Monticello Healthcare

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF804May 19, 2025

  Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value related to not following instructions for puree food preparation. This had the potential to affect 5 residents who received a pureed diet from the kitchen. Finding includes: On 5/14/25 at 10:50 a.m., [NAME] 1 was observed preparing pureed food. She indicated she was going to puree chicken patties. She washed her hands and removed a pan of chicken patties from the oven. She placed 6 chicken patties in the blender and blended them. She stopped the blender, added two cups of water from the faucet, and blended again. She stopped the blender, stirred the contents with a spatula, added another cup of water, and blended longer. […]

• No harm, potential for more than minimal, patternF761Oct 16, 2024

  Based on observation, record review, and interview, the facility failed to ensure medications were stored in accordance with professional standards related to medications for multiple residents stored in the cabinet without the resident's name, medication name, prescribed dose, strength, and expiration date for 1 of 2 medication rooms observed. (Residents D, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, and Z) Finding includes: During an observation of the BCD Unit Medication room on 10/15/24 at 4:35 p.m., there were multiple paper medication cups stored with medication in the cups. The medication cups had another paper medication cup covering the medications. The medication cups used to cover the medications had initials and a 5, 6, or 7 written on them. […]

• No harm, potential for more than minimal, patternF921Mar 7, 2024

  Based on observation and interview, the facility failed to ensure the residents' environment was in good repair related to broken and missing blind slats, chipped paint, marred walls, and loose stripping for 3 of 4 units observed. (Cottage, BCD, and [NAME] Units) Findings include: During the Environmental Tour, on 3/7/24 at 10:40 a.m., the following was observed: 1. Cottage room [ROOM NUMBER]- Stripping surrounding the air conditioner was loose and hanging. Two residents resided in the room. room [ROOM NUMBER]- Slats missing from window blind, peeling paint and caulk above the window and marred walls in the bathroom. Two residents resided in the room. 2. BCD room [ROOM NUMBER]- Slats were broken off the window blinds. […]

• No harm, potential for more than minimal, patternF805May 9, 2023

  Based on observation and interview, the facility failed to ensure food was prepared in a form to meet individual needs related to incorrectly made pureed food. This had the potential to affect 13 residents who received a pureed diet. (Main Kitchen, Cook 1) Findings include: On 5/3/23 at 11:00 a.m., Cook 1 was observed preparing pureed taco salad with chili. A recipe was used and the measured ingredients were prepared in advance. Two cycles were pureed through the blender to complete the taco salad puree portion of the recipe. The cook poured the pureed taco salad in to 13 bowls. The blender was washed and another cycle was performed to puree the chili. The chili was completed and the cook garnished the top of each 13 taco salad bowls with the chili. […]

• No harm, potential for more than minimal, patternF921May 9, 2023

  Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to gouged walls, holes in bathroom walls, a cracked toilet riser, and chipped paint on 3 of 4 units. (BCD Unit, West Wing, and Cottage). Findings include: During the Environmental tour with the Directors of Maintenance and Housekeeping and the Administrator on 5/9/23 at 2:40 p.m., the following was observed: 1. BCD Unit a. In room [ROOM NUMBER], the window had chipped paint and the wall in the bathroom had holes underneath the soap dispenser. Two residents resided in the room. Four residents shared the bathroom. b. […]