Inspection Reports for
Montello Manor Inc.
540 College Street, Lewiston, ME, 04240
Back to Facility Profile18 Reports
Inspection Report — May 6, 2026
Complaint Investigation
Date: May 6, 2026
Visit Reason
Complaint investigation conducted at Montello Manor related to multiple complaints and an incident.
Findings
The facility failed to maintain a safe, clean, and comfortable environment, ensure timely and comprehensive care planning, provide adequate quality of care, maintain proper medication management and storage, and uphold infection control and grievance procedures. Multiple residents' records and care practices were found deficient, including inadequate supervision, missing documentation, and unsafe conditions.
Deficiencies (16)
F0584: The facility failed to adequately provide housekeeping and maintenance services, resulting in chipped paint, broken floor tiles, missing hooks, dirty and damaged areas in multiple resident rooms and common areas.
F0657: The facility failed to review and revise comprehensive care plans within 7 days after assessments for multiple residents, lacking evidence of interdisciplinary team meetings.
F0684: The facility failed to provide quality care by not following physician orders, failing to notify a resident representative of a fall, and not ensuring appropriate activities and supervision for residents.
F0689: The facility failed to ensure a safe environment free of accident hazards, including loose wheelchair arms and inadequate smoking supervision, and failed to maintain proper pharmacy services and medication records.
F0755: The facility failed to ensure controlled substances were properly signed for during shift changes and failed to respond timely to consultant pharmacist recommendations for unnecessary medications.
F0761: The facility failed to properly label and store drugs and biologicals, and failed to provide separate locked compartments for controlled drugs.
F0812: The facility failed to maintain food safety requirements, including cleanliness of kitchen equipment, proper labeling and dating of food, and staff hygiene.
F0582: The facility failed to provide timely Medicaid/Medicare coverage notices and failed to ensure residents were informed of changes and appeal rights.
F0585: The facility failed to establish and implement grievance policies ensuring prompt resolution and confidentiality, and failed to investigate a complaint regarding missing cameras.
F0600: The facility failed to ensure residents were free from abuse and neglect, and failed to provide timely activities of daily living care for a resident dependent on toileting.
F0605: The facility failed to respect residents' rights to be free from chemical restraints and failed to provide adequate documentation and monitoring of psychotropic drug use.
F0628: The facility failed to ensure proper discharge planning and documentation, including timely and accurate medication reconciliation and transfer notices.
F0656: The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and appropriate interventions for residents.
F0695: The facility failed to maintain respiratory care equipment and provide respiratory protocols for residents needing respiratory support.
F0814: The facility failed to maintain a sanitary garbage storage area, resulting in pest hazards.
F0730: The facility failed to complete performance reviews for nurse aides at least once every 12 months.
Report Facts
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Inspection Report — May 5, 2026
Biennial Survey
Date: May 5, 2026
Visit Reason
Federal Recertification Survey conducted to assess compliance with health, safety, and fire protection regulations.
Findings
Montello Manor was found not in substantial compliance with several NFPA and Life Safety Code standards, including generator fuel testing, electrical equipment use, means of egress, exit discharge, smoke barrier doors, smoking regulations, and oxygen equipment storage. Multiple deficiencies could affect residents, staff, and visitors.
Deficiencies (8)
K0918: The facility failed to maintain the Essential Electric System generator by not performing annual fuel testing as required by NFPA 110 and NFPA 99.
K0919: The facility failed to ensure that appliances were not plugged into multi-use adapters or power strips as substitutes for fixed wiring, violating NFPA 70.
K0211: The facility failed to maintain clear aisles, pathways, passageways, corridors, exit discharges, and exit locations free of obstructions to allow full use in emergencies.
K0232: The facility failed to maintain clear aisles, pathways, passageways, corridors, exit discharges, and exit locations free of obstructions to allow full use in emergencies.
K0271: The facility failed to maintain exit discharge free of obstructions; a fenced courtyard with locked gates blocked the egress path to the public way.
K0374: The facility failed to maintain properly working smoke barrier doors; a cross corridor door would not completely close and latch due to rubbing on the door leaf.
K0741: The facility failed to provide fire-safe regulation standard trash receptacles for cigarette waste in the designated smoking area, using noncompliant containers.
K0923: The facility failed to maintain proper storage of oxygen equipment; empty and full cylinders were stored together without proper labeling or separation.
Report Facts
: 2010
: 2012
: 2012
Inspection Report — May 4, 2026
Complaint Investigation
Date: May 4, 2026
Visit Reason
Complaint investigation conducted from 5/4/26 through 5/6/26 regarding multiple complaints and incidents including #2799410, #2799436, #2799449, #2799403, #2799427, #2728167, and incident #2683951.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including housekeeping, care plan revisions, quality of care, accident prevention, pharmacy services, medication storage, discharge process, infection control, freedom from abuse, and others. Numerous deficiencies were identified affecting resident safety, care, and facility operations.
Deficiencies (18)
483.10(i)(2): The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in multiple areas including common areas, resident rooms, and laundry room.
483.21(b)(2): The facility failed to review and revise comprehensive care plans by an interdisciplinary team including resident participation after each Minimum Data Set assessment for 5 of 16 sampled residents.
483.25: The facility failed to provide care in accordance with professional standards for 1 of 2 residents reviewed for activities of daily living and failed to follow physician orders and notify a resident representative of a fall.
483.25(d): The facility failed to ensure the resident environment was free of accident hazards and failed to complete a smoking assessment for 1 resident.
483.45(a)(b): The facility failed to ensure pharmacy services were provided properly including medication administration, record keeping, and responding to pharmacist recommendations for 2 of 5 residents reviewed.
483.45(c): The facility failed to review the drug regimen monthly by a licensed pharmacist and failed to document irregularities and pharmacist recommendations for psychotropic medications.
483.45(g)(h): The facility failed to properly label and store drugs and biologicals including controlled substances in locked compartments with proper temperature controls.
483.60(i)(1): The facility failed to maintain a clean and sanitary kitchen including food storage, preparation, and serving areas, with multiple violations observed such as unclean surfaces, unlabeled food, and improper food storage.
483.60(i)(4): The facility failed to maintain a garbage storage area in sanitary condition preventing pest harborage and feeding for 1 of 2 trash dumpsters.
483.35(d)(7): The facility failed to complete performance reviews for nurse aides at least once every 12 months for 3 of 5 certified nursing assistants reviewed.
483.12(a)(1): The facility failed to ensure a resident was free from verbal, mental, sexual, or physical abuse and neglect, including failure to provide timely activities of daily living care for 1 resident.
483.15(c)(2): The facility failed to document transfers and discharges properly including providing required notices and summaries for residents.
483.80(a): The facility failed to establish and maintain an infection prevention and control program including annual reviews and hand hygiene during dining service observations.
483.90(i)(4): The facility failed to maintain an effective pest control program resulting in fruit flies present in multiple resident areas.
483.10(g)(17): The facility failed to provide timely Medicaid/Medicare coverage notices to residents and failed to ensure proper documentation of advance beneficiary notices.
483.10(j): The facility failed to maintain a grievance policy ensuring prompt resolution and confidentiality of resident grievances including failure to investigate a complaint regarding missing cameras.
483.25(j): The facility failed to maintain respiratory care equipment and provide respiratory protocols for 1 of 3 residents reviewed.
483.60(i)(4): The facility failed to maintain a garbage storage area in sanitary condition preventing pest harborage and feeding for 1 of 2 trash dumpsters.
Report Facts
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Inspection Report — Apr 21, 2026
Complaint Investigation
Date: Apr 21, 2026
Visit Reason
Complaint investigation conducted on 4/21/26 regarding Montello Manor's compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Complaint Details
Complaint #2966062 initiated the investigation of Montello Manor for non-compliance with staffing and clinical record requirements.
Findings
Two deficiencies were found related to medication administration records and staffing levels. Clinical records for residents lacked complete and accurate documentation, and the facility failed to meet minimum staffing requirements on multiple days.
Deficiencies (2)
F0842: Clinical records were incomplete and lacked accurate information for residents, including missing documentation of physician orders and wound care.
T0222: The facility failed to meet minimum staffing ratios as required by regulations, with insufficient direct care staff on multiple days in March and April 2026.
Report Facts
: 2966062
: 3/1/26 to 4/20/26
: 36
Inspection Report — Apr 8, 2025
Follow-Up
Date: Apr 8, 2025
Visit Reason
Follow-up visit conducted to assess deficiencies cited at the annual Long Term Care Survey Process for Federal Recertification dated 2/20/25.
Findings
Montello Manor was found to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; no deficiencies were cited.
Inspection Report — Feb 18, 2025
Biennial Survey
Date: Feb 18, 2025
Visit Reason
The survey was conducted as a Federal Recertification Survey and National Fire Protection Association 101 Life Safety Code survey.
Findings
Montello Manor was found not in substantial compliance with NFPA 101 Life Safety Code and NFPA 99 Health Care Facilities Code. Deficiencies included obstructed egress corridors, non-illuminated exit signage, corridor doors failing to resist smoke passage, untested non-hospital grade electrical receptacles, and improper use of power strips in patient care areas.
Deficiencies (5)
K211: The facility failed to maintain the West wing exit corridor free of obstructions, including storage of a cat cage, cat tree, and litter box, potentially affecting all residents in case of emergency.
K293: The facility failed to maintain illuminated exit signage in accordance with NFPA 101, with a defective bulb replaced on the day of survey.
K363: Corridor doors in the West wing had holes and gaps allowing passage of smoke, failing to meet NFPA 101 requirements for smoke resistance.
K914: The facility failed to test non-hospital grade electrical receptacles at patient bed locations annually as required by NFPA 99, with last documented testing in April-May 2023 and no evidence of corrections.
K920: Power strips were used improperly in the Nurse's station outside the West Wing, with a mini fridge and air conditioning unit plugged into the same power strip as a permanent power source, violating NFPA 99 and NFPA 70 standards.
Report Facts
: Feb 18, 2025
: Feb 28, 2025
: Mar 7, 2025
Inspection Report — Dec 16, 2024
Complaint Investigation
Date: Dec 16, 2024
Visit Reason
Complaint investigation ME#00049717 was conducted at Montello Manor.
Findings
Montello Manor was found to be in compliance with 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities.
Report Facts
: ME#00049717
Inspection Report — Aug 9, 2024
Follow-Up
Date: Aug 9, 2024
Visit Reason
Follow-up desk review conducted for Montello Manor regarding a deficiency cited at the complaint investigation from 5/28/2024 to 5/29/2024.
Findings
Montello Manor was determined to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities. No deficiencies were cited.
Report Facts
: 2024-05-28 to 2024-05-29
Inspection Report — Mar 5, 2024
Follow-Up
Date: Mar 5, 2024
Visit Reason
Follow-up visit conducted off-site to assess correction of deficiencies cited at the annual Long Term Care Survey for Federal Recertification dated 12/12/2023.
Findings
Montello Manor was found to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; no deficiencies were cited.
Inspection Report — Feb 1, 2024
Follow-Up
Date: Feb 1, 2024
Visit Reason
This follow-up survey was conducted to assess the facility's compliance with deficiencies cited during the annual Long Term Care Survey Process for Federal Recertification on 12/12/2023.
Findings
The facility failed to ensure that residents and/or their representatives were involved in the development of and/or provided a summary of the baseline care plan for 4 of 4 sampled residents. Additionally, one baseline care plan lacked interventions needed to provide minimum healthcare information necessary for proper care. The facility's Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction for the cited deficiency.
Deficiencies (2)
F655: The facility failed to ensure that residents and/or resident representatives were involved in the development of and/or provided a summary of the baseline care plan for 4 of 4 sampled residents. One baseline care plan lacked interventions needed to provide minimum healthcare information necessary for proper care.
F867: The facility's Quality Assurance Committee failed to ensure that the Plan of Correction for the cited deficiency was effective, resulting in the same deficiency being recited during the follow-up survey.
Report Facts
: 1
Inspection Report — Nov 28, 2023
Plan of Correction
Date: Nov 28, 2023
Visit Reason
Federal Recertification Survey for Montello Manor, a long term care facility, including Life Safety Code survey.
Findings
This document is the facility's plan of correction for the Federal Recertification Survey completed on 11/28/2023, addressing deficiencies related to means of egress, corridor doors, fire drills, soiled linen and trash containers, gas equipment storage, and oxygen storage closets.
Report Facts
: Nov 28, 2023
: Dec 22, 2023
: one drill per shift, per quarter
: 32
: 32
: 32
: 64
: greater than or equal to 3000 cubic feet, less than 3000 cubic feet
: 3 months
Inspection Report — Aug 16, 2023
Complaint Investigation
Date: Aug 16, 2023
Visit Reason
Investigation of complaint #ME00043332.
Findings
Montello Manor was found to be in substantial compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities. No deficiencies were cited.
Notice — YZ5P11 POC
Date: YZ5P11 POC
Visit Reason
Notice of Survey Results and Enforcement for Montello Manor nursing home
Findings
Montello Manor was found not in substantial compliance with Federal participation requirements for nursing homes. The notice outlines remedies including denial of payment for new admissions and termination of provider agreement if compliance is not achieved.
Report Facts
: Jun 13, 2024
: 12924
: 11995.2
: Aug 29, 2024
: Nov 29, 2024
Inspection Report — 1F4E80 L1 SOD
Date: 1F4E80 L1 SOD
Visit Reason
Federal Recertification Survey for Montello Manor long-term care facility.
Findings
Montello Manor was found not in substantial compliance with several NFPA 101 Life Safety Code requirements, including deficiencies in electrical system maintenance, means of egress, smoke barrier doors, smoking regulations, and gas equipment storage. Multiple specific violations were observed affecting patient and staff safety.
Deficiencies (8)
K0918: The facility failed to maintain the Essential Electric System Generator per NFPA 110 and NFPA 99, lacking annual fuel testing records.
K0919: Appliances were improperly plugged into multi-use adapters and power strips, violating NFPA 70 electrical equipment requirements.
K0211: Medical carts were stored in corridors obstructing aisles and passageways, violating NFPA 101 means of egress requirements.
K0232: Furniture in corridors was unsecured, and an unsecured green chair was observed in a corridor, violating NFPA 101 aisle and corridor width standards.
K0271: Exit discharge path was blocked by locked gates in a fenced courtyard, impeding emergency egress as per NFPA 101.
K0374: A 45-minute cross corridor smoke barrier door would not completely close due to rubbing, preventing proper latching and smoke resistance.
K0741: Smoking waste receptacles in the designated smoking area were noncompliant, lacking ashtrays of noncombustible material and safe design as required by NFPA 101.
K0923: Oxygen cylinder storage rooms had empty and full cylinders stored together without proper signage, violating NFPA 99 storage requirements.
Report Facts
: May 5, 2026
: 9:00 AM to 3:15 PM
: NFPA 101 Life Safety Code 2012 Edition, NFPA 110 2010 Edition, NFPA 99 2012 Edition, NFPA 70 2011 Edition
Inspection Report — QCWE21 SOD
Date: QCWE21 SOD
Visit Reason
Life Safety Code survey conducted by the Office of the Fire Marshal on November 28, 2023.
Findings
The facility was found not to be in substantial compliance with the participation requirements for Life Safety Code only.
Document — QCWE22 SOD
Date: QCWE22 SOD
Report
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