Inspection Reports for Monticello Nursing & Rehab Center
500 Pinehaven Drive, IA, 523102098
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 11, 2025, found the facility to be in substantial compliance with no specific deficiencies detailed. Prior inspections show a mixed history, with earlier annual surveys and complaint investigations identifying deficiencies related to resident supervision, abuse prevention, care planning, medication management, and maintaining a safe environment. The main themes of deficiencies involved failure to prevent resident-to-resident abuse and inadequate supervision, as well as issues with care plan completeness and resident dignity. Several complaint investigations were substantiated, including cases of physical and sexual abuse among residents, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections suggest some improvement following earlier citations, though issues related to resident supervision and abuse prevention have recurred.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 11, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a survey ending November 12, 2025, addressing the facility's compliance status.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification effective November 14, 2025. No specific deficiencies are detailed in this document.
Report Facts
Survey end date: Nov 12, 2025
Certification effective date: Nov 14, 2025
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Nov 12, 2025
Visit Reason
The inspection was conducted as a result of investigation of facility reported incidents #2644149-I, #2654054-I, #2654081-I, #2663456-I, and #2664486-I between October 23, 2025 and November 12, 2025.
Findings
The facility failed to provide adequate supervision to prevent resident to resident behaviors, resulting in incidents of physical and sexual abuse among residents. The facility also failed to prevent resident altercation and abuse, violating requirements for freedom from abuse, neglect, and exploitation.
Complaint Details
The complaint investigation was substantiated based on multiple incidents involving residents #2, #4, #6, #8, and #9, including physical altercations and sexual abuse. Resident #2 has been placed on 1:1 supervision since 10/27/2025. Resident #8 was discharged on 11/14/2025. Staff re-education and monitoring by Administrator and Director of Nursing were implemented.
Severity Breakdown
E: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents. | E |
| Failure to prevent resident to resident abuse including physical and sexual abuse. | E |
| Failure to prevent resident altercation and abuse, violating freedom from abuse, neglect, and exploitation. | D |
Report Facts
Resident census: 48
Deficiency count: 3
Dates of incidents: Incidents occurred between 10/23/2025 and 11/12/2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated details about incidents and supervision measures on 11/12/25 |
| Administrator | Administrator | Signed report and stated monitoring and re-education plans |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 24, 2025
Visit Reason
A complaint investigation was conducted for complaints #2604171-C, #2605282-C, #2561063-C and facility reported incidents #2622523-I, #2623223-I, #2622459-I from September 23, 2025 to September 24, 2025.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 9, 2025
Visit Reason
A complaint investigation was conducted for complaints #128029-C, #128751-C, #128766-C and facility reported incidents #128640-I from July 7, 2025 to July 9, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 10, 2025
Visit Reason
A complaint investigation was conducted for complaints #127291-C, #127371-C, and #127651-C from April 07, 2025 to April 10, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #127291-C, #127371-C, and #127651-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 4, 2024
Visit Reason
The document is a Plan of Correction following acceptance of a credible allegation of substantial compliance for Monticello Nursing & Rehab Center.
Findings
The facility was found to be in substantial compliance and will be certified effective November 14, 2024, based on the accepted Plan of Correction.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 6
Nov 4, 2024
Visit Reason
The inspection resulted from the facility's annual recertification survey and investigation of complaints #123432-C, #123656-C, and a facility reported incident #123454-I conducted from October 28, 2024 to November 4, 2024.
Findings
The facility was found to have multiple deficiencies including failure to protect resident dignity related to catheter bag management, failure to provide proper notification to residents regarding Medicare discharge appeals, incomplete smoking assessments, inadequate supervision for residents who smoke, and failure to maintain communication forms for dialysis patients. Some complaints and incidents were substantiated.
Complaint Details
Complaint #123432-C was substantiated. Facility reported incident #123454-I was substantiated.
Severity Breakdown
SS=D: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure dignity by not covering indwelling urinary catheter drainage bag with a dignity bag for Resident #11. | SS=D |
| Failure to provide proper notification to Medicaid-eligible residents of their rights to appeal discharge decisions from Medicare Part A. | SS=D |
| Failure to develop and revise comprehensive care plans timely, including accounting for resident location when smoking. | — |
| Failure to ensure the environment is free of accident hazards and provide adequate supervision and assistance devices to prevent accidents for residents who smoke. | SS=D |
| Failure to complete smoking assessments on admission and quarterly for residents known to smoke. | SS=D |
| Failure to maintain consistent records of hemodialysis communication for Resident #10. | SS=D |
Report Facts
Census: 50
Deficiencies cited: 6
Dates of Smoking Assessments missed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant (CNA) | Reported catheter bag dignity bag not used and nervousness about catheter care |
| Staff B | Licensed Practical Nurse (LPN) | Reported on catheter bag dignity bag procedures and smoking area observations |
| Director of Nursing | RN, LNHA | Acknowledged deficiencies related to catheter dignity bags, smoking assessments, and dialysis communication |
| Staff A | Registered Nurse (RN) | Completed admission nursing assessment and smoking assessments; reported dialysis communication issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 15, 2024
Visit Reason
A complaint investigation for complaint #120127-C and facility reported incident #117749-I was conducted from May 13, 2024 to May 15, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to complaint #120127-C and facility reported incident #117749-I; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 22, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on December 22, 2023, related to the facility's regulatory compliance.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and plan of correction, the facility will be certified in compliance effective December 22, 2023.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 7
Nov 30, 2023
Visit Reason
The inspection was the facility's Annual Recertification Survey conducted from November 27, 2023 to November 30, 2023.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment, incomplete comprehensive resident assessments, untimely baseline care plans, incomplete comprehensive care plans, medication administration errors, insufficient nursing staff response to call lights, and inadequate pressure ulcer prevention and treatment.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide clean and sanitary wheelchairs and electric scooters for residents. | SS=D |
| Failure to conduct comprehensive resident assessments within required timeframes. | SS=D |
| Failure to complete baseline care plans timely for residents. | SS=D |
| Failure to develop and implement comprehensive care plans with measurable objectives. | SS=D |
| Failure to ensure residents receive medications within scheduled timeframes and correct dosages. | SS=E |
| Failure to prevent, treat, and monitor pressure ulcers adequately. | SS=D |
| Failure to have sufficient nursing staff to respond to call lights within 15 minutes. | SS=E |
Report Facts
Census: 50
Residents with medication errors: 1
Residents with call light delays: 4
Residents reviewed for care plan compliance: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 22, 2023
Visit Reason
A complaint investigation for complaint #114871-C and facility reported incident #114957-I was conducted from August 21, 2023 to August 22, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation related to complaint #114871-C and facility reported incident #114957-I; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 17, 2023
Visit Reason
A complaint investigation was conducted for Complaints #112470-C, #113521-C, #114069-C and a Facility Self-Reported Incident #110925-I from July 10, 2023 to July 17, 2023.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation involved multiple complaints and a self-reported incident; facility found in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 4, 2023
Visit Reason
On-site revisit conducted January 3-4, 2023 for the Recertification/Complaint Survey originally conducted October 24 to November 3, 2022.
Findings
All deficiencies identified during the prior Recertification/Complaint Survey were corrected, and the facility was found to be in substantial compliance effective November 15, 2022.
Complaint Details
The revisit was related to a Recertification/Complaint Survey; deficiencies were corrected and substantial compliance was achieved.
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 8
Nov 3, 2022
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #105249-C and Facility Self-Reported Incidents #106802-I and #108235-I.
Findings
The facility was found to have multiple deficiencies including failure to notify families of significant changes in residents' conditions, inadequate protection from abuse and neglect, failure to prevent resident-to-resident abuse, inadequate care plan updates, insufficient supervision to prevent falls, and failure to maintain proper food safety and medication storage procedures.
Complaint Details
Complaint #105249-C was substantiated. Facility Self-Reported Incidents #106802-I and #108235-I were substantiated.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=J: 1
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to notify families of changes in residents' physical condition for 2 of 2 residents reviewed. | SS=D |
| Failure to protect 1 of 1 residents from abuse by another resident. | SS=D |
| Failure to develop and implement abuse/neglect policies and procedures to prevent abuse and retaliation. | SS=D |
| Failure to update care plans timely for 3 out of 14 residents reviewed. | SS=D |
| Failure to provide nail care for 1 out of 1 resident observed. | SS=G |
| Failure to provide adequate supervision to prevent falls for 1 of 1 residents with a fall history and failure to prevent cognitively impaired residents from exiting unattended. | SS=J |
| Failure to ensure medication carts were locked when unattended. | SS=E |
| Failure to ensure food safety requirements including hair restraints during food preparation. | SS=E |
Report Facts
Census: 53
Residents reviewed: 14
Residents with fall history: 1
Residents with nail care deficiency: 1
Medication carts unlocked: 1
Deficiency counts: 8
Fine amount: 3637
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Larson | Administrator | Signed the report and mentioned in education provision regarding notification of families. |
| Ken Samek | Representative | Submitted the alarm system bid. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 27, 2022
Visit Reason
Investigation of Complaint #101344 conducted from January 25 to January 27, 2022.
Findings
The complaint investigation was completed and found to be not substantiated.
Complaint Details
Complaint #101344 was investigated and found not substantiated.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Dec 13, 2021
Visit Reason
The inspection was conducted as an investigation of Complaint #101076 from 12/7/21 to 12/13/21, which was substantiated according to federal regulations.
Findings
The facility failed to provide adequate quality of care related to pressure ulcer treatment and skin assessments for Resident #1, who had multiple pressure ulcers and skin impairments not properly assessed or treated. Documentation and communication deficiencies were noted among staff and with the Emergency Room provider.
Complaint Details
Complaint #101076 was investigated from 12/7/21 to 12/13/21 and was substantiated as per 42 CFR Part 483, Subpart B.
Deficiencies (1)
| Description |
|---|
| Failure to complete thorough head to toe skin assessments and implement interventions for pressure ulcers and skin impairments for Resident #1. |
Report Facts
Census: 58
Brief Interview for Mental Status (BIMS) score: 14
Pain rating: 3
Dates of skin assessments: Head to toe skin assessments completed on 12/6 and 12/7
Correction completion date: Plan of correction completion date 12/14/21
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Oct 25, 2021
Visit Reason
The inspection was conducted as an investigation of Complaint #100331 from October 20-25, 2021.
Findings
The facility was found to have failed to provide adequate bathing services to residents as required by their care plans, with substantiated deficiencies related to failure to provide showers/whirlpool baths according to the care plan schedules for three residents.
Complaint Details
Complaint #100331-C was substantiated based on clinical records, resident and staff interviews, and observations showing failure to provide bathing as per care plans.
Deficiencies (1)
| Description |
|---|
| Failure to provide bathing services in accordance with the care plan for three residents, including missed shower/whirlpool opportunities in August, September, and October 2021. |
Report Facts
Census: 59
Bathing opportunities missed: 1
Bathing opportunities missed: 3
Bathing opportunities missed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide/Bath Aide | Reported working full time as bath aide and being off work due to illness during part of the inspection period. |
| Staff B | Reported expectation that each resident get a minimum of 2 baths weekly or more if requested. | |
| Director of Nurses | Interviewed regarding staffing and bath aide duties during the inspection period. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 2, 2021
Visit Reason
Investigation conducted from 8/30/21 to 9/2/21 related to a Facility Self-Reported Incident #99433 and Complaints #99437 and #99441-C.
Findings
The Facility Self-Reported Incident #99433 and Complaint #99437-C were substantiated without a deficiency.
Complaint Details
The investigation involved Facility Self-Reported Incident #99433 and Complaints #99437 and #99441-C. The Facility Self-Reported Incident #99433 and Complaint #99437-C were substantiated without a deficiency.
Report Facts
Incident number: 99433
Complaint number: 99437
Complaint number: 99441
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 2
Jun 24, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaints #95429, #95691, #96545, and #96998 from 6/21/21 through 6/24/21. Complaints #95691 and #96998 were substantiated.
Findings
The facility failed to document a resident assessment after a fall resulting in a hip fracture prior to hospital transfer, and failed to label oxygen tubing with the date of last change for three of four residents reviewed. The facility census was 57 residents.
Complaint Details
The visit included investigation of Complaints #95429, #95691, #96545, and #96998. Complaints #95691 and #96998 were substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to document an assessment of a resident after sustaining a fall which resulted in a hip fracture and before the resident was transported to the hospital (Resident #25). | SS=D |
| Failed to label oxygen tubing to indicate the date when last changed for three of four residents reviewed (Residents #8, #29, and #46). | SS=D |
Report Facts
Census: 57
Length of hospital stay: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Reported expectations for nurse documentation prior to resident hospital transfer |
| Staff C | Licensed Practical Nurse (LPN) | Reported expectations for nurse documentation prior to resident hospital transfer and oxygen tubing change |
| Director of Nursing (DON) | Director of Nursing | Reported expectations for nurse documentation and oxygen tubing change procedures |
| Staff B | Registered Nurse (RN) | Reported oxygen tubing change procedures |
| Staff F | Registered Nurse (RN) | Reported oxygen tubing change procedures |
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 0
Nov 24, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 59
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Oct 29, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey and an investigation of Complaint #94105 were conducted on 10/28-29/2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #94105 was not substantiated.
Complaint Details
Complaint #94105 was investigated and found not substantiated.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Jul 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #89233, #89298, #91790, and #92209 was conducted by the Department of Inspections and Appeals from 7/20-7/23/2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaints were not substantiated.
Complaint Details
Complaints #89233, #89298, #91790, and #92209 were investigated and found not substantiated.
Report Facts
Total residents: 68
Inspection Report
Routine
Census: 70
Deficiencies: 0
Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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