Montello Care Center

In the surveyor’s words

From the most serious findings on record at Montello Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 11, 2026

  Based on staff interview and record review, the facility did not provide adequate supervision for 1 resident (R) (R7) of 3 sampled residents who expressed suicidal ideation and threats of self-harm. On 4/19/26, R7 expressed suicidal ideation and was placed on 15-minute checks for 72 hours which the facility failed to complete in full. On 4/22/26, R7 pulled the call light out of the wall and threatened to wrap the cord around R7's neck. The facility failed to implement increased supervision for R7 despite the threats of self-harm. On 4/23/26, R7 was found with the call light cord wrapped around R7's neck. The facility's failure to provide adequate supervision after R7 expressed suicidal ideation and self-harm created a finding of immediate jeopardy that began on 4/22/26. […]

• Immediate jeopardy, isolatedF600Apr 9, 2025

  Based on staff interview and record review, the facility did not ensure the resident environment was free of abuse for 2 residents (R) (R1 and R2) of 9 sampled residents. R2 had a diagnosis of dementia and an activated Power of Attorney for Healthcare (POAHC). R2 had a history of sexually intimate encounters and sexual comments toward other residents and displayed verbally and physically aggressive behavior. On 1/10/25, 1/29/25, and 2/8/25, R2 made sexual comments, was verbally and physically aggressive toward other residents, and exhibited wandering behavior. The facility did not implement interventions to ensure the safety of R2 and other residents. On 3/18/25, a resident walked past R1's room and observed R2 touching R1's breasts underneath R1's shirt. […]

• Immediate jeopardy, isolatedF578Jul 19, 2023

  Based on staff and family interview, and record review, the facility did not ensure an advance directive was followed for 1 Resident (R) (R1) of 3 residents reviewed for code status. R1 had a Do Not Resuscitate (DNR) order signed by R1 on [DATE] and signed by the physician on [DATE]. On [DATE], R1 was found unresponsive. Staff performed cardiopulmonary resuscitation (CPR). R1 sustained fractured ribs and was placed on a ventilator in the Intensive Care Unit (ICU). R1's family made the decision to withdraw life support on [DATE] and R1 passed away. The facility's failure to follow a resident's advance directive created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 9:10 AM. […]

• Immediate jeopardy, isolatedF600Dec 13, 2022

  Based on observation, staff interview and record review, the facility did not ensure residents were free from neglect or abuse as the facility failed to supervise their whereabouts to ensure they did not engage in sexual contact that went beyond hand holding and kissing for 2 Residents (R)(R1 and R2) of 5 sampled residents. The facility was aware that R1, who had a diagnosis of dementia and was assessed to be unable to consent, had a history of sexually intimate encounters. The facility neglected to implement appropriate interventions to supervise and prevent R1 from engaging in sexually intimate encounters with R2, who was also assessed as unable to consent to sexual encounters, and other residents. On 11/26/22, R1 was found in R2's room and R2 was touching R1 in the genital area. […]

• Immediate jeopardy, isolatedF689Dec 13, 2022

  Based on observation, staff interview and record review, the facility failed to supervise their whereabouts to ensure they did not engage in sexual contact that went beyond hand holding and kissing for 2 Residents (R)(R1 and R2) of 5 sampled residents. The facility was aware that R1, who had a diagnosis of dementia and was assessed to be unable to consent, had a history of sexually intimate encounters. The facility neglected to implement appropriate interventions to supervise and prevent R1 from engaging in sexually intimate encounters with R2, who was also assessed as unable to consent to sexual encounters, and other residents. On 11/26/22, R1 was found in R2's room and R2 was touching R1 in the genital area. […]