Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Monticello Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with severe dementia, behavioral symptoms, and total dependence on staff for care was being assisted in bed by two CNAs when the resident jabbed one CNA in the eye. According to an eyewitness CNA and multiple staff interviews, the CNA who was struck became angry, grabbed the resident by the shoulders, shook him, and loudly cursed at him, telling him to "shut the f**k up" and making additional threatening statements, while the roommate overheard profanity directed at the resident. The charge RN was informed that the CNA had yelled at and grabbed the resident, and an assessment showed no physical injury, but the facility’s investigation concluded that the CNA had verbally abused the resident and that physical abuse in the form of aggressively grabbing the resident’s shoulders had been reported, in violation of the facility’s abuse-prevention policy.
A resident with Alzheimer’s disease, traumatic brain injury, seizure disorder, and a documented history of multiple falls and behavioral issues was care planned as a fall risk requiring frequent checks and environmental precautions. Despite this, staff allowed the resident to keep the door closed and relied on the resident’s call light or yelling for needs, and hallway camera footage showed no staff entered the room for the entire night shift after a CNA administered bedtime meds. The next morning, a CNA found the resident in bed with a swollen, bloody lip and abrasions on the arm and shin, with blood on the nightstand, tray table, and floor, and the resident gave inconsistent accounts alleging staff assault. Review of camera footage and staffing records showed no staff entry into the room overnight, and staff concluded the injuries most likely resulted from an unwitnessed fall that occurred while the resident was not visually checked, demonstrating a failure to provide adequate supervision and monitoring to prevent accidents.
Multiple incidents occurred where a resident with severe cognitive impairment physically struck another resident, and another resident with moderate cognitive impairment engaged in inappropriate sexual contact with two female residents. Despite care plans and policies addressing behavioral symptoms and cognitive impairment, supervision and interventions were insufficient to prevent these altercations and inappropriate behaviors.
A resident with severe cognitive impairment and a history of physical behavioral symptoms was involved in multiple physical altercations with another resident, including slapping, after entering the other's room. Staff relied on redirection and periodic checks, but did not provide one-on-one supervision or maintain consistent interventions, resulting in a failure to prevent the altercation.
A facility failed to maintain a resident's dignity by not using a dignity bag for an indwelling urinary catheter, despite multiple observations of the catheter bag being visible. The resident, with severe cognitive impairment, required catheter care as per their care plan. Staff interviews revealed that both CNAs and nurses are responsible for ensuring dignity bags are used, but a CNA admitted to forgetting due to nervousness. The DON confirmed the availability of dignity bags and staff training on their importance.
The facility failed to notify residents of their right to appeal Medicare Part A discharge decisions, despite having remaining benefit days. Documentation lacked evidence of notification, and necessary forms were not completed, affecting three residents who continued to reside in the facility.
A resident with intact cognition was not accounted for when leaving the facility to smoke, as required by their Care Plan. The resident exited and re-entered the facility without signing out or in, and staff were unaware of the requirement. The facility's Smoking Policy did not specify responsibility for tracking resident location during smoking.
A facility failed to maintain consistent Hemodialysis communication records for a resident with chronic kidney disease over two months. The resident's care plan required dialysis thrice weekly, but forms were missing from her clinical record. Staff were unclear about the location of these forms, with only one form found for the period, contrary to policy requirements.
The facility failed to conduct required Smoking Assessments for two residents, one with moderate cognitive impairment and another with intact cognition, both identified as current smokers. The assessments were not completed upon admission or quarterly, as required, leading to a deficiency in ensuring a safe environment. The DON acknowledged the oversight and the facility's Smoking Policy lacked guidance on assessing residents' smoking capabilities.
Verbal and Physical Mistreatment of a Cognitively Impaired Resident by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal mistreatment by staff. The resident involved had severe cognitive impairment due to Alzheimer’s disease, cancer, and a history of physical and verbal behaviors directed toward others. According to the MDS, the resident required staff assistance for transfers, used a wheelchair, and had sustained a prior fall with injury. The care plan directed staff to redirect behaviors, step away and re-approach if the resident was resistive, and to verbally reward positive behavior. On the day of the incident, two CNAs were in the resident’s room providing care before lunch. The resident became combative and jabbed one CNA in the eye while being rolled for incontinence care. Multiple staff accounts, including those of the ADON, DON, charge RN, and the eyewitness CNA, consistently described that after being struck in the eye, the CNA who was hit became upset. The eyewitness CNA reported that the CNA who was struck backed away briefly, then grabbed the resident by the shoulders, shook him, and told him to “shut the f**k up,” repeating this loudly twice. She also reported that he said words to the effect of, “If you weren’t a resident, I would beat the s**t out of you.” The Administrator’s account of the eyewitness report included that the CNA also said, “If you weren’t a resident I would f**ing kill you.” The roommate, who had moderate cognitive impairment, reported hearing the staff member call the resident a “f**er” after the resident poked the staff in the eye, and stated that the staff did not hit or hurt the resident. The charge RN documented that she was notified by a CNA that another CNA yelled at the resident, grabbed him by the shoulders, and made threatening statements. When the RN entered the room shortly after, the resident was smiling, denied pain or discomfort, and a full body assessment revealed no visible injury. The facility’s investigation concluded that verbal abuse was verified based on the eyewitness CNA’s account and corroboration from the roommate, and that physical abuse in the form of aggressively grabbing the resident’s shoulders was reported by the eyewitness CNA, though denied by the accused CNA. The facility’s abuse policy in effect stated that all residents have the right to be free from abuse, including verbal and physical abuse, and that residents must not be subjected to abuse by anyone.
Failure to Adequately Supervise High-Risk Resident Leading to Unwitnessed Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring for a resident with a known history of falls and behavioral issues. The resident had diagnoses including Alzheimer’s disease, hypertension, traumatic brain injury, and seizure disorder, and the MDS documented two or more prior falls with non‑major injury. The care plan identified the resident as a fall risk related to poor safety awareness and impaired balance, and also noted physical behaviors, behaviors directed toward others, and a risk for making false accusations. The care plan interventions included ensuring the call light was within reach, use of appropriate footwear, leaving the bathroom door ajar with the light on, and encouraging the resident to keep the door open at night to allow for more frequent staff checks. Despite these identified risks and interventions, the resident was allowed to keep his door closed with a sign instructing staff to knock before entering, and staff relied primarily on the resident’s use of the call light or yelling from the doorway rather than consistent in‑person checks. On the night of the incident, camera footage showed that a CNA entered the resident’s room at approximately 9:36 p.m. to administer bedtime medication, after which no staff entered the room again until about 6:15 a.m. the following morning. During that interval, the resident did not activate his call light. Staff interviews confirmed that the nurse on duty did not go into the resident’s room during the shift and believed that an aide had done so, while the agency aide assigned to the hall did not actually enter the room, instead only going to the door and listening because the resident became angry when staff opened his door. This pattern of inaction resulted in a prolonged period—roughly the entire night shift—during which no staff member visually assessed the resident, despite his documented fall history, behavioral issues, and care plan direction for more frequent checks. At approximately 6:10–6:15 a.m., a CNA entered the resident’s room for morning care and found him in bed with smeared blood on his chin and a swollen, reddened lower lip with an internal laceration, as well as abrasions on his right arm and right shin. Blood was observed on the nightstand, on the leg of the tray table, and on the floor next to it. The resident reported that an employee had come into his room and assaulted him, at various times describing the assailant as a female employee, a male employee, and later accusing a maintenance worker of beating him and taking his closet door. Review of hallway camera footage and staffing records showed no staff entry into the room during the night and no male CNAs on duty, contradicting the resident’s accounts. Based on the location of the blood and the absence of staff entry, facility staff concluded that the injuries most likely resulted from an unwitnessed fall that occurred while the resident was unsupervised for an extended period, demonstrating that the facility did not ensure adequate supervision and monitoring to prevent accidents for this high‑risk resident. The resident’s prior incident history further underscored his need for closer supervision. Earlier incident reports documented a fall in the hallway after he threw his cane and lost his balance, and another unwitnessed event where staff heard a loud bang and found him seated on the floor near his bathroom door, with the resident unable to explain how it happened. Observations during the survey showed that he typically stayed in his room with the door shut, ate meals there, and often refused to sit in a recliner for meals, preferring the edge of the bed. Staff described him as using his call light or yelling from his doorway when he wanted something, and as being noncompliant with attempts to make him an assist‑of‑one for mobility or to use a gait belt. Despite these known behaviors and risks, staff on the night of the incident did not perform in‑person checks or “lay eyes” on him for many hours, which directly led to his injuries from an unwitnessed event that went unrecognized until the morning. The facility’s own investigation and staff interviews acknowledged that the lack of rounding and failure to visually check the resident during the night were unacceptable and contrary to expectations that residents be checked at least every two hours or hourly. Staff reported that they had been relying on the resident’s call light use and his tendency to yell for assistance, and that the agency aide did not enter the room because the resident disliked having his door opened. The combination of the resident’s closed door, his behavioral and cognitive issues, his fall history, and staff’s failure to conduct required rounds and direct observation resulted in the resident sustaining injuries from an unwitnessed fall or accident that occurred without timely detection or intervention, constituting the cited deficiency in accident prevention and adequate supervision.
Failure to Prevent Resident-to-Resident Altercations and Inappropriate Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations and inappropriate behaviors, as evidenced by multiple incidents involving residents with cognitive impairments and behavioral symptoms. One resident with severe cognitive impairment and a history of physical behavioral symptoms was observed striking another resident in the hallway after a verbal altercation. The care plan for this resident included interventions such as moving the resident to a calm environment and maintaining distance from others, as well as 15-minute checks, but the incident still occurred, indicating a lapse in supervision and implementation of interventions. Another resident with moderate cognitive impairment was involved in two separate incidents of inappropriate sexual contact with female residents. In one case, the resident was observed groping a female resident's breast while watching television, and in another, the same resident was seen rubbing another female resident's thigh in the dining room, despite her attempts to push his hand away. The care plan for this resident directed staff to prevent sexual contact with a specific resident but did not include interventions to prevent similar behavior with other residents. Staff and resident interviews confirmed that these incidents were witnessed and reported by both staff and other residents. The facility's policies on managing inappropriate resident behavior and sexual relationships for cognitively impaired residents were reviewed. The policy on resident-to-resident aggression directed immediate intervention and separation but did not specify further preventive measures. The policy on sexual relationships defined cognitive impairment and outlined the need to protect residents unable to provide consent, but the care plans and supervision in practice were insufficient to prevent repeated incidents. These deficiencies demonstrate a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents and inappropriate behaviors.
Failure to Prevent Resident-to-Resident Altercation Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation involving two residents, one of whom had severe cognitive impairment and a history of physical behavioral symptoms such as hitting, kicking, and pushing. The resident with cognitive impairment had diagnoses including non-Alzheimer's dementia, anxiety, and post-traumatic stress disorder, and was noted to be confused, agitated, and prone to entering other residents' rooms. Despite these known behaviors, the resident was not provided with one-on-one supervision and staff primarily relied on redirection and periodic checks. Multiple incidents were documented in which the cognitively impaired resident physically interacted with others, including elbowing, shoving, and ultimately slapping another resident. The most recent incident involved the resident entering another resident's room, becoming agitated, and slapping the other resident, who then retaliated. Staff responded by separating the residents, but no injuries were observed. Interviews with staff indicated that the resident required frequent redirection and was difficult to monitor continuously, as she would not remain in one place and did not participate in activities. The care plan for the resident with behavioral symptoms included interventions such as 15-minute checks and keeping distance between her and others when she became physically abusive. However, these interventions were not consistently maintained, and the resident was not provided with enhanced supervision despite a pattern of escalating behaviors. The facility's abuse prevention policy required identification and intervention for high-risk situations, but the measures in place were insufficient to prevent the altercation.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to protect a resident's dignity by not ensuring that the indwelling urinary drainage bag was kept in a dignity bag for a resident with an indwelling catheter. The resident, identified as severely cognitively impaired with a BIMS score of 4 out of 15, had diagnoses including cerebral infarction and compression of the brain. Observations on multiple occasions revealed the Foley catheter bag hanging off the bed frame without a dignity bag, visible to anyone entering the room. These observations occurred over two consecutive days, despite the resident's care plan indicating the need for appropriate catheter management. Interviews with facility staff, including a CNA and an LPN, confirmed that both nurses and nurse aides are responsible for ensuring the catheter bag is placed in a dignity bag to respect the resident's privacy. The CNA admitted to forgetting to place the dignity bag during catheter care due to nervousness. The DON acknowledged that dignity bags should be used whenever the catheter bag is visible to others or when the resident has visitors. The facility had dignity bags available and provided training to staff on their importance, yet the deficiency persisted.
Failure to Notify Residents of Medicare Discharge Rights
Penalty
Summary
The facility failed to provide proper notification to residents and/or their representatives regarding the right to appeal decisions for discharge from Medicare Part A, despite having remaining benefit days. This deficiency was identified for three residents who were discharged from Medicare Part A services but continued to reside in the facility. The facility's documentation, including the Beneficiary Notice and Electronic Health Records, lacked evidence of notification prior to discharge for these residents. Additionally, the facility did not complete the necessary forms, such as Form CMS-10055 and the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, which are required to inform residents of their rights and the coverage status. The facility's failure to provide these notifications was confirmed through staff interviews and a review of the relevant documents. The facility was unable to produce completed NOMNC forms for the residents in question, indicating a systemic issue in the notification process. The facility's administrator acknowledged the inability to locate the required forms, further highlighting the deficiency in ensuring residents were informed of their Medicare coverage status and their right to appeal discharge decisions.
Failure to Account for Resident Location During Smoking
Penalty
Summary
The facility failed to account for the location of a resident who chose to smoke, as outlined in the resident's Care Plan. Resident #29, who has intact cognition with a BIMS score of 14 out of 15, was documented to use tobacco and was required to sign out on a Leave of Absence form when leaving the facility to smoke. However, the form was incomplete, with the resident's name and facility left blank, and there was no documented time for signing back in. Observations revealed that Resident #29 exited and re-entered the facility without signing out or in, despite the Care Plan's intervention requirement. Interviews with staff, including an LPN and the DON, confirmed that the designated smoking area was off the premises and that Resident #29 left the building multiple times a day to smoke without signing out. The DON and Administrator acknowledged that Resident #29 had only signed out once in the past month, indicating a failure to adhere to the Care Plan. The facility's Smoking Policy, revised in 2022, did not specify the responsibility for accounting for resident location when smoking, contributing to the deficiency.
Inconsistent Hemodialysis Record-Keeping
Penalty
Summary
The facility failed to maintain consistent records of Hemodialysis communication for a resident with chronic kidney disease and congestive heart failure over a two-month period. The resident, who had intact cognition, required dialysis three times a week as per her care plan. However, her clinical record did not include Hemodialysis communication forms for September and October 2024. Staff interviews revealed confusion about the location of these forms, with one nurse unaware of the existence of a Dialysis book and the Director of Nursing expecting the forms to be in the dialysis book. Only one form was found for the past two months, contrary to the facility's policy that required documentation of vital signs and communication with the dialysis facility before and after dialysis sessions.
Failure to Conduct Smoking Assessments for Residents
Penalty
Summary
The facility failed to complete the required Smoking Assessments for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #1, with moderate cognitive impairment and multiple health conditions, was identified as a current smoker upon admission. However, the facility did not conduct any Smoking Assessments to evaluate Resident #1's capabilities and deficits to safely smoke, neither upon admission nor quarterly as required. This oversight was confirmed by both the resident and the staff responsible for the initial assessment. Similarly, Resident #29, who had intact cognition and was also a current smoker, did not receive the necessary quarterly Smoking Assessments. Although some assessments were completed, there were significant gaps, with missed assessments on several occasions. The Director of Nursing acknowledged these lapses and confirmed that the facility's Smoking Policy did not adequately address the need for assessing residents' capabilities and deficits to safely smoke.
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What surveyors actually found near you
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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.
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Nursing homes near Monticello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anamosa Care Center | 9.6 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Cascade Llc | 9.9 mi | ★★★★★ | 2 | 0 |
| Mercyone Dyersville Senior Care | 17.4 mi | ★★★★★ | 3 | 0 |
| Good Neighbor Home | 21.9 mi | ★★★★★ | 3 | 0 |
| Mechanicsville Specialty Care | 22.4 mi | ★★★★★ | 4 | 0 |
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