Below 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 Cura Of Monticello during CMS and state inspections, most recent first.
Care plans and task documentation were incomplete for several residents. Three residents who met criteria for EBP had wounds or pressure ulcers documented in the EMR, but their comprehensive care plans did not include EBP interventions such as gown and glove use during high-contact care or related staff instructions. In addition, a resident receiving oxygen after a pneumonia-related hospitalization was observed on a nasal cannula, but the care plan and PCC TASK sheet did not document oxygen therapy.
Failure to maintain dignity was cited when two residents who needed help with grooming were repeatedly observed with unshaven facial hair, despite stating they wanted to be clean shaven and needed staff assistance; the EMR lacked documentation that shaving was offered or refused, and one resident’s shaving task was charted as completed when it was not done. In addition, a resident with an indwelling catheter was repeatedly observed with an uncovered urine bag visible in common areas and from the hallway, even though staff stated catheter bags should be covered or placed in a privacy bag to protect dignity.
Missed quarterly assessment for nebulizer self-administration. A resident with COPD, respiratory failure, dysphasia, and chronic respiratory failure with hypoxia had an order allowing self-administration of a nebulizer treatment after nursing setup and assessment, but the last documented competency assessment was not followed by the required quarterly reassessments. During observation, the resident was using the nebulizer with the mask not fully sealed and the medication canister empty while the machine continued to run; an RN and ADON confirmed the resident had not been reassessed and that the observed use without staff supervision counted as self-administration.
Failure to Notify Ombudsman of Resident Transfers and Discharges: The facility did not ensure the Office of the Ombudsman for LTC was notified of one resident’s hospital transfer and later discharge, or another resident’s discharge. Records showed one resident had significant medical issues including traumatic subdural hemorrhage, HTN, and HF, while the other had CHF, CAD, DM, CKD stage 3, PVD, HTN, and OA. The SSD said she tried to fax weekly transfer/discharge notices but had no confirmation and the facility had no documentation that notification occurred.
The facility failed to complete and accurately code BIMS assessments for two residents and failed to complete an accurate physical device assessment for a resident using a wheelchair seat belt. One resident’s quarterly MDS was coded as cognition not assessed despite documentation showing intact cognition, and another resident’s admission MDS was also coded not assessed with no BIMS found in the EMR. A resident with quadriplegia was observed with a wheelchair seat belt in place, but the EMR lacked an assessment addressing that device, and the ADON confirmed the assessment did not address the seat belt.
The facility failed to complete weekly skin assessments for a resident at risk for impaired skin integrity, despite the resident’s care plan requiring them and staff confirming they were to be done on bath days. The facility also failed to implement a positioning care plan for another resident with Parkinson’s disease and significant ADL dependence; OT ordered the custom WC to be reclined at least 10 degrees for midline positioning, but observations showed the WC remained upright while the resident repeatedly leaned to the side or forward and attempted unsafe movements.
Oxygen tubing and cannulas were not changed or labeled as required for multiple residents receiving O2. A resident with COPD and other chronic conditions had tubing and a bubbler that were undated, with no documentation of timely changes; another resident with COPD and chronic respiratory failure had undated tubing with a brown-tinged appearance and no recent change record; and a third resident with asthma and recent pneumonia had undated tubing and a cannula that appeared not to have been changed, with one prong displaced from the nose. Staff stated night shift was responsible for changing the supplies, and the facility policy required weekly cannula replacement and monthly extension tubing changes.
Failure to Monitor Dialysis CVC Site: A resident with ESRD and dependence on hemodialysis used a chest CVC after a failed AV fistula, but the EMR did not contain an order for staff to assess the access site for bleeding, secure placement, or signs of infection. An LPN stated there was no order she was aware of, and the ADON could not locate an order either, despite the facility policy calling for licensed staff to monitor for hemodialysis complications and infection signs.
Failure to follow and discontinue EBP precautions: Staff did not wear the required gown during high-contact care for one resident on EBP and did not perform hand hygiene after toileting assistance. Two residents remained on EBP even though their wounds had healed and wound care had been discontinued, while signage and PPE remained posted and staff relied on the door signs for precaution status.
Failure to Inform a Blind Resident of Medications During Administration: A resident with intact cognition and blindness requested to be told each medication at every med pass, but staff administered meds without identifying them. Family reported the concern had been raised repeatedly, and observation showed a TMA giving meds in applesauce without explaining what they were. The resident stated staff often did not tell her what the meds were or why they were given, and the RN clinical coordinator and ADON confirmed staff were expected to explain medications because the resident could not see.
Failure to Notify Resident Representative After Fall: A resident with intact cognition, severe visual impairment, and fall risk was found on the floor after attempting to transfer from bed to wheelchair. Nursing staff assisted the resident back to the wheelchair, but the EMR had no documentation that the family or legal representative was notified of the fall or the post-fall assessment findings. The FM stated she learned of the incident only after viewing camera footage, and the ADON confirmed the family should have been notified.
Inaccurate reporting of resident fall with injury: A resident with intact cognition, blindness, wheelchair use, and fall risk sustained a fall that later resulted in toe fractures. Facility documentation and staff interviews gave conflicting accounts of whether the resident self-transferred, whether wheelchair brakes were locked, and whether the fall was witnessed. The reports submitted to the SA contained incorrect or incomplete details and did not accurately reflect the incident as documented in the resident record and internal investigation.
A resident with intact cognition, severe visual impairment, and fall risk was left with moved belongings and an unlocked w/c after asking for help getting up. Video showed an NA rearranged items in the room, retrieved the resident’s w/c without locking the brakes, and left the room; the resident then fell while trying to reposition items and reach the w/c. Records and interviews showed incomplete post-fall documentation, inconsistent accounts of the event, and no clear nursing assessment before the resident was moved from the floor.
Soiled Wheelchair Not Kept Clean: A resident with Parkinson’s disease, depression, and moderate cognitive impairment was observed in an adaptive WC with yellow and white food debris, chunks of food, and dried liquid on the seat area and cushion. The same debris remained on later observations, including during breakfast when the resident was feeding himself with his mouth over the soiled area. An RN stated WCs are supposed to be cleaned at least weekly and when noted to be soiled.
Survey results were kept in a binder at the front desk, but the binder and surrounding area did not clearly identify where the results were located or direct residents, visitors, and staff to the last 3 years of survey results. A resident was unsure where the survey results were kept, and the RDOO stated there should have been signage and clearer labeling on the binder.
Care Plans Failed to Reflect EBP and Oxygen Therapy Needs
Penalty
Summary
The facility failed to ensure comprehensive care plans were updated to include Enhanced Barrier Precautions (EBP) interventions for 3 residents who met criteria for EBP. R11’s quarterly MDS identified intact cognition, assistance with ADLs, blindness, fall risk, and a stage 2 pressure ulcer, and the EMR showed EBP was required due to wounds on the coccyx and back of the thigh. R14’s annual MDS identified intact cognition, assistance with ADLs, oxygen therapy, and multiple chronic conditions including COPD and chronic respiratory failure with hypoxia, while the EMR showed EBP was required due to a pressure ulcer on the right medial ankle. R28’s quarterly MDS identified the need for assistance with ADLs and multiple neurological and psychiatric diagnoses, and the EMR showed EBP was required due to wounds on the right and left buttocks. Review of each resident’s comprehensive care plan showed no interventions addressing EBP, including the use of gowns and gloves during high-contact resident care activities, staff instructions, or infection control measures. During interviews, nursing assistants confirmed that staff relied on posted signage to identify precautions and stated that gowns, gloves, and a face mask were to be used during high-contact care. The RN clinical coordinator and ADON confirmed that R11, R14, and R28 required EBP and that EBP were not addressed in the residents’ care plans, stating that EBP should be included so staff are aware of how to care for each resident and understand the reason for the precautions. The facility also failed to ensure the care plan and TASK sheet for R1, who was admitted after a hospital stay for pneumonia, documented oxygen therapy. R1’s admission MDS indicated assistance with ADLs, oxygen use, and moderate cognitive impairment. During observation, R1 was wearing a nasal cannula, the tubing had no date showing when it was last changed, and the cannula prongs had a slight tan color. R1 could not remember when the oxygen tubing was last changed. The care plan initiated for R1 did not document oxygen use, and the TASK section in PCC also lacked documentation that R1 was receiving oxygen therapy until it was updated after review by nursing leadership.
Failure to Maintain Resident Dignity With Grooming and Catheter Privacy
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity and respect by not ensuring routine shaving was offered and performed for two residents who required assistance with personal hygiene and grooming. One resident had intact cognition, required assistance with ADLs, and had diagnoses including arthritis, osteoporosis, anxiety, depression, COPD, respiratory failure, a displaced bimalleolar fracture, complex regional pain syndrome, neuralgia and neuritis, dysphasia, lymphedema, and chronic respiratory failure with hypoxia. On multiple observations, long white hairs were seen along the right side of the resident’s jawline and chin, and the resident stated she did not like having them and needed staff help with shaving. The resident’s EMR and care plan identified a need for staff assistance with personal hygiene and grooming, but there was no documentation that shaving was offered or refused. The second resident had diagnoses including progressive neurological conditions, Parkinson’s disease with dyskinesia with fluctuations, hypertension, non-Alzheimer’s dementia, anxiety disorder, psychotic disorder, hallucinations, obstructive sleep apnea, and adjustment disorder with anxiety. The resident required assistance with ADLs and was observed repeatedly with long facial hair extending beyond the chin and upper lip. The resident stated he preferred to be clean shaven and needed staff assistance with shaving. His care plan identified staff assistance with personal hygiene and grooming, and the EMR included a task for staff to assist with shaving every morning; however, the task was documented as completed on days when observations and interview showed shaving had not been performed. The EMR also lacked documentation that shaving assistance was offered or refused. The facility also failed to conceal a catheter bag containing urine from public view for a resident dependent on staff for ADLs who had an indwelling catheter and diagnoses including hypertensive heart and chronic kidney disease with heart failure, hyperlipidemia, benign prostatic hyperplasia, and urinary retention. On multiple observations, the catheter bag was hung on the resident’s wheelchair or visible from the hallway while the resident was in the common area, dining room, or room, and yellow urine was visible in the bag. Staff interviews confirmed that catheter bags should be covered with a privacy flap or placed in a privacy bag when the resident was out of the room, and the facility policy stated staff shall promote dignity and assist residents as needed by helping keep urinary catheter bags covered.
Missed Quarterly Assessment for Nebulizer Self-Administration
Penalty
Summary
The facility failed to ensure a resident was assessed as scheduled for the ability to safely self-administer a prescribed nebulizer treatment. The resident had intact cognition and required assistance with ADLs, and diagnoses included COPD, respiratory failure, dysphasia, chronic respiratory failure with hypoxia, and oxygen therapy use. The resident had a physician order allowing self-administration of the nebulizer treatment after nursing setup and assessment, but the last documented self-administration assessment was completed on 3/24/25, with no evidence of the required quarterly reassessments through 1/14/26. During observation on 1/15/26, the resident was sitting in a wheelchair with eyes closed and head hanging forward while the nebulizer mask was not fully sealed around the mouth and nose and the medication canister was empty while the machine continued to run. A TMA stated she set up the nebulizer solution, assisted with the mask, turned the machine on, and left the room, and said the resident usually turned it off when finished. The RN care manager and ADON confirmed self-administration assessments were required quarterly, that the resident had not been reassessed since 3/24/25, and that the observed nebulizer use without staff supervision would be considered self-administration of medications.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to ensure the Office of the Ombudsman for Long-Term Care was notified of a resident’s transfer to the hospital and subsequent discharge from the facility for 2 of 2 closed records reviewed. One resident had an admission MDS showing cognition was not assessed and required assistance with ADLs, with diagnoses including traumatic subdural hemorrhage with loss of consciousness, hypertension, and heart failure. That resident was transferred to the hospital and later discharged from the facility, but review of the complete medical record, transfer documentation, discharge paperwork, and Ombudsman notification logs found no evidence that the Ombudsman was notified of either the hospital transfer or the discharge. The second resident’s admission MDS identified the resident as cognitively intact and requiring assistance with ADLs, with diagnoses including traumatic congestive heart failure, atherosclerotic heart disease, diabetes, chronic kidney disease stage 3, peripheral vascular disease, hypertension, and osteoarthritis. That resident discharged home, but review of the complete medical record, transfer documentation, discharge paperwork, and Ombudsman notification logs found no evidence that the Ombudsman was notified of the discharge. During interview, the social services designee stated she attempted to fax the Ombudsman weekly on Fridays for transfers and discharges, used the same fax cover sheet without a date or time, and did not receive confirmation that the fax was successfully sent; she confirmed the facility had no documentation verifying notification occurred. The facility’s Discharge Policy required notification to the Ombudsman for resident transfers and discharges.
Incomplete Cognitive and Physical Device Assessments
Penalty
Summary
The facility failed to ensure the Brief Interview for Mental Status (BIMS) was completed and accurately coded for two residents’ MDS assessments. For one resident, a quarterly MDS coded cognition as not assessed even though the annual MDS identified intact cognition, the resident was alert, able to communicate, and capable of responding to questions during routine care and nursing assessments during the same assessment reference period. The resident also had diagnoses including progressive neurological conditions, Parkinson’s disease with dyskinesia, hypertension, non-Alzheimer’s dementia, anxiety disorder, psychotic disorder, hallucinations, obstructive sleep apnea, and adjustment disorder with anxiety, and required assistance with ADLs. During interview, the corporate MDS nurse confirmed the BIMS was not completed for the quarterly MDS and was coded as not assessed when the MDS was submitted, and stated there was no clinical justification or documentation to support that coding. For the second resident, the admission MDS also coded cognition as not assessed, but review of the EMR through the survey date did not show a completed BIMS. The resident required staff assistance with ADLs, had diagnoses including hypertensive heart and chronic kidney disease with heart failure, hyperlipidemia, benign prostatic hyperplasia, history of transient ischemic attack, retention of urine, repeated falls, and anemia, and the care plan did not address cognitive status. The facility also failed to ensure a physical restraint assessment was completed accurately for a resident who used a wheelchair seat belt. The resident had quadriplegia, dysphagia, autonomic dysreflexia, and cramp and spasm, and the care plan stated the seat belt was used because of quadriplegia with core instability and that the resident could state when he wanted it on or off. Survey observations showed the resident seated in the wheelchair with the seat belt buckled on multiple days, and the resident stated staff applied the seat belt when he was placed in the wheelchair and that he only unbuckled it when going back to bed. Review of the EMR found no physical device assessment addressing the seat belt use, and the assistant director of nursing confirmed the assessment was expected but the located assessment did not address the wheelchair seat belt.
Missed Skin Assessments and Failure to Follow Positioning Orders
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed as scheduled for a resident with intact cognition who required assistance with ADLs and had diagnoses including arthritis, osteoporosis, anxiety, depression, a displaced bimalleolar fracture of the right lower leg, complex regional pain syndrome, neuralgia and neuritis, dysphasia, and lymphedema. The resident’s care plan identified the resident as at risk for impaired skin integrity and required weekly head-to-toe skin assessments. Record review showed the weekly skin assessment documentation was missing for two consecutive weeks, and there were no nursing notes, skin assessment forms, or wound monitoring records showing the assessments were completed. Staff interviews confirmed that weekly skin assessments were expected to be completed on residents’ bath days and documented by nursing staff. The RN clinical coordinator and ADON stated the assessments were required for residents at risk for skin breakdown and confirmed staff were responsible for completing and documenting them each week. They also confirmed the resident’s weekly skin assessments were not completed as scheduled and that the last documented skin assessment was completed earlier than required. The facility also failed to implement a resident’s care plan related to positioning after occupational therapy issued an order to keep the custom wheelchair reclined back at least 10 degrees for optimal midline positioning. The resident had Parkinson’s disease, major depression, substantial/maximal ADL dependence, substantial/maximal assistance needs for transferring and positioning, and moderate cognitive impairment. The care plan and nursing assistant Kardex instead directed staff to recline the wheelchair to assist the resident in sitting more upright and prevent leaning, while observations repeatedly showed the wheelchair back remained in a 90-degree position and the resident was leaning to the right, leaning forward, or attempting self-transfers. The occupational therapist stated she was unaware of the leaning issues and that nursing should notify therapy if re-evaluation was needed.
Oxygen tubing and cannulas not changed or labeled as required
Penalty
Summary
The facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 3 of 5 residents reviewed for oxygen services. R4 had diagnoses including COPD, chronic kidney disease with heart failure, dementia, and dependence on supplemental oxygen. During observation, R4’s oxygen concentrator, tubing, and humidifier were present, but the tubing and bubbler were not labeled or dated, and visible condensation was noted in the bubbler. R4 stated she used oxygen at night and needed staff assistance to apply it, but was not aware of when the tubing or humidifier had last been changed. Record review showed no documentation that the tubing or bubbler had been changed within the prior 23 days, and the last documented tubing change was on 12/23/25. R14 had diagnoses including COPD, respiratory failure, chronic respiratory failure with hypoxia, anxiety, and depression, and the MDS indicated oxygen therapy was received. During observation, R14 was using oxygen via nasal cannula, but the tubing was not labeled or dated and had a brown-tinged appearance. Record review showed no documentation that the tubing had been changed within the prior 30 days, with the last documented tubing change on 12/3/25. Staff interviews confirmed that oxygen tubing and bubbler components should be changed weekly and labeled and dated when changed, but RN-C and ADON-B confirmed R4’s tubing and bubbler had not been changed weekly and R14’s tubing had not been changed weekly. R1 had diagnoses including hypertension, paroxysmal atrial fibrillation, and asthma, and was admitted after a hospital stay for pneumonia. R1’s MDS indicated she required assistance with ADLs, received oxygen, and had moderate cognitive impairment. During repeated observations, R1’s oxygen tubing remained undated and appeared not to have been changed, with the cannula prongs showing a slight tan color. On one observation, one cannula prong was not in the nose and rested on the cheek. Staff stated the night shift was responsible for changing oxygen tubing and cannulas, and the facility policy stated nasal cannulas are to be replaced weekly and extension tubing monthly, but the observed equipment was not labeled or dated and did not reflect those change intervals.
Failure to Monitor Dialysis CVC Site
Penalty
Summary
The facility failed to ensure monitoring of the dialysis access site for one resident who required hemodialysis. The resident’s annual MDS identified the resident as cognitively intact and independent with ADLs except for needing assistance with toileting and showering. The resident had diagnoses including end stage renal disease, dependence on hemodialysis, chronic pain, osteoarthritis, and hypertension, and used a central venous catheter (CVC) in the chest for dialysis after a failed AV fistula. Review of the resident’s EMR did not identify an order for facility staff to assess the CVC for bleeding, secure placement, or signs of infection such as redness, swelling, drainage, tenderness, or warmth. During interview, an LPN stated there was no order she was aware of to assess the CVC, though she did look at the site because she knew the resident received dialysis. The ADON reviewed the resident’s orders and was unable to locate an order to assess the CVC site, and stated such an order was expected and that assessment was important for the health and safety of a resident receiving dialysis. The facility’s hemodialysis policy stated licensed staff would monitor for complications related to hemodialysis, including bleeding and signs or symptoms of infection.
Failure to Follow and Discontinue EBP Precautions
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not follow Enhanced Barrier Precautions (EBP) during resident care for one resident, and when isolation precautions were not discontinued for two residents after the precautions were no longer clinically indicated. One resident had intact cognition and required assistance with ADLs, with diagnoses including CHF, HTN, arthritis, depression, atrial fibrillation, bilateral blindness, a stage 2 pressure ulcer, congenital glaucoma, and Barrett’s esophagus. That resident had been placed on EBP for wound-related concerns, but record review showed the wound care had been discontinued and documentation indicated the resident no longer met criteria for EBP, while signage and isolation status remained in place without a documented reassessment or order to discontinue precautions. A second resident had intact cognition and required assistance with ADLs, with diagnoses including arthritis, osteoporosis, anxiety, depression, COPD, respiratory failure, a displaced bimalleolar fracture, complex regional pain syndrome, neuralgia and neuritis, dysphasia, lymphedema, and chronic respiratory failure with hypoxia. During observation, a nursing assistant assisted this resident from a wheelchair to the bathroom using a mechanical lift while the resident remained on EBP precautions, but the nursing assistant did not don the required gown before resident contact and provided hands-on toileting and hygiene care without following EBP precautions. The nursing assistant then exited the room without performing hand hygiene. Throughout the survey, EBP signage remained posted and PPE was stored on the doors for both residents. Staff interviews confirmed that both residents had been on EBP for a long time, that staff relied on posted signage to determine precautions, and that staff were expected to wear gloves, a gown, and a face mask for high-contact care. The RN clinical coordinator and ADON confirmed both residents had been placed on EBP for wounds that had healed, wound care had been discontinued, and both residents remained on EBP even though the precautions should have been removed.
Failure to Inform Blind Resident of Medications During Administration
Penalty
Summary
The facility failed to ensure a resident with intact cognition and blindness was informed of the medications being administered at the time of administration in accordance with the resident’s expressed preferences. The resident had diagnoses including chronic systolic CHF, HTN, arthritis, depression, atrial fibrillation, pain in both hands, blindness in both eyes, severe visual impairment, a stage 2 pressure ulcer, congenital glaucoma, and Barrett’s esophagus without dysplasia. The resident’s MDS identified that she was blind and required assistance with medication administration, and the EMR special instructions and banner indicated she requested to receive medications in private and to be informed of all medications at every medication pass. Family reported that they had repeatedly asked staff to tell the resident what medications she was receiving before each administration because of her blindness, but the concern remained unresolved. During observation, a TMA prepared the resident’s medications in applesauce and administered them without telling her what they were. The TMA stated she did not tell the resident what she was receiving unless the resident questioned it. The resident stated she could not see the medications, relied on staff to tell her what she was receiving, and said staff often gave medications without explaining what they were or why they were given. The RN clinical coordinator and ADON confirmed staff were expected to explain medications when administering them because the resident could not see and had the right to know what she was receiving.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to ensure the resident's representative was notified after a fall for 1 of 1 resident reviewed for notification of change. R11's quarterly MDS identified intact cognition, assistance with ADLs, blindness in both eyes, and risk for falls. R11's diagnoses included chronic systolic CHF, hypertension, arthritis, depression, atrial fibrillation, pain in both hands, severe visual impairment, a stage 2 pressure ulcer, congenital glaucoma, and Barrett's esophagus without dysplasia. R11's EMR documented that on 4/29/25, R11 was found on the floor in her room after attempting to transfer from bed to wheelchair, and nursing staff assisted R11 back into the wheelchair. The record did not include documentation that the resident's family or legal representative was notified of the fall or informed of the post-fall assessment findings. During interview, FM-A stated she had not been notified of the fall and learned of it only after viewing video footage from the camera in R11's room. The ADON confirmed the family should have been notified after the fall and acknowledged there was no documentation of notification in the medical record.
Inaccurate reporting of resident fall with injury
Penalty
Summary
The facility failed to ensure accurate reporting of an alleged violation involving resident neglect after a resident fall with injury. The resident had intact cognition, was blind, used a wheelchair for mobility, required assistance with ADLs, and had diagnoses including CHF, HTN, arthritis, depression, atrial fibrillation, pain in both hands, congenital glaucoma, a stage 2 pressure ulcer, and Barrett’s esophagus without dysplasia. The resident was identified as being at risk for falls in the MDS. The resident experienced a fall in the room when she leaned over to a table for support during a transfer and the table slid, causing her to fall. Initial documentation described a witnessed fall with a bruise to the left elbow and no deep skin tear. Later review of the medical record showed the resident underwent an x-ray after family requested further evaluation, and the x-ray revealed fractures to multiple toes related to the fall. The facility’s internal documentation and interviews reflected differing accounts of how the fall occurred, including whether the resident self-transferred, whether the wheelchair brakes were locked, and whether staff were present and assisting at the time. The facility submitted reports to the State Agency that contained inaccurate or incomplete information about the circumstances of the fall and the resulting injury. One report stated the resident self-transferred to the wheelchair and slid to the ground, while another described the resident pushing the table back and slipping because the wheelchair brakes were not on. Facility investigation notes and staff interviews also varied regarding whether the fall was witnessed, whether the resident was assisted off the floor before assessment, and whether the RN completed a post-fall assessment at the time. Current leadership later reviewed the investigation and confirmed the report did not fully or accurately reflect the incident as it occurred.
Failure to Provide Safe Supervision and Fall Prevention for a Blind Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent an avoidable accident for a resident who had intact cognition, was blind, used a wheelchair for mobility, and was identified as being at risk for falls. The resident’s care plan directed staff not to rearrange items in the room, to keep the call light within reach, and to discuss any changes in item placement with the resident because of severely impaired vision and fall risk. Video footage showed a nursing assistant entered the resident’s room while the resident was asking for help getting up. The nursing assistant moved the resident’s call light, water pitcher, Bible, and bedside table, then retrieved the resident’s wheelchair and left it next to the bed without applying the brakes. The resident stood, attempted to reposition items and reach the wheelchair, and the wheelchair rolled backward, causing the resident to fall forward into the bedside table and land on her left side. The nursing assistant returned after the fall, called for assistance, and the resident was then lifted from the floor and placed into the wheelchair. Record review and interviews showed the post-fall documentation was incomplete and inconsistent. The facility’s post-fall investigation did not indicate whether the fall was reviewed by the interdisciplinary team or include new or updated fall interventions. Progress notes did not document whether a nursing assessment, vital signs, or pain/injury assessment were completed before the resident was moved from the floor. Interviews with the resident, family member, nursing assistant, RN, and other staff differed regarding whether the fall was witnessed and whether the resident was assessed before being assisted up. An x-ray later showed a nondisplaced fracture of the third metatarsal neck and possibly the fourth metatarsal neck, and the resident also had a new bruise to the left elbow documented after the fall.
Soiled Wheelchair Not Kept Clean
Penalty
Summary
The facility failed to ensure a resident’s wheelchair was kept clean. R41’s admission record and diagnosis listing documented Parkinson’s disease and a major depressive episode. R41’s quarterly MDS, with a correction assessment completed on 1/6/26, indicated he required substantial/maximal assistance with most ADLs, needed substantial/maximal assistance with transferring and positioning, and was moderately cognitively impaired. On 1/12/26, R41 was observed in his room partially seated in his adaptive wheelchair with his upper body leaning over the grab bar attached to his bed while attempting to get into bed. At that time, the right seat area of the wheelchair and the cushion were stained with yellow and white food debris, including chunks of food and dried liquid, covering roughly a three-inch by three-inch area of the cushion and visible under-sling seat. The same food debris was still present on 1/13/26. During a breakfast observation on 1/15/26, R41 was sitting at a dining room table feeding himself after staff set him up, while leaning to the right and holding the table with his left hand; his mouth was over the same stained area of the wheelchair cushion and seat support. RN-B later observed food debris on the right corner and cushion of the chair and stated wheelchairs are supposed to be cleaned at least weekly by night shift staff, that wheelchair cleaning is listed on the nursing assistant Kardex, and that staff should clean a chair when it is noted to be soiled. A copy of the nursing assistant Kardex and a facility policy for wheelchair cleaning were requested but not received.
Survey Results Not Clearly Posted for Review
Penalty
Summary
The facility failed to ensure survey results were placed in a prominent location and that the binder or signage identified where the last three years of survey results could be found. During interview, a resident stated they were not sure where the survey results were kept. During observation and interview, the business office manager stated the survey results were in a binder labeled Resource Book on the front of the binder, which was on the edge of the reception desk within easy reach of anyone. The binder had a clear front pocket with a paper showing the facility name and Nursing Home Residents' Resource Binder, and the edge of the binder included the facility name and Documents Available for Review, but there was no indication on the outer part of the binder that survey results were inside. No signage was observed showing where the survey results were located for review. The regional director of operations stated there should be a sign identifying where to locate the survey results and that the binder should have indicated Facility Name - Survey Results so residents, visitors, and staff could review them if desired. Facility policy regarding survey results was requested but not provided.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 70 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
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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) |
|---|---|---|---|---|
| Lake Ridge Care Center Of Buffalo, Inc. | 10.1 mi | ★★★★★ | 7 | 0 |
| Park View Health Care Center | 10.4 mi | ★★★★★ | 1 | 0 |
| Guardian Angels Care Center | 10.7 mi | ★★★★★ | 5 | 0 |
| Annandale Care Center Inc | 16.5 mi | ★★★★★ | 1 | 0 |
| The Estates At Delano Llc | 19.4 mi | ★★★★★ | 7 | 0 |
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