Montello Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an effective pest control program so that the facility is free of pests for 2 of 2 units(North and East), the sitting area near the front door, and the conference room. Findings:1. On 5/4/26 at 9:10 a.m., in an interview with a surveyor, Resident #15 (room [ROOM NUMBER]) stated that there's fruit flies that come in the room with the food all the time. 2. On 5/4/26 at 9:11 a.m., in an interview with a surveyor, Certified Nursing Assistant(CNA #2) stated that there are fruit flies and they are worse in the bathroom of resident room [ROOM NUMBER]. A surveyor observation of resident room [ROOM NUMBER] bathroom, with CNA #2, revealed many fruit flies that were flying around the sink.3.On 5/4/26 at 9:30 a.m., during an interview with Resident #2 in resident room [ROOM NUMBER], a surveyor observed fruit flies flying around the resident. Resident #2 stated they have been in the room for weeks.4.On 5/4/26 at 9:49 a.m., during an interview with Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interview, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (NOMNC) form was provided at least two days prior to end of Skilled services for 1 of 3 residents whose Medicare Part A Skilled services were discontinued (Residents #40). In addition, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form 10055, which included appeal rights and liability of payment was provided at least two days prior to a resident's last covered day for 2 of 2 residents whose Medicare Part A services were discontinued and remained in the facility (#40 and #41).Findings:1. Resident #40's NOMNC indicated that the resident's Medicare Part A services would end on 12/11/25 and was signed by the resident on 12/10/25, one day prior to end of skilled services. Furthermore, the medical record lacked evidence that the resident was provided a SNFABN when the Medicare A coverage for skilled services was discontinued. The resident remained living in the facility.2. Resident #41's clinical record lacked evidence that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, record review, and interviews, the facility failed to investigate a complaint/grievance for 1 of 1 resident reviewed for personal property (Resident #6).Findings:Facility policy titled Grievances/Complaints, Recording and Investigating states: Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations.Review of Resident #6's annual Minimum Data Set (MDS) dated [DATE] revealed Resident had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she is cognitively intact.On 5/4/26 at 9:01 a.m., in an interview with Resident #6, he/she stated that about 4-5 months ago he/she had 4 vintage cameras go missing.On 5/5/26 at 2:24 p.m., in an interview with the Administrator, she states about a month or two ago she remembers Resident #6 telling her that he/she had 4 missing cameras. At this time, the Administrator stated she never investigated or filed a complaint/grievance for his/her missing cameras.On 5/6/26 at 10:31…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure resident received timely Activities of Daily Living (ADL) care for a resident who is dependent for ADL care for 1 of 1 resident reviewed for toileting (Resident #4).Findings:1.During an initial observation on 5/4/26 at 8:34 a.m., Resident #4 was observed sitting in a wheelchair located in the back corner of the dining room with no activity. The television (TV) is on in the opposite corner, not in Resident #4's line of vision and the volume is not high enough for him/her to hear. Another resident is observed sitting at a small table directly in front of the T.V. During a follow up observation at 12:35 p.m., Resident #4 was observed in the same spot with no activity, TV is on, not in line of vision, volume is not high enough for him/her to hear. Another resident is observed sitting at a small table directly in front of the TV. At this time a surveyor asked the Director of Nursing (DON) why Resident #4 was still in the corner of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide evidence of documentation to justify the continued use of psychotropic medication and failed to ensure an as needed (PRN) psychotropic medication met the required 14-day limit for 1 of 5 residents reviewed for unnecessary medications. (#26)Findings:Review of Resident #26's clinical record shows an active physician order dated 4/15/26 for Lorazepam oral concentrate 2MG/ML (milligram/milliliter) with instructions to Give 0.25 ml by mouth every 1 hours as needed for anxiety/agitation with no stop date. Further review of the clinical record lacked evidence of clinical rational to continue the medication for longer than 14 days.On 5/6/26 at 11:30 a.m., the above information was discussed and confirmed with the Director of Nursing.

Based on record review and interviews, the facility failed to ensure that a discharge summary, including a recapitulation of stay and medication reconciliation, was provided to 1 of 1 resident reviewed for discharge planning (Resident #39).Finding:A review of Resident #39's clinical record indicated that he/she was admitted to the facility in March 2026.Review of Resident #39's care plan states, . admission discharge goal. wants to return to Apartment at. independent living, with referral to [home health agency] for PT [Physical Therapy], OT [Occupational Therapy], HHA [Home Health Aide] also signed on for services. for med [medication] set up/mgt [management] and PSS [Personal Support Specialist] to assist with care.Further review of Resident #39's clinical record revealed that on 4/3/26, he/she had a planned discharge from the facility to independent living. The clinical record lacked evidence of a discharge summary, including a recapitulation of stay and medication reconciliation. On 5/6/26 at 2:00 p.m. a surveyor discussed the above finding during an interview with the Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, record review, and interview's, the facility failed to ensure that a care plan was adequately developed/followed in the areas of bowel and bladder care for 1 of 1 resident's reviewed for ADL (activities of daily living) care (Resident #4) and smoking for 1 of 1 resident reviewed for smoking (Resident #18). 1.Resident #4 has diagnosis to include senile dementia and is receiving hospice services for end of life care. Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating he/she is not cognitively intact. He/she is dependent on staff for all toileting needs. Review of Resident #4's care plan updated 3/5/26 states [Resident #4] has bladder and bowel incontinence r/t dementia.Incontinent: check and change every 2 hours and as required for incontinence. wash, rinse and dry perineum. Review of Bladder Elimination task states Resident #4 received brief assistance on 4/30/26 at 8:08 a.m., and 20:14, on 5/2/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, the facility failed to maintain respiratory equipment for 1 of 3 residents reviewed for respiratory (Resident #15).Findings:Observation of Resident #15's oxygen concentrator located next to bed, revealed visible debris build up on the filter on 5/4/26 at 9:18 a.m., on 5/5/26 at 11:15 a.m., and 5/6/26 at 10:00 a.m., and 3:14 p.m. Review of Resident #15's care plan updated 3/2026 states . has the potential for altered respiratory status/difficulty r/t Sleep Apnea, . Care/cleaning of equipment and supplies per facility protocol. The facility did not provide respiratory protocol by the end of survey.Review of Resident #15's active orders revealed order with start date of 3/30/26 to change 02 tubing weekly on Tuesday; date and initial new tubing and store in bag when not in use, and clean concentrator filter every day shift every Tuesday for change; and date new tubing. Review of Resident #15's Treatment Administrator Record (TAR) states it was completed 5/5/26 during the day shift.During an interview on 5/4/26 at 9:19 a.m., Resident #15 stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain a garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 trash dumpsters for 1 of 3 days of survey (5/6/26).Findings:On 5/6/26 at 8:00 a.m., a surveyor observed 1 of 2 dumpsters with the top front right lid open exposing trash. On 05/6/26 at 8:02 a.m., in an interview with a surveyor, the Director of Food and Nutrition confirmed the finding.

Based on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for Medication Administration Record (MAR) and Treatment Administration Record (TAR) (Resident #1) and 1 of 3 residents reviewed for wound care (Resident #2).Findings:1. Review of Resident #1's MAR and TAR for the month of April lacked evidence of completed documentation for the following physician orders: Lavage left ear with warm water. One time a day to irrigate, Triad cream to open area on left stage 2 (presently) buttocks crease daily in the afternoon for open area stage 2, Monitor for signs and symptoms of respiratory infection/COVID: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, SOB (shortness of breath), cough, and new loss of taste of smell every day and night, Air mattress on bed every shift for skin care, Document if resident has shortness of breath. , Encourage off loading of right hip , HOB (head of bed) to be elevated >30 degrees at all times for every shift, If…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure a residents call bell was within reach for 4 of 15 sampled residents for 2 of 3 days of survey with multiple observations. (Resident #24, #7, #15, #188) Findings: 1. On 2/18/25 at 10:11 a.m., observation of Resident #24 sitting in a wheelchair beside the middle of the bed. The call bell was at the head of the bed hanging down. At this time, Resident #24 attempted to move the wheelchair and was unable to twist his/her body to reach the call bell. 2. On 2/18/25 at 10:54 a.m., observation of Resident #7 sitting up in a broda chair with a hoyer pad underneath him/her and the broda chair positioned at the foot of the bed. The call bell was wrapped up on the side rail at the head of the bed, not within reach. On 2/18/25 at 12:57 p.m., an additional observation of Resident #7, sitting in a broda chair at the foot of the bed, with a tray table in front of resident. The call bell was placed on the bed behind the broda chair, not within reach. 3. On 2/18/25 at 11:05 a.m. and at 12:57 p.m., observations of Resident #15,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 2 of 2 wings (North and East) and the Laundry room for 1 of 1 facility tour. Findings: On 2/20/25 from 9:05 a.m. to 10:00 a.m., a surveyor conducted an Environmental Tour with the Maintenance Director in which the following findings were observed: North Wing: - Resident room [ROOM NUMBER] - The wooden board to the right of the bed holding the metal base board heating unit, had chipped/gouged paint exposing untreated wood. The metal base board heating unit had chipped/gouged paint creating an uncleanable surface. - Resident room [ROOM NUMBER] - The wheelchair right arm rest had a ripped/torn/peeling plastic surface and the wheelchair was visibly dirty with food debris and dust. The bathroom floor had three stained and broken floor tiles around the toilet. - Resident room [ROOM NUMBER] - There was a bed pan and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Chronic Obstructive Pulmonary Disease (COPD) and failed to implement the care plan in the area of ADL (Activities of Living) and oxygen maintenance for 4 of 15 residents care plans reviewed ( #8, #7, #10 and #24) Findings: 1. Review of Resident #8's current physician orders noted Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg(milligram)/3ml(milliliter)-1 application Inhale orally four times a day for COPD- start date- 1/15/25 1100, morning(am) 06, noon, evening(pm) 15, night(hs)18. Resident #8's current care plan was reviewed and it lacked evidence that the care plan was updated to include goals and interventions for the care area of COPD/Nebulizer use. On 2/20/25 at 2:00 p.m., in an interview, the Administrator confirmed that Resident #8's care plan was not updated to include goals and interventions for the care area of COPD/Nebulizer use. 2. On 2/18/25 at 10:54 a.m., and on 2/18/25 at 12:57 p.m., Resident #7 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to follow physician orders in the area of urinary care, activities of daily living, and respiratory care for 3 of 15 residents sampled (Resident #12, #7, and #10). 1. Review of Resident #12's clinical record contained a physician order dated 1/8/25 instructing nursing to flush resident's foley catheter with 60 cc (cubic centimeter) of normal saline every day for obstructive uropathy. The clinical record lacked evidence of this was being completed. On 2/19/25 at 9:59 a.m., during an interview, the Administrator confirmed the above physician order was not completed daily by staff. 2. Review of Resident #7's provider order, dated 9/14/24 instructs nursing to provide, Minced and Moist diet, minced texture, Nectar consistency, Fed by Staff, use plastic spoon. On 2/19/25 at 8:20 a.m., observation of Resident #7 eating breakfast independently, no staff supervision and using a metal spoon, scooping up egg yolk. At 8:24 a.m., a certified nurse's aide (CNA) entered the room and made his/her bed then exited the room. At…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 4 of 4 observations for 2 of 3 days of survey (2/18/25 and 2/20/25). Findings: 1. On 2/18/25 at 10:28 a.m., a surveyor observed an unsecured 40 oz bottle of Ajax laundry detergent on the back of the toilet in Resident room [ROOM NUMBER]'s bathroom, which is shared with occupied resident room [ROOM NUMBER]. 2. On 2/18/25 at 11:08 a.m., 2 surveyors observed an unsecured 40 oz bottle of Ajax laundry detergent on the back of the toilet in Resident room [ROOM NUMBER]'s bathroom, which is shared with resident room [ROOM NUMBER] and occupied. 3. Resident #4, who occupies room [ROOM NUMBER], stated in an interview that he/she accesses the bathroom for use. On 2/18/25 at 12:36 p.m., , in an observation and interview, the Environmental Services Director confirmed there was an unsecured 40 oz…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to maintain a respiratory program to help prevent the development and transmission of disease and infection related to respiratory equipment care for 4 of 4 residents reviewed for respiratory care (Resident #19, #7, #10, and #187) for 3 of 3 days of survey. (2/18/25, 2/19/25 and 2/20/25) Findings: 1. On 2/18/25 at 11:02 a.m., a surveyor observed an unbagged oxygen tubing and a nasal canula hanging on an oxygen tank that was secured to the back of Resident #19's wheelchair which was stored in the hallway outside of the resident's room. The oxygen tubing was not dated. 2. On 2/18/25 at 2:20 p.m., 2 surveyors observed an unbagged oxygen tubing and a nasal canula hanging on an oxygen tank that was secured to the back of Resident #19's wheelchair which was stored in the hallway outside of the resident's room. The oxygen tubing was not dated. 3. On 2/19/25 at 8:20 a.m., Observation of Resident #7's nebulizer machine with an unlabeled mask and tubing stored on the dresser next to the television. Review of the Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and the facilities Medication Administration Policy, the facility failed to ensure that licensed staff are provided with training and are assessed for competency which includes transcription of physician orders in the facilities electronic clinical documentation program Point Click Care (PCC) the facility utilizes for 2 of 7 residents reviewed for medications. (Resident #1 & Resident #34) Findings: 1. A Nursing Progress note dated 9/12/24 indicating Resident #1 was seen by the provider regarding increased delusions and complaints of visual hallucinations. The progress notes further indicated the resident had received Bupropion 300 milligrams (mg) and Bupropion 450 mg daily for 4 days. Physicians' orders were obtained to immediately discontinue the Bupropion ER 450 mg, hold the Bupropion ER 300 mg for 4 days and hold the antidepressant medication Duloxetine for 4 days. Continue to monitor resident and send to the emergency room for evaluation or deterioration of condition. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year. (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5 ) Finding: 1. CNA #1 was hired on 11/26/2018. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 2. CNA #2 was hired on 7/31/2023. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 3. CNA #3 was hired on 9/5/1991. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 4. CNA #4 was hired on 7/31/2023. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 5. CNA #5 was hired on 2/6/2017. The employee record lacked evidence of an annual performance evaluation being completed for 2024. On 2/20/25 at 11:47 a.m., during an interview with the Facility Administrator and 2 surveyors present, the above information was confirmed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of facility report sent to the Division of Licensing and Certification, record reviews, and interviews, the facility failed to ensure that 2 of 5 sampled residents reviewed for medications was free of significant medication errors. (Resident #1 & Resident #34) Findings: 1. On 9/18/24 a facility report was submitted to the Division of Licensing and Certification. A review of the facility report and the five day follow-up report stated the following: Adult Protective Services (APS) received an anonymous report of an overdose. A medication error was discovered on 9/12/24 involving incorrect dosing of the antidepressant Wellbutrin (Bupropion). Provider on-site and evaluate Resident #1. Orders obtained to hold Wellbutrin (Bupropion) and Duloxetine for four days. Monitor for seizures or worsening of condition and send to the emergency room if any decline in status or seizure activity. Resident #1 was removed from the facility by Emergency Medical Services (EMS) shortly after. A Nursing Progress note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 12/12/23, were effective. The Federal citations F584, F623, F625, F689, and F806 were cited again during the annual Long Term Care Recertification Survey dated 2/20/25. Findings: During the Annual Long Term Care Survey Process for Federal Recertification dated 2/20/25, it was determined that F584, F623, F625, F689, and F806 would be recited for the same reasons: F584 for failure to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment; F623 failure to issue a written transfer/discharge notice to a Resident or their legal representative for a facility-initiated transfer/discharge; F625 failure to issue a written bed hold notice to include cost of care to the Resident and/or resident representative; F689 failure to ensure that the resident's environment was free of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNA attended the required 12 hours of annual in-service education training for 5 of 5 randomly selected CNAs employed greater than 1 year. Furthermore the facility failed to ensure that the CNA attended the mandatory yearly dementia trainings for 3 of 5 CNA's employed greater than 1 year. (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5). On 2/20/25 a surveyor reviewed the following employee files: 1. CNA #1 was hired on 11/26/2018. Review of CNA #1 Employee In-service/attendance Records lacked evidence of dementia training along with the required 12 hours for continuing education for the year of 2024. 2. CNA #2 was hired on 7/31/2023. Review of CNA #2 Employee In-service/attendance Records lacked evidence of dementia training along with the required 12 hours for continuing education for the year of 2024. 3. CNA #3 was hired on 9/5/1991. Review of CNA #3 Employee In-service/attendance Records lacked evidence of the required 12 hours for continuing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 1 of 2 Resident's reviewed for hospitalization (Resident #11). Findings: Review of Resident 11's clinical record revealed that on 7/12/24 resident was transferred to an acute care hospital and subsequently admitted . Further review of Resident 11's clinical record lacked evidence that the resident and/or resident representative and the Ombudsman's office were provided a written transfer/discharge notice. On 2/19/25 at 12:45 p.m., in an interview, the Administrator confirmed the clinical record lacked evidence that a transfer notice was provided in writing to the resident and/or resident representative and the Ombudsman's office.

Based on record review and interview, the facility failed to issue a written bed hold notice to include cost of care to the Resident and/or resident representative for 1 of 2 sampled Resident's reviewed for transfer to an acute care hospital (Residents #11). Finding: Review of Resident 11's clinical record revealed that on 7/12/24 resident was transferred to an acute care hospital and subsequently admitted . Review of Resident 11's clinical record lacked evidence that the resident and/or resident representative was provided a written bed hold notice upon this transfer. On 2/19/25 at 12:45 p.m., in an interview, the Administrator confirmed the clinical record lacked evidence that a bed hold notice was provided in writing to the resident and/or resident representative.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide food that accommodates the resident preferences and failed to provide a second-choice meal/alternative that is similar in nutritive value as the first-choice meal for 1 of 1 resident reviewed for food choices (Residents #10), this has the potential to affect all residents who have a Minced and moist diet and Puree diet. Findings: 1. On 2/18/25 at 10:42 a.m., during an interview, Resident #10 stated, there is not enough staff to do mechanical soft for just me. I get minced moist. Speech therapist tested me and gave me a list of what I could and could not eat and they still said no. On 2/19/25 at 8:24 a.m., in an additional interview, Resident #10 stated, Speech ok'd a list of foods that are good but they are not giving them to me because it's too much trouble for the kitchen. All those foods, I can only choose 2 items. I used to have graham crackers .They serve French toast here but I'm not able to have it. He/she then stated, he/she is not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interviews, the facility failed to ensure that the clinical records were complete and contained accurate documentation for 1 of 4 residents review for respiratory care. (Resident #10) Findings: On 2/18/25 at 10:33 a.m., and at 2:10 p.m., observations of Resident #10 using a nasal cannula for his/her oxygen (O2) administration with the tubing dated 1/28/25. Review of Resident #10's provider order dated 12/2/24 instructs nursing to, change and date O2 and C-pap tubing Clean concentrator filter every night shift every Mon. Review of the medication administration record for January 2025 has documentation of the O2 nasal canula tubing being changed on 1/27. February 2025 record has documentation of the O2 nasal cannula tubing being changed on 2/3, 2/10 and 2/17. On 2/19/25 at 2:20 p.m., the above was discussed with the Administrator.

Based on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that an Infection Preventionist and the Director of Nursing attended 1 of 4 quarterly QAA meetings. Findings: A review of the quarterly QAA meeting attendance sheets indicated that the Director of Nursing did not attend the February 20, 2024 quarterly QAA meeting and an Infection Preventionist did not attend the June 4, 2024 quarterly QAA meeting. On 2/20/25 at 12:28 p.m., in an interview, the above was confirmed with the Administrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to disinfect reusable resident equipment during medication administration for 2 of 4 residents observed during medication administration. In addition, the facility failed to implement infection prevention measures for 1 of 3 days of survey (2/20/25). Findings: 1. On 2/19/25 at 8:44 a.m., Certified Nursing Assistant (CNA)- Med Tech was observed taking a blood pressure (BP) with a BP cuff for Resident #10 with a reading of 97/60. The CNA-M removed the BP cuff and did not sanitize afterwards. On 2/19/25 at 9:13 a.m., Certified Nursing Assistant - Med Tech was observed taking a blood pressure with a BP cuff for Resident #31 with a reading of 109/79. The CNA-M removed the BP cuff and did not sanitize afterwards. During an interview on 2/19/25 at 9:22 a.m., the CNA-M indicated equipment should be cleaned in between residents with a sanitizing wipe but she forgot today. The facility policy Cleaning and Disinfecting Resident Care Items and Equipment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, the facility failed to conduct regular inspection of all bed frames and mattresses as part of a regular maintenance program to ensure that the mattresses and bed frames are compatible and identify areas of possible entrapment for 1 of 37 beds.(Resident #11's) Finding: On 2/18/25 at 10:28 a.m., a surveyor observed Resident #11's bed and found the mattress was approximately 12 inches to short for the bed and left a large gap between the mattress and the footboard of the bed creating an area of possible entrapment. On 2/18/25 at 11:08 a.m., 2 surveyors observed Resident #11's bed and found the mattress was approximately 12 inches to short for the bed and left a large gap between the mattress and the footboard of the bed creating an area of possible entrapment. On 2/18/25 at 12:36 p.m., in an interview, the Maintenance Director confirmed the mattress was approximately 12 inches to short for the bed and left a large gap between the mattress and the footboard of the bed creating an area of possible entrapment. On 2/18/25 at 12:44 p.m., in an interview, a surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Employee Personnel Records, review of the Maine State Board of Nursing Regulatory Licensing and Certified Nursing Assistants (CNA) Registry and interviews, the facility failed to ensure that all nursing staff maintained an active license and/or Certification and was in good standing with the Maine State Board of Nursing for 3 of 9 nursing staff reviewed. Findings: 1. During a review of the Director of Nursing (DON) Registered Nurse (RN) employee file, the DON RN's license was noted to have expired from [DATE] through [DATE]. Review of the DON RN's timecard indicated that she had worked in the facility for all 5 days with an expired license. On [DATE] at 1:17 p.m., during an interview, the DON RN confirmed she had worked on an expired license. 2. On [DATE], during a review of a Certified Nursing Assistant (CNA #2) employee file, the CNA certification was noted to have expired on [DATE]. Review of the CNA's timecard from [DATE] through [DATE] indicated that CNA #2 has worked 20 shifts with an expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 2 Units (North and East) and common areas for 2 of 2 environmental tours (11/28/23 and 11/30/23) Findings: 1. On 11/28/23 at 9:55 AM., a surveyor observed the North Unit shower room which had a code lock, but was unlocked. The cove base around the shower was peeling away and had a brown and black substance and debris caked between the molding and tile. Clothing items were crumpled on the floor in the corner immediately to the left upon entering room. The room had a musty odor. The wall cabinet to the left of the door had peeling vinyl type and the molding had a dark dried substance visible between the molding and the cabinet surface. A spray bottle of Hyperfact 256 one step disinfecting cleaner was sitting on top of the wall cabinet. On 11/28/23 at 10:00 AM., in an interview, the Director of Nursing confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, the facility's Resident Food Storage policy and procedure, Food Storage policy and Refrigerator and Freezer Temperature policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the walk-in freezer, the ice machine, an exhaust vent, a ceiling air intake vent, a food slicer and fans four one of one kitchen tour ( 28/23). In addition, the facility failed to ensure that the dish machine was maintaining proper temperature ranges for proper cleaning and sanitizing. Further, the facility failed to monitor and document refrigerator and freezer temperatures for the resident food refrigerator kept in the medication room. Findings: The Facility's Food Storage policy and procedure: 7. b. Food should be dated as it is placed on shelves if required by state regulation. c. Date marking will be visible on all high risk food to indicate the date by which a ready to eat. 8. All containers must be legible and accurately labeled and dated. The Facility's Resident Food Storage policy and procedure: 1. Food or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the annual Long Term Care Recertification Survey, dated 12/12/23, was effective. The Federal citation F655 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 2/1/24. Findings: During the annual Long Term Care survey, dated 11/28/2023 through 12/1/2023; 12/6/2023 through 12/8/2023 and 12/12/2023, a deficiency was cited at F655 for the facilities failure to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum health care information necessarily to properly care for residents. The facility's POC, dated 1/5/24, indicated that all baseline care plans and comprehensive were reviewed and revised to resident's current status and needs also to include and ensure that resident and family participation was offered and documented in the resident's record and Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents that was reviewed for baseline care plans. (Resident #188). Finding: Review of Resident #188's clinical record noted that he/she was admitted to the facility in November of 2023 with a primary diagnoses of Iron Deficiency, Cirrhosis of Liver, Chronic obstructive pulmonary disease(C0PD), Crohn's Disease, Type 2 diabetes, Depression, Anxiety Disorder, 0bsructive sleep apnea, Gastro esophageal reflux disease(GERD) and Hyperlipidemia. The medical record lacked evidence that a base line care plan was developed within 48 hours that included the problems, interventions, and goals. On 11/30/23 at 2:00 PM, in an interview, a Registered Nurse confirmed that the baseline care plan was still in progress and had not been completed within 48 hours for Resident #188.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility lacked evidence to support the monitoring of medication storage room refrigerator temperatures per facility policy to ensure proper medication and vaccine storage temperatures for 1 of 1 medication storage rooms. Finding: The Medication Refrigerator Temperature Policy and Procedure reads, All temperatures will be taken on the refrigerator twice per day. The temperatures will be logged on the sheet provided by the door. Refrigerator temperatures will be at 41 degrees Fahrenheit or less. Any temperature that does not fall within these parameters will be reported to the Director of Nursing, (DON) or the Charge Nurse immediately, who will then take corrective action to remedy the situation. On [DATE] at 11:35 AM, during a tour of the facility's medication storage room, a surveyor observed the medication storage room refrigerator had an internal temperature reading of 41 degrees Fahrenheit. The DON confirmed that the medications and vaccines in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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