Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Woods, A Nightingale Community during CMS and state inspections, most recent first.
A resident with dementia exited the facility unsupervised after being given the door code by staff, and multiple residents were found to have knowledge of exit codes, which were routinely shared by staff. Residents used these codes to leave and re-enter the building without staff awareness, and staff interviews confirmed that supervision was not consistently provided when residents accessed outdoor areas.
A resident with dementia, identified as an elopement risk and exhibiting wandering behaviors, was found outside the facility without staff knowledge. Despite this, the quarterly MDS assessment completed after the incident did not document the resident's wandering behavior, resulting in an inaccurate assessment as confirmed by the MDS Coordinator.
CNAs did not fully cleanse a resident's skin during incontinent care, as observed when fecal residue remained after care was reported complete. The resident, who required assistance due to dementia and other conditions, was not properly cleaned until prompted by surveyors. Staff and leadership confirmed that all skin areas should be cleansed, but the facility lacked a written hygiene policy.
During incontinent care, CNAs failed to change gloves and perform hand hygiene between dirty and clean tasks, handled clean supplies with contaminated gloves, and attempted to sanitize gloved hands instead of changing gloves, resulting in improper infection control practices for a resident with dementia and incontinence.
A resident with moderate cognitive impairment and incontinence was improperly cleaned by a CNA, who wiped back to front and failed to remove soiled bedding, exposing the resident to waste. The DON confirmed the improper cleaning could lead to infection.
A facility failed to ensure proper hand hygiene when a CNA touched objects in a resident's room with dirty gloved hands after providing care. The resident had moderate cognitive impairment and was incontinent of bowel and bladder. The facility's infection control policy requires hand hygiene after contact with bodily fluids or inanimate objects near the patient.
A facility failed to notify the State LTC Ombudsman of a resident's hospital transfers, as required by policy. The resident was hospitalized four times, but there was no proof of notification. The Administrator struggled to access records and indicated that notification responsibilities had shifted among staff members.
A resident with a tracheostomy and cognitive intactness required an assistive communication device, as per their care plan, to communicate effectively. However, staff failed to consistently use the device, which was kept in a medication cart and not brought into the room during interactions. This resulted in the resident's communication needs not being met, as observed during multiple instances when the call light was activated and staff entered the room without the device.
A resident with a PEG tube was not administered enteral feed and flush at the physician's ordered rate. Observations showed the feeding pump set incorrectly, and staff interviews revealed reliance on outdated MARs and inconsistent verification processes.
The facility failed to promptly remove expired food items, properly cover and seal food in storage, and maintain a clean kitchen environment. Additionally, dietary employees did not wash their hands after handling dirty objects, posing a risk of cross-contamination. These deficiencies potentially affected 69 residents.
The facility failed to remove expired drugs and biologicals from two medication storage rooms and did not secure drugs behind locked compartments in one storage room. Expired items were found in the Memory Care Unit and the East Hall Medication Storage Room, with the latter's door being ajar. The DON acknowledged the issues and stated that the storage room door should have shut automatically.
The facility failed to ensure meals were served at appropriate temperatures, affecting 24 residents who received meal trays in their rooms. Observations and resident interviews revealed that food was often lukewarm or cold by the time it was delivered, due to the use of unheated food carts.
The facility failed to ensure proper nail care for a resident with severe cognitive impairment, Type 2 diabetes, and dementia. Despite the care plan indicating a need for assistance, observations revealed the resident's nails were long, jagged, and dirty. CNA #3 confirmed the nails needed attention, and the DON provided guidelines for nail care, which were not followed.
The facility failed to prevent and properly treat pressure ulcers for a resident, leading to worsened wounds and infection. Inconsistent documentation and missed treatments were noted, and wound assessments were inaccurate. The DON confirmed the lack of proper documentation, and the treatment nurse admitted to possible lapses in care.
The facility failed to ensure a raised toilet seat and the outer toilet bowl were cleansed of a dark brown substance, identified as stool, for a resident with legal blindness and morbid obesity. Observations over three consecutive days revealed the presence of the substance, indicating a lack of proper cleaning and sanitation.
The facility failed to properly manage resident funds, resulting in misallocated social security checks and incorrect interest distribution. Seven resident trust accounts were affected, with issues persisting for at least a year.
The facility failed to maintain separate accounting for each resident's funds, resulting in negative balances in some accounts due to the misallocation of social security checks. The facility's policy mandates separate accounting and prohibits commingling of resident funds with nursing facility funds.
Failure to Prevent Resident Elopement Due to Staff Sharing Door Codes
Penalty
Summary
A deficiency occurred when a resident was able to exit the facility without staff knowledge by using a code to the entrance/exit doors that had been provided by facility staff. The resident, who had a diagnosis of non-Alzheimer's dementia and was considered cognitively intact with a BIMS score of 15, was found outside the building by a CNA after being unsupervised for approximately 5-10 minutes. The resident reported that the code to the door was given by a CNA, and further interviews revealed that multiple residents knew the codes to various exit doors, which were also provided by staff. Observations and interviews indicated that several residents, including those who smoked, routinely used the door codes to exit and re-enter the building without staff supervision. Staff members confirmed that residents had been seen using the codes to access outdoor areas, and some residents stated that all residents who smoked or wanted to go outside had the code. It was also noted that the alarm on the door used by the resident did not function, and that staff were not always aware when residents exited the building. The facility had multiple exit doors, some of which led to areas with potential hazards such as cleaning equipment and concrete surfaces. Staff interviews confirmed that residents were able to obtain the codes from aides or nurses, and that supervision was not consistently provided when residents exited. The care plan for the resident involved indicated a history of wandering and attempts to hoard smoking materials, and the resident's family had previously requested placement on a secure unit. Despite these factors, the resident was able to exit the facility unsupervised due to staff providing door codes and lack of effective monitoring.
Inaccurate MDS Assessment of Resident's Wandering Behavior
Penalty
Summary
The facility failed to ensure the accuracy of a quarterly Minimum Data Set (MDS) assessment for one resident. Record review showed that the resident, who had a diagnosis of non-Alzheimer's dementia and was identified in the care plan as an elopement risk with wandering behaviors, was found outside the building without staff knowledge. Despite this incident occurring prior to the completion of the quarterly MDS, the assessment did not reflect the resident's wandering behavior. The MDS Coordinator confirmed that the MDS should have indicated wandering behaviors but did not, resulting in an inaccurate assessment. The Director of Nursing acknowledged the incident but could not confirm the accuracy of the MDS assessment as she was not responsible for its completion.
Failure to Ensure Complete Cleansing During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to properly cleanse all areas of a resident's skin during incontinent care. During direct observation, after assisting the resident to bed and removing soiled clothing, the CNAs indicated they had completed incontinent care. Upon request from the surveyor, one CNA removed the resident's brief and used a clean wipe to cleanse the genital area, revealing a brown streak on the wipe, indicating that fecal matter remained. The CNA continued to cleanse the area until no further fecal residue was observed, but did not change gloves between tasks. The resident involved had diagnoses including dementia with agitation, overactive bladder, and osteoarthritis, and required assistance with personal hygiene and toileting. Interviews with the CNAs, DON, and Administrator confirmed that all areas of the skin should be cleansed during incontinent care to remove feces and urine. The facility did not have a written policy for resident bathing and hygiene at the time of the incident.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control protocols during incontinent care for a resident with dementia, overactive bladder, and osteoarthritis. During the observed care, both CNAs sanitized their hands and donned gloves before beginning, but did not change gloves or perform hand hygiene at appropriate times. One CNA handled soiled clothing, touched clean supplies, and provided care to the resident without changing gloves or sanitizing hands between dirty and clean tasks. The same gloved hand that had been in contact with soiled items was used to remove clean wipes and provide care, and clean items in the room were touched with contaminated gloves. Additionally, after cleaning feces from the resident, the CNA removed gloves, sanitized hands, and put on a new pair of gloves, but then continued care without changing gloves between tasks. The other CNA did not change gloves at any point during the process. At one point, a CNA attempted to sanitize a gloved hand and then put on a clean glove over the sanitized glove, which is not an appropriate infection control practice. Both CNAs demonstrated a lack of adherence to hand hygiene and glove-changing protocols during the provision of care. Interviews with the CNAs, Director of Nursing, and Administrator confirmed that staff are expected to perform hand hygiene and change gloves between dirty and clean tasks, and not to touch clean items or surfaces with contaminated gloves. Facility policy and infection prevention guidelines require frequent glove changes and hand hygiene to prevent cross-contamination, but these procedures were not followed during the observed care event.
Improper Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide proper incontinence care for a resident with moderate cognitive impairment, who was incontinent of bowel and bladder. During an observation, a CNA was seen improperly cleaning the resident after an incontinence episode. The CNA wiped the resident's genital region from back to front, a method that can spread germs and potentially cause urinary tract infections. Additionally, the CNA did not thoroughly clean the resident's genital area, leaving liquid waste on the resident's brief, incontinence pad, and fitted sheet. The CNA did not remove the soiled pad or sheet before rolling the resident back onto them, exposing the resident to moisture and liquid waste. The CNA later acknowledged that the genitals were not cleaned properly and that the resident had urinated through the brief, incontinence pad, and onto the fitted sheet. The Director of Nursing confirmed that the cleaning method was improper and could lead to infection. The facility's policy on Accident Hazards Prevention emphasizes the responsibility to provide care that promotes quality of life, which was not adhered to in this instance.
Improper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was used by staff while providing care to a resident with moderate cognitive impairment and bowel and bladder incontinence. During an observation, a Certified Nursing Assistant (CNA) was seen touching objects in the resident's room, such as the bedside drawer and privacy curtains, with dirty gloved hands after providing care. The CNA acknowledged touching these items with contaminated gloves. The Director of Nursing confirmed that the items were contaminated due to the improper hand hygiene practices. The resident involved had a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, and was always incontinent of bowel and bladder, requiring the use of adult disposable briefs. The facility's infection control policy mandates performing hand hygiene after contact with bodily fluids, the patient's intact skin, or inanimate objects in the immediate vicinity of the patient.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman in writing of a resident's transfer to the hospital. The facility's policy required that a copy of the transfer notice be sent to the Ombudsman. However, a review of the resident's electronic health record showed that the resident was hospitalized four times over a period of several months, and there was no proof that the Ombudsman had been notified of these hospitalizations. The Administrator was unable to provide evidence of notification and reported difficulties accessing the necessary computer records. It was revealed that the responsibility for sending these notifications had shifted between staff members, including the Business Office Manager and the Assistant Director of Nursing, before the Administrator assumed the responsibility.
Failure to Utilize Assistive Communication Device for Resident with Tracheostomy
Penalty
Summary
The facility failed to ensure that an assistive communication device was utilized for a resident with a tracheostomy, who required the device to communicate effectively. The resident, who was cognitively intact, had a medical history of a tracheostomy and carcinoma in situ of the pharynx. The resident's care plan specified the need for a [brand name] valve to assist with communication, and staff were instructed to ensure the device was available and functioning. However, during multiple observations, the assistive communication device was not used, and the resident was unable to communicate effectively with staff. On several occasions, the resident's call light was activated, and staff entered the room without utilizing the assistive communication device. The device was kept in a medication cart and was not brought into the room when staff attended to the resident. Interviews with staff, including an LPN and the DON, revealed that the device was not consistently used as intended, and staff did not take the device into the room every time they interacted with the resident. This lack of adherence to the care plan resulted in the resident's communication needs not being met.
Failure to Administer Enteral Feed at Ordered Rate
Penalty
Summary
The facility failed to administer enteral feed and flush at the physician's ordered rate for a resident receiving nutrition and water through a PEG tube. The resident, who was cognitively intact, had a diagnosis of dysphagia and gastrostomy status. The physician's order specified an enteral feed rate of 53 ml/hr and a flush rate of 40 ml every hour. However, observations revealed that the feeding pump was set to a feed rate of 43 ml/hr and a flush rate of 40 ml/hr, which did not align with the physician's orders. Interviews with nursing staff revealed a lack of clarity and consistency in verifying and updating the feeding pump settings against the physician's orders. One LPN confirmed the incorrect settings and was unable to access the electronic health record due to an internet outage, relying instead on a paper MAR that contained outdated information. Another LPN stated that she relied on the MAR to ensure the pump settings were correct, indicating a potential gap in the process of updating and verifying orders. The facility's enteral feeding procedure guideline was reviewed but did not provide specific instructions on ensuring the accuracy of pump settings.
Expired Food and Sanitation Issues in Kitchen
Penalty
Summary
The facility failed to ensure expired food items were promptly removed from stock, as observed with two 32-ounce boxes of half and half and a 46-ounce box of nectar thickened apple juice, both past their expiration dates. Additionally, food items in the refrigerator and dry storage area were not properly covered or sealed, including an open box of sausage, an open box of salt, and an open bag of breakfast cereal. These practices increase the potential for foodborne illness among residents. Furthermore, food items in the refrigerator lacked proper labeling with opened or received dates, such as a bottle of syrup, a bottle of Italian sweet creamer, a plastic storage bag containing tuna salad, and another containing fried fish, which could lead to improper food rotation and usage. The facility also failed to maintain a clean and sanitary kitchen environment. The deep fryer had a layer of yellow grease covered with crumbs, and various air vents and ceiling tiles in the kitchen and dishwashing areas were observed to be dirty, rusty, or covered with lint. Additionally, dietary employees were observed not washing their hands after handling dirty objects and before handling clean equipment or food items, which poses a risk of cross-contamination. These deficiencies were observed to potentially affect 69 residents who received meals from the kitchen, out of a total census of 72 residents.
Expired and Unsecured Medications Found in Storage Rooms
Penalty
Summary
The facility failed to ensure expired drugs and biologicals were removed from two of four medication storage rooms and failed to secure drugs and biologicals behind locked compartments in one of four storage rooms. During an interview, the Director of Nursing (DON) stated that each nursing station had a bin for nurses to place medications that were no longer needed or expired, which she checks weekly. However, during an observation of the Medication Storage Room on the Memory Care Unit, expired items such as Ipratropium Bromide and Albuterol Sulfate with an expiration date of 01/05/2024 and two 1-liter bottles of enteral feeding dated use before 1MAR2024 were found. The Licensed Practical Nurse (LPN) present stated that the expired medications should have been placed in a locked cabinet, but she did not have the key to access it. Additionally, the surveyor observed the Medication Storage Room on the East Hall with its door ajar, and upon inspection, found a bottle of Iron Supplement Liquid with an expiration date of 02/24. The LPN confirmed the expiration date and acknowledged that the door should have been closed. The DON was informed of these concerns and stated that the medication storage room door on the East Hall should have shut automatically. The facility's policy on the storage of medications requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, and that discontinued, outdated, or deteriorated drugs be returned to the dispensing pharmacy or destroyed. Compartments containing drugs and biologicals are to be locked when not in use, which was not adhered to in these instances.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to ensure meals were served at appropriate temperatures and in a manner that maintained the appearance and palatability of the food. This deficiency was observed during meal deliveries to residents' rooms on multiple halls. Specifically, food items were found to be lukewarm or cold by the time they reached the residents, which was confirmed through temperature readings taken by the Dietary Supervisor. For instance, milk was recorded at 55 degrees Fahrenheit, scrambled eggs at 110 degrees Fahrenheit, and hash browns at 101.4 degrees Fahrenheit during one observation. Similar temperature issues were noted during another observation, with milk at 52 degrees Fahrenheit and meat loaf at 102 degrees Fahrenheit. Interviews with residents corroborated these findings, with one resident specifically mentioning that food was lukewarm when delivered to their room but hot when eaten in the dining room. The use of unheated food carts for meal delivery was identified as a contributing factor to the temperature discrepancies. These practices affected a total of 24 residents who received meal trays in their rooms across different halls, potentially impacting their nutritional intake and overall satisfaction with the meals provided.
Failure to Maintain Proper Nail Care for Resident
Penalty
Summary
The facility failed to ensure proper nail care for a resident with severe cognitive impairment, Type 2 diabetes, dementia, and presbyopia. The resident's care plan indicated a need for limited assistance with personal hygiene, including nail care. Despite this, observations on multiple occasions revealed that the resident's fingernails were over 0.25 inches long, jagged, and had a dark brown substance underneath them. Certified Nursing Assistant (CNA) #3 confirmed that the resident's nails needed to be clipped and cleaned, and acknowledged that nail care should be performed during showers. However, the resident's nails were not properly maintained, posing a risk of infection and germ transmission. The Director of Nursing (DON) provided documentation stating that nail care should be performed on shower days and as needed, with CNAs responsible for trimming nails unless the resident is diabetic, in which case a licensed nurse must perform the task. Despite these guidelines, the resident's nails were not adequately cared for, indicating a lapse in adherence to the facility's nail care standards. This deficiency highlights a failure in the facility's duty to maintain the personal hygiene and grooming of residents who require assistance.
Failure to Prevent and Properly Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper care and services to prevent new pressure ulcer development for a resident with existing pressure ulcers. Resident #30 had a right heel wound that worsened over time, with dimensions indicating deterioration. The Treatment Administration Record (TAR) showed inconsistent documentation and treatment orders, with missed treatments on specific dates. The Assistant Director of Nursing (ADON) provided wound pictures that did not accurately depict the full extent of the wounds, leading to incorrect assessments of healing progress. During an observation, fresh blood was noted on the dressing, indicating improper wound care. The Director of Nursing (DON) confirmed that treatments were not documented on certain dates, and the treatment nurse, LPN #1, admitted to possibly forgetting to document the treatments. The urgency of following physician orders to prevent infection and promote healing was acknowledged but not adhered to. Additionally, the facility's Wound Care Policy emphasized the importance of proper documentation and care, which was not followed, leading to a wound infection requiring antibiotic treatment. The facility's failure to provide consistent and accurate wound care documentation and treatment resulted in avoidable pressure ulcers and infection for Resident #30.
Failure to Maintain Sanitary Bathroom Environment
Penalty
Summary
The facility failed to ensure a raised toilet seat and the outer toilet bowl were cleansed of a dark brown substance, identified as stool, to promote a clean and sanitary environment for a resident with legal blindness and morbid obesity. The resident required assistance with toileting hygiene and had a moderately impaired cognitive status. Observations over three consecutive days revealed the presence of the dark brown substance on the toilet seat and bowl, indicating a lack of proper cleaning and sanitation. Housekeeper #1 confirmed the presence of stool on the toilet seat and bowl and acknowledged that housekeeping was responsible for cleaning the residents' bathrooms daily. The facility's housekeeping policy emphasized the importance of cleaning restrooms to prevent the spread of germs and bacteria, but this policy was not followed in the case of Resident #173, leading to an unsanitary bathroom environment.
Failure to Properly Manage Resident Funds
Penalty
Summary
The facility failed to act as a responsible fiduciary of the resident's funds, failing to hold, safeguard, manage, and account for the personal funds of the residents deposited with the facility. During a record review, it was found that the facility's fund management system showed two accounts with negative balances and one account with a significantly high balance due to the misallocation of social security checks. The Business Office Manager (BOM) and Administrator confirmed that these negative balances were due to three resident social security checks being deposited into one resident's account, which had a balance of $16,026.18. Further investigation revealed that the interest was not being allocated to the residents with negative balances, and the account with the misallocated funds was earning interest on monies that did not belong to that resident. The BOM was unable to explain how these discrepancies affected the interest earnings of other residents. The issue affected seven resident trust accounts, with records showing the problem persisted for at least a year. The facility's policy on managing resident funds was not adhered to, as it mandates a full, complete, and separate accounting of funds entrusted to the facility on the residents' behalf.
Failure to Maintain Separate Accounting for Resident Funds
Penalty
Summary
The facility failed to maintain separate accounting for each resident's funds. A review of the Patient Trust Fund account revealed two accounts with negative balances of -$1,104.00 and -$1,283.75, and one account with a balance of $16,026.18. During an interview, the Business Office Manager (BOM) and Administrator explained that the negative balances were due to three residents' social security checks being deposited into one resident's account, which had a balance of $16,026.18. Additionally, the facility's policy on the management of resident and elder trust accounts, which aligns with 42 C.F.R. 483.10(f)(10), mandates a full, complete, and separate accounting of funds entrusted to the nursing facility on the resident's behalf, and prohibits the commingling of resident funds with nursing facility funds. The policy also requires notification to Medicaid residents when their account balance reaches $200 less than the SSI resource limit for one person.
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Illustrative
What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monticello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belle View Estates Rehabilitation And Care Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Chapel Woods Health And Rehabilitation | 14.5 mi | ★★★★★ | 2 | 0 |
| Dermott City Nursing Home | 21.4 mi | ★★★★★ | 3 | 1 |
| The Blossoms At Star City Rehab & Nursing Center | 22.1 mi | ★★★★★ | 0 | 0 |
| The Green House Cottages Of Southern Hills | 31.9 mi | ★★★★★ | 0 | 0 |
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