Inspection Report Summary
The most recent inspection on June 12, 2025, found Monticello Healthcare in compliance with applicable regulations following a paper review and complaint investigation. Earlier inspections showed a pattern of deficiencies primarily related to resident care documentation, medication storage, food preparation, and life safety code issues such as smoke barrier doors and emergency preparedness. Complaint investigations were mostly unsubstantiated except for one related to medication storage practices that resulted in a citation. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed some prior issues, but life safety and care-related deficiencies have recurred intermittently over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
57% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 12, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00459697 completed on May 19, 2025.
Findings
Monticello Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Complaint Details
Investigation of Complaint IN00459697 completed on May 19, 2025; facility found in compliance.
Inspection Report
Life Safety
Census: 66
Capacity: 116
Deficiencies: 1
Jun 11, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to a corridor door that would not latch and resist the passage of smoke, potentially affecting over 10 residents and staff. The Maintenance Director confirmed the issue and corrective actions were planned.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure all corridor doors would resist the passage of smoke; specifically, the corridor door to Resident Room #147 would not latch and resist smoke passage. | SS=E |
Report Facts
Certified beds: 116
Census: 66
Residents potentially affected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schiavone | Executive Director | Signed report and participated in exit conference |
| Maintenance Director | Confirmed corridor door deficiency and responsible for corrective actions |
Inspection Report
Life Safety
Deficiencies: 0
Jun 11, 2025
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted on 06/11/25 and completed on 06/25/25.
Findings
Monticello Healthcare was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 75
Capacity: 75
Deficiencies: 6
May 19, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00459697.
Findings
The facility was found deficient in several areas including inaccurate Minimum Data Set (MDS) assessments related to insulin use, failure to monitor and assess skin discolorations, incomplete dietary interventions documentation, failure to ensure oxygen therapy was administered as ordered, inadequate monitoring of vital signs prior to medication administration, and improper preparation of pureed foods.
Complaint Details
Complaint IN00459697 was investigated during this survey, with federal/state deficiencies cited related to the allegations at tags F684 and F692.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to insulin use for 1 of 18 MDS assessments reviewed (Resident 52). | SS=D |
| Failed to ensure residents received necessary treatment and services related to monitoring and assessment of skin discolorations for 1 of 7 residents reviewed (Resident B). | SS=D |
| Failed to fully implement care-planned dietary interventions for a resident at risk for weight loss related to incomplete meal consumption logs and lack of supplement/substitute documentation for 1 of 18 records reviewed (Resident C). | SS=D |
| Failed to ensure a resident who required respiratory care received oxygen as ordered by the physician for 1 of 2 residents reviewed (Resident B). | SS=D |
| Failed to ensure adequate monitoring of vital signs per physician's orders prior to administration of medication that alters heart rate/rhythm for 1 of 5 residents reviewed (Resident 22). | SS=D |
| Failed to ensure food was prepared by methods that conserve nutritive value related to not following instructions for pureed food preparation, potentially affecting 5 residents. | SS=E |
Report Facts
Census: 75
Total Capacity: 75
Medicare Census: 3
Medicaid Census: 61
Other Payor Census: 11
Survey Dates: 6
Deficiency Severity D Count: 5
Deficiency Severity E Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schiavone | Executive Director | Signed the report and mentioned in administrative capacity |
| LPN 1 | Interviewed regarding resident care and oxygen therapy | |
| Cook 1 | Observed preparing pureed food and interviewed about food preparation practices | |
| Dietary Manager | Interviewed regarding pureed food preparation and recipe usage | |
| Director of Nursing | DON | Interviewed multiple times regarding MDS coding, oxygen therapy, skin assessment, and dietary documentation |
| RAI Support Specialist | Responsible for in-service training and quality assurance monitoring of MDS assessments | |
| DNS/designee | Responsible for quality assurance audits and staff in-service related to skin management, meal documentation, oxygen therapy, medication administration, and puree diet preparation |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 7, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00443901 and IN00444365 completed on October 16, 2024.
Findings
Monticello Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00443901 and IN00444365, with paper compliance confirmed.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 1
Oct 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443901 and IN00444365 regarding medication storage practices.
Findings
The facility failed to ensure medications were stored according to professional standards, with multiple medications stored improperly in the medication room prior to administration times.
Complaint Details
The investigation was related to complaints IN00443901 and IN00444365. Federal/state deficiencies related to the allegations were cited at F761.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications were stored in the cabinet without resident's name, medication name, prescribed dose, strength, and expiration date for multiple residents. | SS=E |
Report Facts
Census: 73
Total Capacity: 73
Medicare Residents: 4
Medicaid Residents: 58
Other Payor Residents: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schiavone | Executive Director | Signed the report |
| LPN 1 | Interviewed regarding medication storage practices | |
| Director of Nursing | Interviewed regarding medication storage practices and responsible for corrective action |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Jul 25, 2024
Visit Reason
This visit was for the investigation of Complaint IN00434955.
Findings
Monticello Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00434955. No deficiencies related to the allegations were cited.
Complaint Details
Complaint IN00434955 - No deficiencies related to the allegations are cited.
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 7
Medicaid Census: 58
Other Payor Census: 7
Inspection Report
Re-Inspection
Census: 77
Capacity: 116
Deficiencies: 0
May 9, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/26/2024.
Findings
At this PSR survey, Monticello Healthcare was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility has a fire alarm system and sprinkler coverage in all resident and service areas except for a detached shed and a storage building.
Report Facts
Certified beds: 116
Census: 77
Inspection Report
Renewal
Deficiencies: 0
Apr 1, 2024
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on March 7, 2024.
Findings
Monticello Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 78
Capacity: 116
Deficiencies: 11
Mar 26, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness requirements, including failure to conduct required full-scale emergency exercises, and multiple life safety code deficiencies such as improperly locked exit doors, missing exit signage, improperly maintained kitchen fire suppression system, unsecured fire alarm control panel, smoke barrier doors not closing properly, exposed electrical wiring, lack of combustion air for fuel-fired equipment, incomplete fire drill documentation, improper use of extension cords, and missing emergency generator alarm annunciator at a monitored location.
Severity Breakdown
SS=F: 3
SS=E: 7
SS=C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to conduct required full-scale emergency preparedness exercises at least biennially. | SS=F |
| Exit doors in a required means of egress were magnetically locked without posted access code. | SS=E |
| Missing exit signage in Memory Care unit corridor. | SS=E |
| Kitchen range hood fire suppression nozzles not properly positioned over cooking equipment. | SS=E |
| Fire alarm control panel not secured; key left in panel. | SS=C |
| Smoke barrier doors had gaps and non-functioning latches, failing to restrict smoke movement. | SS=E |
| Exposed electrical wiring due to missing outlet cover plate. | SS=E |
| Fuel-fired water heater lacked outside combustion air source. | SS=E |
| Fire drills lacked documentation of fire alarm signal transmission to monitoring station for night shifts. | SS=F |
| Use of flexible cords and extension cords as substitutes for fixed wiring in basement and IT closet. | SS=E |
| Emergency generator lacked alarm annunciator at a location monitored 24 hours by operating personnel. | SS=F |
Report Facts
Certified beds: 116
Census: 78
Fire drills missing transmission documentation: 4
Residents potentially affected: 16
Residents potentially affected: 18
Staff potentially affected: 6
Residents potentially affected: 20
Staff potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schiavone | Executive Director | Named as facility representative and involved in interviews and exit conferences. |
Inspection Report
Renewal
Census: 72
Capacity: 72
Deficiencies: 2
Mar 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of Complaint IN00423488.
Findings
The facility was found deficient in ensuring assessment and monitoring of skin discolorations for one resident and failed to maintain a safe, functional, sanitary, and comfortable environment due to broken and missing blind slats, chipped paint, marred walls, and loose stripping in multiple units. No deficiencies were related to the complaint investigation.
Complaint Details
Complaint IN00423488 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure assessment and monitoring of skin discolorations for Resident 50. | SS=D |
| Failed to ensure residents' environment was in good repair related to broken and missing blind slats, chipped paint, marred walls, and loose stripping in 3 of 4 units observed. | SS=E |
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 5
Medicaid Census: 58
Other Payor Census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schiavone | Executive Director | Signed the report. |
| Assistant Director of Nursing | Interviewed regarding skin assessment but no full name provided. |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420655 at Monticello Healthcare.
Findings
No deficiencies related to the allegations in Complaint IN00420655 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00420655 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 77
Medicare residents: 5
Medicaid residents: 54
Other residents: 18
Inspection Report
Re-Inspection
Census: 78
Capacity: 116
Deficiencies: 0
Jul 20, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/31/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Monticello Healthcare was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. All resident-accessible areas and facility service areas were sprinklered except for a detached shed and a building used for facility storage.
Report Facts
Facility capacity: 116
Census: 78
Inspection Report
Life Safety
Census: 78
Capacity: 116
Deficiencies: 3
May 31, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to maintain means of egress free from obstructions, incomplete coverage of kitchen hood fire extinguishing system, and failure to ensure annual inspection and testing of fire door assemblies.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain the means of egress free from obstructions in 1 of 8 corridors due to storage of plastic cans and trash containers. | SS=E |
| Failed to ensure kitchen hood extinguishing system provided complete coverage for equipment producing grease-laden vapors; spray nozzles not aimed over cooking area. | SS=E |
| Failed to ensure annual inspection and testing of fire door assemblies on the oxygen transfilling room door were completed as required. | SS=E |
Report Facts
Deficiency affected residents: 14
Deficiency affected staff: 5
Deficiency affected visitors: 2
Facility capacity: 116
Census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schiavone | Executive Director | Named in relation to exit conferences and survey. |
| Maintenance Director | Interviewed and acknowledged deficiencies related to means of egress obstruction and kitchen hood extinguishing system. | |
| Maintenance Director-in-training | Present during exit conferences and interviews regarding deficiencies. |
Inspection Report
Recertification
Census: 75
Capacity: 75
Deficiencies: 6
May 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00405528, IN00407175, and IN00407457.
Findings
The facility was found deficient in multiple areas including quality of care related to resident treatment and care, nutrition and hydration, pain management, dental services, food preparation, and environmental conditions. Specific deficiencies included failure to provide ordered palm protectors, assess skin discolorations, administer nutritional supplements, manage pain medication dosing, provide dental assessments, prepare pureed food correctly, and maintain a clean and safe environment.
Complaint Details
Complaint IN00405528 - No deficiencies related to the allegations are cited. Complaint IN00407175 - No deficiencies related to the allegations are cited. Complaint IN00407457 - Federal/State deficiencies related to the allegations are cited at F697 (Pain Management).
Severity Breakdown
SS=D: 4
SS=E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a palm protector was in place for 1 of 1 residents reviewed for limited range of motion and failed to assess and monitor skin discoloration and leg wraps for other residents. | SS=D |
| Failed to ensure a nutritional supplement was given as ordered for 1 of 4 residents reviewed for nutrition. | SS=D |
| Failed to ensure a resident's pain medication was administered as ordered, resulting in acetaminophen doses exceeding 3 grams in 24 hours. | SS=D |
| Failed to ensure a resident received routine and/or emergency dental services related to lack of oral assessment for a resident complaining of mouth pain and swollen gums. | SS=D |
| Failed to ensure food was prepared in a form to meet individual needs related to incorrectly made pureed food affecting 13 residents. | SS=E |
| Failed to ensure the residents' environment was clean and in good repair related to gouged walls, holes in bathroom walls, cracked toilet riser, and chipped paint on 3 of 4 units. | SS=E |
Report Facts
Census: 75
Total Capacity: 75
Medicare Census: 5
Medicaid Census: 60
Other Payor Census: 10
Deficiency Count: 6
Acetaminophen Dose: 3250
Residents affected by pureed food: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Schiavone | Executive Director | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
May 9, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00407457 completed on May 9, 2023.
Findings
Monticello Healthcare was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and complaint investigation.
Complaint Details
Investigation of Complaint IN00407457 was completed and found in compliance.
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