Montello Care Center: Botched Incident Investigation - WI
The resident, identified only as R1 in inspection records, entered the dining room yelling, "I want to leave. Why won't you let me leave?" A cook who witnessed the scene told inspectors the resident was followed by two to four aides as R1 moved from door to door trying to get out. The resident eventually sat in the lobby. The cook stood behind the chair with both hands on the back of it, trying to help calm the situation down.
CNA-G, who coordinated the staff response, told inspectors that one worker was positioned outside a door R1 tried to open, and that CNA-G asked another aide to hold it shut. R1 was swinging. Staff tried to stay out of R1's line of sight and moved other residents into their rooms. When police arrived, R1 was calm. The resident had been trying to get to a spouse, and said R1 didn't recognize anyone around them.
CNA-G worked three or four more shifts after the incident without receiving any follow-up education. The cook was never asked for a statement. The nurse who worked that evening was never asked for a statement. The CNA who was actually injured was never asked for a statement, and her account was missing from both the police report and the facility's own investigation file.
When the nursing home administrator, NHA-A, was interviewed by the surveyor on October 13, NHA-A said the director of nursing had handled staff interviews. The director of nursing said NHA-A had. Neither had. NHA-A had not obtained the police report. NHA-A had not obtained the county crisis report. NHA-A acknowledged the facility should have completed staff interviews.
The injured aide's account of what happened that night remains uncollected.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Montello Care Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
Montello Care Center in Montello, WI was cited for violations during a health inspection on October 22, 2025.
The resident, identified only as R1 in inspection records, entered the dining room yelling, "I want to leave.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.