Cura of Monticello

In the surveyor’s words

From the most serious findings on record at Cura of Monticello, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Jul 12, 2023

  Based on interview and document review, the facility failed to ensure oxygen therapy was provided per physician orders for 1 of 3 residents (R1) when R1, who required continuous oxygen (O2), had her oxygen removed by a nursing assistant (NA). This resulted in an immediate jeopardy (IJ). The immediate jeopardy began on [DATE], when R1's O2 was removed by a nursing assistant (NA). R1 went limp and unresponsive after approximately 9 minutes in the bathroom. R1 subsequently died . The administrator and director of nursing (DON) were notified of the immediate jeopardy at 3:39 p.m. on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore issued at Past Noncompliance. […]

• Actual harm, isolatedF686Apr 16, 2025

  Based on observation, interview and document review, that facility failed to comprehensively assess and implement interventions for 1 of 2 residents (R26) reviewed for pressure ulcers. R26 developed pressure ulcers after splint placement for ankle fracture resulting in actual harm when the facility did not clarify orders for monitoring or when to remove the splint. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively intact and received extensive assistance to complete activities of daily living (ADL's) including dressing, grooming and bathing, R26 required extensive assistance of two staff with transfers and toileting. […]

• No harm, potential for more than minimal, patternF656Jan 15, 2026

  Based on record review and interview, the facility failed to ensure residents' comprehensive care plans were updated to include Enhanced Barrier Precautions (EBP) interventions for 3 of 3 residents reviewed (R11, R14, and R28) who met criteria for EBP. Furthermore, based on observation, interview and document review, the facility failed to ensure resident care plans and TASK sheets contained information for 1 of 1 resident (R1) in the sample who received oxygen. Findings include: R11R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 had intact cognition and required assistance with activities of daily living (ADLs). […]

• No harm, potential for more than minimal, patternF755Jun 17, 2021

  Based on observation, interview and document review, the facility failed to ensure staff were properly documenting shift to shift narcotic count for 14/14 residents to prevent drug diversion. Findings include: During observation of narcotic count books, it was noted that approximately 25 signatures were missing for May 2021 and 22 missing for June 2021. During an interview on 06/16/21, at 01:43 p.m. registered nurse (RN)-A stated narcotics are signed off by two nurses for at administration, for shift count and disposal and then goes into the steri-cycle (box for safely destroying medications) for secure storage, DON reviews disposition. During interview on 6/16/21, at 2:30 p.m. […]

• No harm, potential for more than minimal, patternF761Jun 17, 2021

  Based on observation, interviews, and record review the facility failed to ensure expired medications were removed from use on 2 of 4 medication carts reviewed for medication storage. Findings include: During observation on 6/16/21, 1:43 p.m. 2 of 4 medication carts were reviewed and expired medications were found. -[MEDICATION(S)]- no open date noted on vial, dose: 12 Units /HS- almost full pen -Unlabeled [MEDICATION(S)]- Exp March 27, 2020 -Stock Tylenol 325mg- 1000 tablets opened 12/13/20- exp 3/21 -[MEDICATION(S)] 1% vial- Mix 2.1ml in [MEDICATION(S)] (1g) -[MEDICATION(S)] 4mg- Filled 3/17/20 and refill as needed through 3/17/21 During an interview with the consulting pharmacist (CP) on 06/17/21, 10:49 a.m. […]