Monticello Nursing & Rehab Center

Inspectors wroteBased on observation, record review, resident, and staff interviews the facility failed to keep a resident free from physical restraints during a period of behaviors. A staff member used her body to force a resident to ambulate to her room for 1 out of 1 residents reviewed with behaviors (Resident #1). The facility reported a census of 43 residents.

Inspectors wroteBased on record review, staff interview and policy interview the facility administered a antipsychotic medication without a physician's order for 1 out of 1 residents reviewed with agitation and behaviors (Resident #1). The facility reported a census of 43 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy review the facility failed to ensure a resident remained free from verbal mistreatment by staff for one of three residents reviewed (Resident #1). The facility reported a census of 51 residents. The facility corrected the deficient practice per past noncompliance through the following actions: -An all-staff meeting was held on 3/1/2026. Abuse training completed and abuse policy signed by all attendees.-Two additional all-staff meetings were held on 3/2/2026. All attendees completed abuse training and signed the abuse policy. -All alert and oriented residents were interviewed regarding their safety. -Incident review by Quality Assurance Performance Improvement (QAPI) meeting on 3/10/2026.

Inspectors wroteBased on observation, clinical record review, and staff and resident interviews, the facility failed to ensure adequate supervision was provided for a resident with a history of falls for one of three residents reviewed (Resident #2). The facility reported a census of 51 residents. The facility corrected the deficient practice per past noncompliance through the following actions: -Staff education initiated on 3/10/2026 regarding importance of proper rounding and resident monitoring. Education continued on 3/11/2026, and ongoing until all Certified Nursing Assistants (CNAs) and nurses have completed and signed the education form. -Alert and oriented residents were interviewed regarding their safety and well-being. -Incident was added to the Quality Assurance and Performance Improvement (QAPI) agenda.

Inspectors wroteBased on observation, record review and staff and resident interviews the facility failed to provide adequate supervision to prevent resident to resident behaviors (Resident # 2, Resident #4, Resident #6, Resident #8, Resident #9). The facility identified a census of 48 residents.

Inspectors wroteBased on observation, record review, resident and staff interviews the facility failed to prevent a resident to resident altercation, involving Resident #1 and Resident #2, for 1 out of 2 incidents reviewed. The facility identified a census of 48 residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to protect a resident's dignity by failing to ensure the indwelling urinary drainage bag was kept in a dignity bag for one of three residents reviewed with an indwelling catheter (Resident #11). The facility reported a census of 50 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 and had the following diagnoses: Cerebral Infarction and Compression of the Brain. The MDS identified Resident #11 was dependent on staff for toileting, showers, lower body dressing, and putting on/taking off footwear and had an indwelling urinary catheter. [...]

Inspectors wroteBased on staff interview, clinical record review, and review of Centers for Medicare/Medicaid Services document, Form CMS-20052, the facility failed to provide proper notification to residents and/or resident representatives of the right to appeal decision for discharge from Medicare Part A for 3 of 3 residents reviewed for discharge from Medicare Part A with benefit days remaining (Residents #18, #303, and #304). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, resident, and staff interviews the facility failed to account for the resident's location when a resident chose to smoke per Care Plan for one of two residents reviewed (Resident #29). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, resident, family, and staff interviews the facility failed to complete the facility Smoking Assessment to assess for resident's capabilities and deficits to safely smoke for 2 of 2 residents reviewed (Residents #1 and #29). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review the facility failed to maintain consistent records of Hemodialysis communication for 2 out of 2 months for 1 out of 1 resident reviewed (Resident#10). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, resident and family interviews, and facility policy review, the facility failed to provide the opportunity for the resident and/or resident representative to participate in the development, review and revision of his/her Care Plan on a quarterly basis for 4 of 4 residents reviewed (Residents #16, #18, #44 and #46). The facility reported a census of 50 residents. Findings Include: 1. The Significant Change Minimum Data Set (MDS) dated [DATE] documented Resident #46 had an admission date of 11/28/22 and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS indicated the resident had diagnoses that included quadriplegia, dysphagia, neurogenic bladder, anxiety disorder, depression, diabetes mellitus and asthma. [...]

Inspectors wroteBased on observation, interview, clinical record review, and facility policy review, the facility failed to administer medications within the facility scheduled time frame for 4 of 7 residents (Resident #2, #34, #44, #50) observed during medication administration and further failed to administer the correct dosage of the medication Torsemide, to Resident #2, according to physician's order. The facility reported a census of 50 residents. Findings Include: 1. On 11/29/23, the following observations were made while watching Staff H, Licensed Practical Nurse (LPN) complete a Medication Pass to residents as they sat in the dining room: a. At 9:15 AM, Staff H, Licensed Practical Nurse (LPN), prepared and administered medications to Resident #2. b. At 8:36 AM, Staff H, prepared and administered medications to Resident #34. c. [...]

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to respond to resident's needs within the required fifteen minute time frame when residents activated their call lights. Observations of call lights revealed 4 of 14 call lights were over the fifteen minute time frame when responded to (Resident #3, #13, #42, and #205). The facility reported a census of 50 residents. Findings Include: 1. Resident #13 admitted to the facility 2/7/21. The Quarterly MDS dated [DATE] identified Resident #13 had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. The resident had diagnoses including non-Alzheimer's dementia, seizure disorder, traumatic brain injury, and ataxia. The MDS revealed the resident was independent with bed mobility, transfers, and toileting and required supervision of 1 staff person for personal hygiene. [...]

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility failed to provide clean and sanitary wheelchairs or electric scooter for 3 of 3 residents whom required wheelchair/scooter transportation (Residents #5, #9, and #47). The facility reported a census of 50 residents. Findings Include: On 11/28/23 at 8:49 AM, wheelchairs that belonged to Resident #5 and #47 sat empty in a carpeted area of dining room during breakfast. The residents sat in dining room chairs for the meal. Resident #5's wheelchair held a folded bed pad on the seat of wheelchair with yellow colored rings stained across the pad. Noted wheelchair for Resident #47 with crumbs and white smeared stains across the top of the seat. Both Resident #5 and #47 were transported back into wheelchairs following the meal. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review, the facility failed to conduct comprehensive assessments of residents in accordance with the timeframes specified for 2 of 2 residents reviewed (Residents #12 and #205). The facility reported a census of 50. Findings Include: 1. The Minimum Data Set (MDS) for Resident #12 dated 8/31/23 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnoses included chronic congestive heart failure, end stage renal disease, and anemia. MDS section O failed to include documentation of the resident's need for Dialysis. The Care Plan included a diagnosis of dependence on renal dialysis. A Focus Area dated 9/29/21 indicated the resident needed Dialysis (hemo) related to chronic kidney disease. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to complete a Baseline Care Plan within the timeframes specified for 2 of 2 residents reviewed (Resident #11 and #205). The facility reported a census of 50. Findings Include: 1. The Minimum Data Set (MDS) for Resident #205 dated 11/23/23 was in progress and the electronic health record indicated the submission was 3 days overdue. At the time of review on 11/29/23 sections A, B, E, GG, H, I, J, L, M, N, O, and P remained incomplete. On 11/30/23 at 10:15 AM, the resident's chart lacked a Baseline Care Plan. On 11/30/23 at 2:20 PM, the Administrator confirmed that the facility was unable to locate the resident's Baseline Care Plan. She believed the Director of Nursing (DON) was completing these and she was out of the building. 2. [...]

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to develop and implement a person centered Care Plan that included measurable objectives regarding safety and risk reduction for 1 of 1 residents reviewed (Resident #30). The facility reported a census of 50 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #30 revealed the resident scored 00 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The staff assessment section for cognition was not completed and indicated the resident was able to complete the BIMS. The facility failed to complete the resident's Preadmission Screening and Resident Review (PASRR), dated 11/11/22, prior to admission. [...]

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review, the facility failed to notify the physician, assess a resident, or document an incident following a medication error for 1 of 1 residents (Resident #2) reviewed for medication dosage error. The Facility reported a census of 50 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 11/15/23, revealed diagnoses include Chronic diastolic heart failure and atrial fibrillation. Resident #2 had Brief Interview for Mental Status (BIMS) score of 5 out of 10, indicative of severe cognitive impairment. The Care Plan Focus Area, initiated 8/12/2019, for diuretic (water pill) medications indicated a goal that Resident #2 will receive diuretic as ordered and be free from medication side effects. [...]

Inspectors wroteBased on clinical record review, observations, staff interviews and facility policy review the facility failed to put interventions in place as directed by the Care Plan to aid in prevention of the reoccurrence of pressure sore areas for 1 out of 4 residents reviewed (Resident #11). The facility reported a census of 50 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to notify the provider timely of a significant weight lost for 1 of 2 residents reviewed for nutrition (Resident #52). The facility reported a census of 50 residents. Findings Include: Resident #52 admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. The resident had diagnoses that included coronary artery disease, gastroesophageal reflux disease, diabetes mellitus, non-Alzheimer's dementia, depression and open wounds of right and left lower legs. The resident required moderate assistance with toileting, transfers, supervision with personal hygiene and was independent with eating. [...]