Montereau, Inc.

In the surveyor’s words

From the most serious findings on record at Montereau, Inc., in the surveyor’s own words.

• Immediate jeopardy, isolatedF686May 19, 2025

  On [DATE], a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess, monitor, and intervene for a resident with a history of skin breakdown. The facility failed to accurately identify the status of a resident at high risk for skin breakdown, failed to accurately and timely document the resident's skin condition, failed to accurately care plan, provide, and monitor the success or failure of interventions for the resident's deteriorating skin condition, and failed to communicate the resident's deteriorating skin condition to other disciplines of the resident's care team. […]

• No harm, potential for more than minimal, widespreadF812May 19, 2023

  Based on observation and interview, the facility failed to ensure resident food was prepared and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 61 residents received their meals from the kitchen. Findings: On 05/16/23 at 12:17 p.m., the noon meal service was observed on the 100 hall kitchenette. Dietary Aide #2 was observed to not have a hair net. The dietary aide was observed to have a beard and mustache and was not wearing a beard guard. Cook #3 and Dietary Aide #2 were observed to exit the kitchenette and enter the pantry then re-enter the kitchenette without washing their hands multiple times. A hand washing sink was observed in the kitchenette. […]

• No harm, potential for more than minimal, patternF656Apr 7, 2026

  Based on observation, record review, and interview, the facility failed to ensure a care plan was developed to address immediate needs of residents for 2 (#1 and #48) of 8 sampled residents reviewed for care plans.The administrator identified 56 residents resided in the facility.Findings:1.On 03/30/26 at 2:20 p.m., Resident #1 was observed in a wheelchair in their room with a urinary catheter in place.A physician order for Resident #1, dated 02/27/26, showed to admit the resident to the SNF.A physician order for Resident #1, dated 02/27/26, showed the resident had an order for apixiban (an anticoagulant) 5 mg every morning and at bedtime.An admission assessment for Resident #1, dated 03/05/26, showed the resident had medical diagnoses including atrial fibrillation and heart failure. […]

• No harm, potential for more than minimal, patternF725Nov 21, 2025

  Based on record review and interview, the facility failed to provide sufficient staff to answer call lights in a timely manner for 1 (#1) of 3 sampled residents reviewed for call light response.The DON identified 46 residents resided at the facility. Findings:Review of the Alarms by Room report, dated 08/07/25 through 08/25/25, for Resident #1, showed:a. on 08/07/25 at 4:11 p.m., call light initiated on bed for 1 hour 19 minutes 18 seconds;b. on 08/07/25 at 4:33 p.m., call light initiated on bath for 30 minutes 46 seconds; c. on 08/07/25 at 5:06 p.m., bath call light initiated on for 27 minutes 8 seconds;d. on 08/08/25 at 5:11 a.m., call light initiated on bed for 1 hour 6 minutes 12 seconds; e. on 08/12/25 at 12:35 a.m., bed call light initiated on for 59 minutes 54 seconds; f. […]

• No harm, potential for more than minimal, patternF761Nov 21, 2025

  Based on observation and interview, the facility failed to ensure medications were secured for 2 (first floor North treatment cart #2 and second floor South treatment cart #2) of 2 treatment carts observed to be unlocked and unattended.The DON identified six treatment carts and six medication carts in the facility. Findings: 1.On 10/27/25 at 1:57 p.m., in the chateau on the second floor, the South treatment cart #2 was observed to be unlocked next to the nursing station. Three staff were observed to be behind the nurses' station and one staff was observed to be in front of the nurses' station. On 10/27/25 at 1:59 p.m., two staff were observed to be behind the nurses' station and the one staff in the front of the nursing station left. […]