible, after MDS assessments for 5 of 16 sampled residents. Record review showed that Resident #3 had an MDS Quarterly Assessment completed on 4/14/26, but there was no evidence that an IDT meeting was held within 7 days after the assessment. Resident #27 had an MDS Significant Change Assessment completed on 10/16/25, and the IDT meeting was held on 10/29/25, 13 days after the assessment, with no evidence of a meeting within 7 days. Resident #1 had an MDS Annual Assessment completed on 3/20/26 and an MDS Quarterly Assessment completed on 12/19/25, but the IDT meetings held on 4/1/26 and 12/31/25 were not within 7 days of the completed assessments. Resident #21 had an MDS Annual Assessment completed on 9/16/25, but the only documented IDT meeting was held on 9/11/25, which was 5 days before the assessment, and there was no evidence of a meeting within 7 days after completion. Resident #14 had an MDS Annual Assessment completed on 11/13/25, and the documented IDT meeting on 11/25/25 was not within 7 days of the assessment. During interviews on 5/6/26 and 6/6/26, the MDS Coordinator stated that the facility schedules IDT meetings 14 days from the ARD and only holds them on Wednesdays, and confirmed that the listed IDT meetings were not held within 7 days after completion of the MDS assessments.
Failure to follow care plans, physician orders, and fall notification requirements
Penalty
Summary
Resident #4, who had diagnoses including dementia and was receiving hospice services for end-of-life care, was observed repeatedly sitting in a wheelchair in the far corner of the dining room with no apparent activity available and the television out of view and not audible. The resident’s MDS indicated a BIMS score of 3 of 15, dependence on staff for all ADLs, and that it was very important to do things with groups, enjoy favorite activities, and go outside for fresh air. The care plan directed staff to assist or escort the resident to activities, offer preferred activities, and provide in-room activities when group participation was not chosen, but the record and observations showed no evidence that the resident was asked to attend activities or offered individualized activities. Staff also stated the resident was normally left in the dining room and was not routinely checked or brought to activities, and the bladder elimination record lacked documented brief assistance for the resident during the review period. Resident #14, admitted with diagnoses including COPD, vascular dementia with agitation, depression, morbid severe obesity, and hospice enrollment, had physician orders for daily weights and intake monitoring with a 2-liter fluid restriction. The clinical record lacked evidence that daily weights were obtained or refused on multiple days in May 2026, and the TAR lacked intake documentation on some day and evening shifts in May 2026 and on several shifts in April 2026. During interview, the DON stated the daily weights should have been discontinued because the resident was on hospice and said staff would need to update the orders, while also stating she would talk to staff about documenting appropriately. Resident #7 sustained an unwitnessed fall in the room, with a bruise to the left elbow, and the physician ordered neurological checks with vital signs at specified intervals after the fall. The clinical record lacked evidence that any neurological checks were completed, and it also lacked evidence that the resident’s family was notified. The DON confirmed in interview that no neurological checks were completed after the fall and that family was not notified.
Accident Hazard From Loose Commode and Incomplete Smoking Assessment
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards related to a commode for 3 of 3 observations over 2 survey days. On 5/5/26, Resident #5 showed a surveyor a commode in the resident's room next to the door, and the bilateral arms were observed to be very loose, would not stay in place, and posed an accident hazard. Resident #5 stated the commode was needed because the resident could not get into the bathroom and said the resident had been asking for a new one for quite a while. The loose commode arms were later confirmed by the Director of Environmental Services, who stated they were very loose, would not stay in place, and would not stay tightened. On the following day, surveyors again observed the same commode arms to still be very loose, and the Director of Nursing confirmed the loose commode arms were an accident hazard. The facility also failed to adequately complete Resident #18's smoking assessment; the smoking evaluation completed on 2/25/26 lacked evidence of whether the resident was independent with smoking or required supervision. The Director of Nursing confirmed this missing information during interview.
Missing Controlled Substance Shift Count Signatures
Penalty
Summary
The facility failed to ensure that two people authorized to administer medications signed the Shift Count page to document that all controlled substances were counted at the change of shift for both the East and North Units. Review of the East Wing Med Cart Controlled Substance Log showed multiple missing outgoing and incoming signatures on several shift changes between 12/13/25 and 4/22/26. Review of the North Wing Med Cart Controlled Substance Log also showed multiple missing outgoing and incoming signatures on several shift changes between 3/20/26 and 4/28/26. On 5/5/2026 at 10:08 a.m., the Director of Nursing reviewed and confirmed these findings.
Pharmacist Recommendations Not Addressed
Penalty
Summary
The facility failed to ensure that the consultant pharmacist’s monthly drug regimen review recommendations were addressed in a timely manner for 2 of 5 sampled residents reviewed for unnecessary medications. One resident had dementia, chronic pain, and was receiving Hospice services for end-of-life care. The pharmacist’s recommendation noted an order for Diclofenac 1% topical gel for hand pain and asked that the amount to be applied be clarified because the maximum total body dose should not exceed 32 g per day. The clinical record did not show evidence that the provider responded to this recommendation, and the DON confirmed during interview that there was no evidence that a provider reviewed pharmacy recommendations. A second resident had an active order for Lorazepam oral concentrate 2 mg/mL, scheduled twice daily and also available every 1 hour as needed for anxiety/agitation. The pharmacist’s recommendation stated that the resident was currently on PRN Lorazepam for anxiety and asked that the current diagnosis, behaviors, and use patterns be evaluated, noting that PRN psychotropic orders cannot exceed 14 days unless the prescriber documents a rationale and duration in the medical record. During interview, the DON confirmed that the provider did not respond to the pharmacist’s recommendation.
Improper Medication Refrigerator Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure medications were stored properly in the medication storage refrigerator and failed to monitor temperature controls for that refrigerator. During observation of the medication storage room with the DON, a dormitory-style refrigerator with ice buildup was seen containing Insulin Lantus, Ativan, and tuberculin purified protein (PPD). The DON stated that the refrigerator currently did not contain vaccinations, but that this was where they would be stored. Review of the CDC vaccination storage guidance stated that dormitory-style refrigerators should not be used because ice buildup on the coils can affect refrigerator temperature and compromise insulin integrity. Review of the manufacturer instructions for Lantus Solostar stated unopened Lantus should be stored in a refrigerator between 36 and 46 degrees Fahrenheit. Review of the medication refrigerator temperature logs showed missing temperatures for 1 of 28 days in April and temperatures out of range for 25 of 28 days, and missing temperatures for 4 of 5 days in May.
Kitchen Sanitation, Food Labeling, and Facial Hair Protection Deficiencies
Penalty
Summary
The kitchen was found not to be maintained in a clean and sanitary manner during the initial tour with the Food Service Director. The cook stove hood was heavily soiled with dust and dirt, the kitchen floor had food and debris under equipment and shelving, the wall mounted air conditioning unit was heavily soiled with dust and dirt, and the food slicer had food particles on the base. A hood over a food preparation area had chipped and missing paint, creating an uncleanable surface. The surveyor also observed multiple food storage and labeling issues in the kitchen, dry storage room, walk-in refrigerator, and walk-in freezer. Two large bags of rice in the kitchen and four large bags of cereal in the dry storage room were not labeled, two 12-ounce bags of whipped topping in the walk-in refrigerator had no thaw date, and a large bag of what appeared to be meat in the walk-in freezer was not labeled. In addition, a kitchen staff member with facial hair was observed working without facial hair protection, and the Director of Food and Nutrition confirmed the finding.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an Infection Control Program designed to provide a sanitary environment and help prevent the development and transmission of disease and infection during a dining service observation. During lunch service in the dining room, a CNA observed a resident with clear nasal drainage. The CNA put on gloves, used a tissue to wipe the resident’s nose, discarded the tissue, removed and discarded the gloves, and then, without sanitizing her hands, put on a clean pair of gloves and began to feed the resident by lifting the cover on the resident’s meal plate. When the surveyor intervened, the CNA stated that she sometimes forgets to wash her hands and that she would do it then. The facility also failed to conduct an annual review of its Infection Prevention and Control Program (IPCP). Review of facility policies showed multiple infection control-related policies, including Infection Prevention and Control, Vaccination of Residents, Influenza Vaccine, Pneumococcal Vaccine, and isolation policies, with review dates in 3/2025. The Infection Prevention and Control policy stated that policies and procedures are reviewed and revised as necessary and at least annually. During interview, the DON confirmed that these policies were the most current and stated she was unaware that they needed annual review.
Ineffective Pest Control Program With Fruit Flies Throughout Facility
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the North and East units, the sitting area near the front door, and the conference room free of pests. During observations and interviews, residents and staff repeatedly reported and confirmed the presence of fruit flies in multiple resident rooms and common areas. Resident #15 stated that fruit flies come into the room with food all the time, and CNA #2 stated that fruit flies were present and worse in the bathroom of one resident room, where a surveyor observed many fruit flies flying around the sink. In another resident room, fruit flies were observed flying around Resident #2 during an interview, and Resident #14 and Resident #35 were also observed with fruit flies buzzing around them in their rooms. Surveyors also observed fruit flies on the meal cart arriving to the East Wing, with 14 resident meal trays on the cart and vent openings on the covered plates large enough to allow flies into the food. Multiple flies were then observed swarming in the hall, and CNA #5 stated the flies had been present for a couple of weeks. Additional observations found fruit flies on the wall and in the doorway outside another resident room, in the bathroom of a resident room confirmed by CNA #2 and the Director of Environmental Services, in the conference room used by the survey team, in the MDS Coordinator’s office on the North Unit, and in the sitting area near the front door. The Administrator later confirmed that the facility’s pest management program was not effective.
Failure to Provide Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to ensure required Medicare coverage notices were provided before skilled services ended for residents who remained in the facility. For Resident #40, the Notice of Medicare Provider Non-Coverage (NOMNC) stated that Medicare Part A skilled services would end on 12/11/25, but the form was signed on 12/10/25, only one day before the end of skilled services. The medical record also lacked evidence that a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was provided when Medicare A coverage for skilled services was discontinued. For Resident #41, the clinical record also lacked evidence that an SNFABN was provided when Medicare A coverage for skilled services ended on 2/18/26. During an interview on 5/6/26, the DON stated that the facility had not been giving ABNs to residents, and this was confirmed during the discussion.
Failure to Investigate Resident Grievance for Missing Personal Property
Penalty
Summary
The facility failed to investigate a grievance involving Resident #6’s missing personal property, specifically four vintage cameras. Resident #6’s annual MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During an interview, Resident #6 stated that the cameras had gone missing about 4 to 5 months earlier. The Administrator later stated that she remembered the resident reporting the missing cameras about 1 to 2 months earlier, but she never investigated the matter or filed a complaint/grievance. The DON also reported speaking with the resident’s POA, who confirmed that four cameras had been brought in for the resident about 4 months earlier.
Failure to Provide Timely Toileting and ADL Care
Penalty
Summary
The facility failed to ensure timely ADL care for a resident who was dependent on staff for toileting and other needs. Resident #4 had a BIMS score of 3 of 15 and was documented as totally dependent on 2 staff for toileting, with directions to check and change every 2 hours and as required for incontinence. The care plan also noted the resident needed 1:1 bedside or in-room visits and activities if unable to attend out-of-room events, and assistance with escorting to activities. Despite this, the resident was repeatedly observed sitting in a wheelchair in the back corner of the dining room with no activity, while the TV was on in the opposite corner and not in the resident’s line of vision or audible range. These observations occurred over multiple days and times, including morning and afternoon periods, with the resident remaining in the same location without visible engagement. Staff interviews indicated the resident was often left in the dining room for long periods, and CNA #3 stated that if it was a hospice day, staff may change or check the resident, but they do not normally do it. CNA #6 stated the resident should still be checked even if he/she was usually a no-void resident, but that this does not happen. The DON stated the expectation was that residents are toileted at least every 2 hours, and later stated she had been told that if a resident fell asleep during an activity, they had to be removed from the room.
Unnecessary Psychotropic Medication and PRN Limit Not Met
Penalty
Summary
The facility failed to provide evidence of documentation to justify the continued use of a psychotropic medication and failed to ensure that a PRN psychotropic medication met the required 14-day limit for one resident reviewed for unnecessary medications. The resident had an active physician order for Lorazepam oral concentrate 2 mg/mL, with instructions to give 0.25 mL by mouth every 1 hour as needed for anxiety/agitation and no stop date. Review of the clinical record showed no evidence of clinical rationale to continue the medication beyond 14 days. On 5/6/26 at 11:30 a.m., this information was discussed and confirmed with the DON.
Missing Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of stay and medication reconciliation, was provided for Resident #39 when the resident had a planned discharge from the facility to independent living. The resident had been admitted in March 2026, and the care plan documented a discharge goal of returning to an apartment in independent living with referrals for PT, OT, HHA services, medication setup/management, and PSS assistance. Review of the clinical record showed that on 4/3/26 the resident was discharged, but there was no evidence in the record of a discharge summary containing the required information for continuing care providers. During interviews on 5/6/26, the DON stated she could not find any evidence of a discharge summary that provided the necessary information to the resident's continuing care providers.
Care Plans Lacked Required Bowel/Bladder and Smoking Interventions
Penalty
Summary
The facility failed to ensure that Resident #4’s care plan was adequately developed and followed for bowel and bladder care. Resident #4 had diagnoses including senile dementia and was receiving hospice services for end-of-life care. The MDS dated [DATE] showed a BIMS score of 3 out of 15, indicating the resident was not cognitively intact, and the resident was dependent on staff for all toileting needs. The care plan updated 3/5/26 stated the resident had bladder and bowel incontinence related to dementia and directed staff to check and change every 2 hours and as required for incontinence, with perineal care to wash, rinse, and dry. However, the bladder elimination task record showed brief assistance documented only at scattered times on 4/30/26, 5/2/26, 5/4/26, and 5/5/26, and no documented evidence of brief assistance as of 11:16 a.m. on 5/6/26. The DON stated during interview that it was her expectation that residents are toileted at least every 2 hours. The facility also failed to ensure that Resident #18’s smoking care plan contained appropriate goals and interventions. The facility’s smoking policy stated that any smoking-related privileges, restrictions, and concerns, including the need for close monitoring, are to be noted in the care plan and that all staff caring for the resident shall be alerted to these issues. Review of Resident #18’s clinical record showed a smoking care plan that lacked evidence of appropriate goals and interventions related to how the resident smokes and how the resident would smoke safely. During review of the care plan with the DON on 5/5/26 at 11:15 a.m., she confirmed that the care plan lacked appropriate goals and interventions related to smoking.
Respiratory Equipment Not Maintained
Penalty
Summary
The facility failed to maintain respiratory equipment for Resident #15, who had sleep apnea and used oxygen while sleeping every night. Surveyors observed visible debris buildup on the oxygen concentrator filter next to the resident’s bed on multiple occasions, including 5/4/26, 5/5/26, and 5/6/26. The resident’s care plan noted a potential for altered respiratory status/difficulty related to sleep apnea. The active order required the oxygen tubing to be changed weekly on Tuesday and the concentrator filter to be cleaned every day shift every Tuesday, but the Treatment Administrator Record showed the task was completed on 5/5/26 during the day shift. During interview, an LPN stated she had never been shown how to clean the filter and marked that she did not know how to do it, and the DON stated the LPN was new and had not yet been shown how to clean the oxygen concentrator.
Improperly Maintained Dumpster Lid Exposed Trash
Penalty
Summary
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 over 1 of 3 days of survey. On 5/6/26 at 8:00 a.m., a surveyor observed one of the two dumpsters with the top front right lid open, exposing trash. At 8:02 a.m., the Director of Food and Nutrition confirmed the observation during interview.
Missed Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete performance reviews at least once every 12 months for 3 of 5 Certified Nursing Assistants reviewed, including CNA #4, CNA #6, and CNA #8. CNA #4 was hired on 11/26/18 and had a last annual review dated 3/11/25, but the personnel file did not show an annual review completed for 3/2026; during interview, CNA #4 stated annual reviews were always done in March and confirmed the March 2025 review had been completed but not the March 2026 review. CNA #6 was hired on 9/5/91 and also had a last annual review dated 3/11/25, with no evidence of a 3/2026 review in the file. CNA #8 was hired on 8/28/18 and had a last annual review dated 3/17/25, with no evidence of a 3/2026 review. During interview, the Administrator confirmed annual reviews are done in March but had not been completed because the DON had not had time yet.
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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 190 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 4 | 1 |
| Marshwood Center | 2 mi | ★★★★★ | 12 | 0 |
| Odd Fellows Health Care Center | 3.4 mi | ★★★★★ | 10 | 0 |
| Clover Health Care | 3.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.