Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Healthcare during CMS and state inspections, most recent first.
Staff prepared pureed food without following standardized recipes or clear guidelines, relying on subjective consistency tests and adding water from the faucet instead of broth as typically recommended. The Dietary Manager confirmed the absence of specific instructions for pureed food preparation, leading to inconsistent methods for residents on pureed diets.
A resident with diabetes was incorrectly coded as receiving insulin on the MDS assessment, despite only receiving Ozempic, a non-insulin injectable medication. The MAR did not show any insulin administration during the assessment period, and staff interviews revealed confusion about proper coding for non-insulin injectables.
A resident with respiratory failure and other chronic conditions was observed receiving continuous oxygen therapy at 3 liters via nasal cannula, despite a physician's order specifying oxygen use only while sleeping or napping. Staff interviews revealed confusion about the correct order, resulting in the resident not receiving respiratory care as prescribed.
A resident with dementia, Parkinson's disease, and atrial fibrillation was prescribed digoxin with orders to check and document pulse before each dose and to hold the medication if the pulse was below 60. The MAR for two months showed no documentation of pulse checks at the time of administration, though the medication was given daily. The DON confirmed the documentation requirement was not communicated to nursing staff.
A resident with multiple diagnoses and on hospice care was observed with a large dark purple discoloration on her left elbow on two occasions, but there was no documentation or assessment of this skin alteration in her record. Facility staff, including an LPN and the DON, were unaware of the issue, and required protocols for reporting and assessing skin changes were not followed.
A resident with dementia, COPD, and diabetes, who was at nutritional risk and required assistance with eating, had multiple instances where meal intake was 50% or less without documentation that a supplement or substitute was offered, as required by the care plan. Additionally, some meals lacked intake documentation entirely. The DON confirmed that while substitutes were available and offered, staff did not document this as required by facility policy.
The facility failed to store medications according to professional standards, as observed in the BCD Unit Medication room. Medications for multiple residents were pre-set in paper cups, contrary to the facility's policy requiring medications to be prepared for one resident at a time and stored in original containers. Interviews with an LPN and the DON confirmed this improper practice.
Failure to Follow Standardized Pureed Food Preparation Methods
Penalty
Summary
The facility failed to ensure that pureed food was prepared according to methods that conserve nutritive value and follow established guidelines. During observation, a staff member was seen preparing pureed chicken patties by blending them and adding water from the faucet, followed by thickener, without using a standardized recipe or specific instructions regarding the amount or type of liquid and thickener to use. The consistency was checked using the spoon tilt test, but the process relied on subjective judgment rather than a set protocol. The staff member indicated that a book of pureed recipes previously used by the kitchen was no longer available. Interviews with the Dietary Manager confirmed that the facility no longer used pureed recipes and instead followed the IDDSI guidelines, which only required the food to pass consistency tests without specifying preparation details. The Dietary Manager stated that typically broth would be used instead of water, but there were no written guidelines on the exact preparation process. The Administrator was informed of the concern but did not provide additional information. Facility documentation referenced the use of broth or gravy for meats and milk or water for other foods, but did not provide specific instructions, contributing to inconsistent preparation methods for pureed diets.
Inaccurate MDS Assessment Coding for Insulin Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for a resident with diagnoses including Parkinson's disease, diabetes, and schizophrenia. The resident's quarterly MDS assessment indicated insulin use, but a review of the Medication Administration Record (MAR) for the assessment period showed the resident only received Ozempic (semaglutide), a non-insulin injectable medication for diabetes. There was no documentation that the resident received insulin during the assessment period. The MDS Coordinator stated she coded insulin use because Ozempic lowers blood sugar, but later acknowledged uncertainty and sought further guidance. The DON clarified that Ozempic should be coded as an injected medication, not as insulin. Facility policy requires documentation to be consistent with physician orders and insulin administration records.
Failure to Administer Oxygen Therapy as Ordered by Physician
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, hypertension, dementia, diabetes mellitus, and respiratory failure was observed receiving oxygen therapy via nasal cannula at 3 liters while awake and in common areas. The resident's care plan indicated a need for oxygen administration as ordered by the physician, and the May 2025 Physician's Order Summary specified oxygen at 3 liters per nasal cannula only while sleeping or napping, every shift. However, observations showed the resident receiving oxygen continuously, not limited to sleep or nap times as per the physician's order. Interviews with staff revealed a lack of clarity regarding the physician's order, with an LPN stating the resident needed oxygen at all times and indicating the need to clarify the order with the physician. The facility's policy required verification of physician orders and knowledge of flow rate and duration of use, but the resident was not receiving oxygen therapy in accordance with the documented physician order at the time of the survey.
Failure to Monitor Vital Signs Before Administering Heart Medication
Penalty
Summary
The facility failed to ensure adequate monitoring of vital signs as required by physician's orders prior to administering a medication that affects heart rate and rhythm for one resident. The resident, who had diagnoses including dementia, Parkinson's disease, and atrial fibrillation, was prescribed digoxin with instructions to check the pulse before administration and to hold the medication if the pulse was less than 60 beats per minute. Review of the Medication Administration Record for April and May 2025 showed no documentation of the resident's heart rate at the time of digoxin administration, although the medication was marked as given daily. The Director of Nursing confirmed that the order was implemented upon the resident's readmission, but the requirement to document the heart rate with each administration was not communicated to the nursing staff.
Failure to Assess and Monitor Non-Pressure Skin Discoloration
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, dementia, diabetes mellitus, and respiratory failure, who was also on hospice care and had a life expectancy of less than six months, was observed with a large dark purple discoloration on her left elbow on two separate occasions. Despite the presence of this discoloration, the resident's medical record, including the most recent weekly skin assessment, did not document any skin integrity alterations or bruising, nor was there any evidence that the discoloration had been assessed or monitored. Interviews with facility staff revealed that the LPN was unaware of the discoloration, and the Director of Nursing confirmed there was no prior documentation of assessment or monitoring for the skin issue. The facility's care plan required weekly and as-needed skin assessments, with abnormal findings to be reported to the physician, and the facility's policy mandated that any skin alterations be reported and assessed by a licensed nurse. These actions were not followed, resulting in the deficiency.
Failure to Document and Implement Dietary Interventions for At-Risk Resident
Penalty
Summary
The facility failed to fully implement care-planned dietary interventions for a resident at risk for weight loss. The resident, who had diagnoses including dementia, COPD, and type 2 diabetes mellitus, was severely cognitively impaired and required setup help for eating. Care plans required staff to record meal and fluid intake percentages and to offer a substitute if the resident consumed less than 50% of a meal. However, review of intake records over a one-month period showed multiple instances where the resident consumed 50% or less of meals, with no documentation that a supplement or substitute was offered. Additionally, there were several meals with no intake documentation at all. During an interview, the DON confirmed that staff were expected to document substitutes offered in the electronic record, but acknowledged that while substitutes were always available and offered, this was not documented. Facility policy required documentation of foods and fluids consumed at each meal, as well as documentation of substitute offerings and resident acceptance or refusal when intake was 50% or less. The lack of documentation for both meal intake and substitute offerings constituted a failure to follow the care plan and facility policy for this resident.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with professional standards. During an observation of the BCD Unit Medication room, multiple paper medication cups were found stored with medications inside, covered by another paper medication cup. These cups were labeled with initials and numbers indicating the time of medication administration (5 p.m., 6 p.m., and 7 p.m.) for multiple residents. This practice was not in line with the facility's procedure, which required medications to be prepared for one resident at a time and stored in their original containers. Interviews with LPN 1 and the Director of Nursing confirmed that the medications should not have been set up and stored prior to the administration times. The facility's policy, dated 8/2024, also indicated that medications should be stored in the containers they were originally received in. This deficiency was related to complaints IN00443901 and IN00444365, highlighting a failure in adhering to proper medication storage and administration protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 138 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| White Oak Health Campus | 1 mi | ★★★★★ | 12 | 0 |
| St Elizabeth Healthcare Center | 13.5 mi | ★★★★★ | 8 | 0 |
| Parkview Haven | 17 mi | ★★★★★ | 0 | 0 |
| Indiana Veterans Home | 20.6 mi | ★★★★★ | 4 | 0 |
| Heritage Healthcare | 21.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Monticello Healthcare.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.