Montello Manor

F-F584 for failure to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment;

F-F623 failure to issue a written transfer/discharge notice to a Resident or their legal representative for a facility-initiated transfer/discharge;

F-F625 failure to issue a written bed hold notice to include cost of care to the Resident and/or resident representative;

F-F689 failure to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured; and

F-F806 failure 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.

On 2/20/25 at 12:28 p.m., during an interview, the above findings were discussed with the Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 205006 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205006 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Montello Manor 540 College St Lewiston, ME 04240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 37440 potential for actual harm Based on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the Residents Affected - Few 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 205006 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205006 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Montello Manor 540 College St Lewiston, ME 04240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33639 potential for actual harm Based on observation, record review, and interview, the facility failed to disinfect reusable resident Residents Affected - Few 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 revised 2/2022 Policy Interpretation and Implementation - 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents.

On 2/19/25 at 11:35 a.m., a surveyor discussed the above finding in an interview with the Administrator.

37440

2. On 2/20/25 at 9:40 a.m., during an environmental tour, a surveyor asked to go into Resident room [ROOM NUMBER] on the North wing and was told by the Maintenance Director that Resident #1 had Norovirus and that room is under contact precaution. The surveyor and the Maintenance Director observed no contact precaution sign stating that there was contact precaution or what staff needs to wear when going into that room. He said the room will not be cleaned until he is told by Nursing administration that the room is no longer on contact precaution. On 2/20/25 at 9:43, the Administrator observed resident room [ROOM NUMBER] with a surveyor and the Maintenance Director, stated the resident had been sent to the hospital and confirmed that there should be a contact precaution sign on the door.

On 2/20/25 at 10:06 a.m., in an interview, the Infection Preventionist(IP0 confirmed that if a resident on Transmission Based Precaution(TBP) was sent to the hospital then the room stays shut with precaution signs on the door and remains on precautions. The IP went on to state that it is still a precaution room and there are germs in side of it and the 48 hours hasn't passed where that resident would be off precaution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 205006 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205006 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Montello Manor 540 College St Lewiston, ME 04240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm 37440

Residents Affected - Few 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 discussed the finding with the Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 205006 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 205006 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Montello Manor 540 College St Lewiston, ME 04240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 51331

Residents Affected - Some 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 education for the year of 2024.

4. CNA #4 was hired on 7/31/2023. Review of CNA #4 Employee In-service/attendance Records lacked evidence of dementia training along with the required 12 hours for continuing education for the year of 2024.

5. CNA #5 was hired on 2/6/2017. Review of CNA #5 Employee In-service/attendance Records lacked evidence of the required 12 hours for continuing education for the year of 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 205006