Inspection Reports for
Monticello Nursing & Rehab Center

The complaint investigation involved multiple incidents of resident-to-resident physical abuse and inappropriate sexual contact. Substantiation is implied by the findings and interventions documented, including 15-minute checks, 1:1 supervision, and resident separation.

The facility failed to prevent multiple resident-to-resident altercations and inappropriate sexual behaviors involving several residents. Despite interventions such as 15-minute checks and 1:1 supervision, incidents of physical aggression and sexual misconduct occurred, indicating inadequate supervision and intervention.

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.

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.

The facility failed to complete Smoking Assessments to evaluate residents' capabilities and deficits to safely smoke for 2 of 2 residents reviewed. The facility missed 8 required assessments and the Smoking Policy did not address assessing residents' capabilities to safely smoke.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not using dignity bags for catheter care, failure to provide proper notification of Medicare discharge appeal rights, failure to account for resident location when smoking, failure to complete smoking assessments quarterly, failure to maintain consistent dialysis communication records, and incomplete care planning documentation.

Complaint #123432-C was substantiated. Facility reported incident #123454-I was substantiated.

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.

The facility was found deficient in multiple areas including failure to maintain clean wheelchairs, incomplete resident assessments and care plans, medication administration errors including a dosage error, delayed response to call lights, inadequate pressure ulcer prevention interventions, and failure to timely notify providers of significant weight loss.

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.

The visit was complaint-related, triggered by allegations of failure to notify families of residents' condition changes, resident abuse, inadequate care and supervision, and safety hazards. The complaint investigation substantiated multiple deficiencies including failure to notify families, resident-to-resident abuse, failure to update care plans, inadequate nail care, failure to provide appropriate treatment, inadequate supervision leading to elopement and falls, unlocked medication carts, and improper food handling practices.

The facility failed to notify families of significant changes in residents' conditions, protect residents from abuse by other residents, update care plans timely, provide adequate nail care, implement proper assessments and interventions for residents' care needs, ensure adequate supervision to prevent elopement and falls, secure medication carts, and enforce dietary staff hygiene policies. These failures resulted in minimal to actual harm and an immediate jeopardy situation related to resident safety and supervision.

Complaint #105249-C was substantiated. Facility Self-Reported Incidents #106802-I and #108235-I were substantiated.

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 #101076 was investigated from 12/7/21 to 12/13/21 and was substantiated as per 42 CFR Part 483, Subpart B.

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 #100331-C was substantiated based on clinical records, resident and staff interviews, and observations showing failure to provide bathing as per care plans.

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.

The visit included investigation of Complaints #95429, #95691, #96545, and #96998. Complaints #95691 and #96998 were substantiated.

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.