Montello Care Center: Abuse Report Failure - WI
That is what a state surveyor found when they visited the facility on October 22, 2025, following a complaint inspection. The visit uncovered a single deficiency, but it was a significant one: the nursing home had received credible allegations of abuse involving a resident and did nothing with them, at least not in any of the ways required.
The resident, identified in inspection records only as R1, had dementia. At some point before the inspection, R1 became agitated when staff would not allow R1 to leave the facility. The situation escalated to the point that law enforcement was called. A sergeant, identified in the report as SGT-I, responded to the facility after being dispatched for a disorderly resident.
When SGT-I arrived, staff were holding R1 in a chair. They told the sergeant they were doing so because of safety concerns. R1, for their part, told the sergeant something else entirely: that R1 had been attacked by numerous individuals at the facility.
SGT-I contacted the county crisis line. That call generated documentation. The police response generated a report. Both records existed and were available. The nursing home had obtained neither of them.
The facility's administrator, identified in the report as NHA-A, was interviewed by the surveyor on October 13, 2025, at 3:51 in the afternoon. NHA-A explained why the incident had not been reported to the state survey agency. There were no resident injuries, NHA-A said. The incident was related to R1's increase in behaviors. R1 had not eloped from the facility. There had been no resident-to-resident altercations.
None of those explanations address what R1 told the police.
NHA-A confirmed during that interview that the facility had not conducted its own interviews with any of the staff members who worked the night of the incident. The only statements the facility had were the ones law enforcement collected. NHA-A had not obtained the county crisis documentation. NHA-A had not obtained the police report. NHA-A had not seen, at the time of the interview, the written record showing that staff held R1 in a chair, or the record showing that R1 alleged being attacked by multiple people.
When the surveyor presented those findings, NHA-A acknowledged that the allegations of abuse should have been reported to the state survey agency.
The deficiency was cited under F0609, which covers the obligation to report alleged violations involving mistreatment, neglect, and abuse. The level of harm was assessed as minimal harm or potential for actual harm. A few residents were listed as affected.
What the inspection report does not say is whether anyone ever went back and conducted those staff interviews. It does not say whether the county crisis documentation or the police report were ever formally reviewed by facility leadership before the surveyor's visit. It does not say what happened to R1 after that night, or whether R1 remained at the facility, or whether anyone sat with R1 and tried to understand what R1 experienced.
What the report does say is that a person with dementia, already in a facility because they need help navigating a world that has become increasingly difficult to understand, became frightened enough, or angry enough, or both, to try to leave. That when staff stopped R1 from leaving, the situation became violent enough that police were called. That when police arrived, R1 said they had been attacked by numerous people. And that the nursing home's response, in the weeks that followed, was to conclude that because no one was visibly injured and because R1 hadn't made it out the door, there was nothing that needed to be escalated.
The administrator's reasoning, as recorded by the surveyor, reflects a particular way of thinking about incidents involving residents with dementia. The behavior was framed as an increase in behaviors, a clinical phrase that can function as an explanation and a dismissal at the same time. When a resident with dementia says they were attacked, the statement can be received as a symptom rather than a report. The confusion that comes with dementia is real. But it does not make an allegation disappear, and it does not relieve a facility of the obligation to investigate.
Holding a resident in a chair is a restraint. Whether it was appropriate under the circumstances, whether it was the least restrictive option available, whether it was documented and ordered and monitored, none of that is addressed in the inspection report. What is addressed is that it happened, that a law enforcement officer witnessed it, that the county crisis system was notified, and that the nursing home did not treat any of this as something the state needed to know about.
The surveyor obtained the county crisis documentation on October 13, 2025. That documentation confirmed what SGT-I had reported: staff were holding R1 in a chair when the sergeant arrived. It also confirmed that R1 had alleged being attacked by numerous individuals. The facility's administrator learned about the contents of those records during the surveyor's interview, not before.
Montello Care Center is a small facility in Marquette County, in the central part of Wisconsin. The inspection that produced this deficiency was a complaint inspection, meaning someone had contacted the state with a concern before surveyors arrived. The report does not identify who filed the complaint or what specifically prompted it.
The deficiency carries no dollar figure in this report, no immediate jeopardy designation, no federal fine attached. It is a single citation at the lower end of the harm scale, the kind that can be easy to look past in a database full of facilities with longer violation histories and more dramatic findings.
But the center of it is a person with dementia who told a police sergeant they had been attacked. That statement went into a police report. It went into county crisis documentation. It did not go to the state. The facility's administrator, by their own account, had not even read those records before a surveyor showed up weeks later and asked about them.
NHA-A, at the end of that interview, said the allegations should have been reported.
R1 had already spent those weeks without anyone at the facility formally investigating what R1 said happened to them.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
Montello Care Center in Montello, WI was cited for abuse-related violations during a health inspection on October 22, 2025.
That is what a state surveyor found when they visited the facility on October 22, 2025, following a complaint inspection.
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.