Monticello Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Monticello Nursing & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 3, 2022

  Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to provide adequate supervision for one of one residents reviewed with a fall history to prevent a fall with injury to occur (Resident #14). The facility also failed to prevent two out of two cognitively impaired, wandering residents from exiting the facility unattended and unnoticed (Resident #18 and Resident # 22). This failure of supervision resulted in an Immediate Jeopardy (IJ) to the health, safety, and security of the residents. The facility reported a census of 53 residents. Findings Include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 shown diagnoses include Hypertension, Diabetes and [CONDITION(S)]. […]

• Actual harm, isolatedF684Nov 3, 2022

  Based on observation, clinical record review, policy review and staff interviews, the facility failed to appropriately provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the Nursing Staff failed to do a thorough assessment and implement interventions for 2 of 2 residents reviewed (Resident #50 and #106). The facility reported a census of 53 residents. Findings Include: 1. Resident #50's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. The MDS documented the resident required supervision while eating. […]

• Actual harm, isolatedF684Dec 13, 2021

  Based on clinical record review, hospital record review, facility policy review, Primary Care Provider interview, and staff interviews the facility failed to provide quality of care in treatment and care for 1 of 3 residents reviewed with identified pressure ulcers. Resident #1 had identified skin impairments by the facility and upon arrival to the emergency room (ER) on 12/3/21, the resident had additional open wounds identified to the right lower abdominal fold, the left upper arm, the bilateral heels, and the left hip (areas A, B, C, & D). The facility failed to complete a thorough head to toe assessment and/or implement interventions that identified the areas A, B, C, or D. […]

• No harm, potential for more than minimal, patternF689Nov 12, 2025

  Based 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. Findings include:1.) The Minimum Data Set(MDS) assessment tool, dated 8/21/25, listed diagnoses for Resident #2 which included anemia, hypertension (high blood pressure), arthritis and Non-Alzheimer's Dementia, anxiety and post traumatic stress disorder. The MDS stated the resident was independent for transferring and listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, which indicated severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF657Nov 30, 2023

  Based 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 admitted [DATE] 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. […]