Montello Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 12, 2023

  Based on record reviews and interviews, the facility failed to provide supervision and assistance to a resident who was identified with swallowing issues and requiring assistance with meals. This failure to provide supervision and assistance at the supper meal on [DATE] resulted in the death of one resident and placed the remaining 11 residents, who had been identified as having swallowing issues at risk; thus it was determined an immediate jeopardy situation existed. Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements. […]

• No harm, potential for more than minimal, patternF584May 8, 2026

  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), a common area, a dining/sitting room and the Laundry room for 1 of 1 facility tour.Findings:On 5/6/26 from 8:15 a.m. to 9:00 a.m., a surveyor completed an Environmental Tour with the Director of Environmental Services in which the following findings were discussed and observed:Common area:- The common area double doors to the nursing units had chipped/missing paint creating an uncleanable surface. - There were 26 broken floor tiles in the common area hallway between the nurse's station and the entrance to the North wing. […]

• No harm, potential for more than minimal, patternF657May 8, 2026

  Based on record review and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 5 of 16 sampled residents reviewed for care planning (Residents #1, #3, #14, #21, #27).Findings: 1. Review of Resident #3's clinical record revealed an MDS Quarterly Assessment was completed on 4/14/26. Further review of Resident #3's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment. 2. Review of Resident #27's clinical record revealed an MDS Significant Change Assessment was completed on 10/16/25. […]

• No harm, potential for more than minimal, patternF684May 8, 2026

  Based on record review, observations, facility policy, and interviews, the facility failed to provided care in accordance with professional standards of practice, based on the comprehensive person-centered care plan, and the residents' choices for 1 of 2 resident reviewed for activities of daily living (Resident #4). Additionally, the facility failed to follow physician orders for 2 of 17 resident's reviewed (Resident #7 and #14) and failed to notify a resident representative of a fall for 1 of 1 resident reviewed for falls. (Resident #7)Findings: 1.Resident #4 has diagnoses to include dementia and is receiving hospice services for end of life care. During observation of Resident #4 the following was observed: -5/4/26 at 8:34 a.m. […]

• No harm, potential for more than minimal, patternF689May 8, 2026

  Based on observations, facility policy, record review, and interviews, the facility failed to ensure that the resident's environment was free of accident hazards relating to a commode for 3 of 3 observations for 2 of 3 days of survey (5/5/26 and 5/6/26). Furthermore, the facility failed to ensure that a resident's smoking assessment was adequately completed for 1 of 1 resident reviewed for smoking. (Resident #18)Findings: 1.On 5/5/26 at 11:56 a.m., Resident #5 wheeled up to a surveyor stating he/she have something to show the surveyor. A surveyor observed Resident #5's commode in his/her room next to the door. The bilateral arms were very loose and would not stay in place and posed an accident hazard. Resident #5 stated he/she can't get into the bathroom so he/she had to have it. […]