Montello Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Maine.
- Location
- 540 College St, Lewiston, Maine 04240
- CMS Provider Number
- 205006
- Inspections on file
- 19
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Montello Manor during CMS and state inspections, most recent first.
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and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders.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 Additionally, a resident used outdated oxygen tubing, and another could not reach the call bell, violating care plan interventions.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 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.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
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 develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
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.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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