Montello Care Center: Incomplete Assault Investigation - WI
The incident began when a resident, identified in inspection records only as R1, became agitated and told staff she wanted to go home. Licensed Practical Nurse LPN-L sprinted down a hallway to find help. By the time additional staff arrived, R1 was hitting CNA-E, one of the aides providing care that night. When R1 saw more staff approaching, she stopped hitting CNA-E and ran for the exits.
What followed was a facility-wide scramble. R1 moved from door to door trying to get out. Staff blocked fire exits, with one employee positioning herself outside a door and another holding a door shut from the inside. A cook, identified as CK-J, stepped between R1 and the dining room door when R1 tried to push through it. Multiple aides followed R1 through the building. At one point, R1 sat in the lobby and CK-J stood behind her with hands on the back of her chair, trying to calm her down.
R1 was yelling. CK-J told the surveyor what R1 said when she entered the dining room: "I want to leave. Why won't you let me leave?" R1 told staff she didn't recognize anyone and was trying to reach her spouse. She was calm by the time police arrived.
CNA-E, the aide R1 struck, was injured during the incident. Her name does not appear in the police report. Her statement is not in the facility's internal investigation.
Neither is LPN-L's, the nurse who ran for help when it started. Nor CK-J's, the cook who physically blocked a door. Nor CNA-G's, the aide who had experience with similar situations, took charge of directing staff to give R1 space, and worked three or four more shifts at the facility before anyone thought to ask what she saw. Nobody asked her. She received no additional training before returning to work.
When the surveyor interviewed the nursing home administrator, identified as NHA-A, on October 13, the administrator said she had been at the facility earlier that day and R1 had seemed fine. She thought the director of nursing, DON-B, had conducted the staff interviews after the incident. DON-B told the surveyor she had not obtained staff statements, but said the facility had copies of statements that staff gave to law enforcement the night it happened.
When the surveyor returned to NHA-A that same afternoon, the administrator acknowledged she had not obtained the police report. She had not obtained the county crisis report. She was not aware that staff had blocked exit doors during the incident. She was not aware that staff had potentially put hands on R1.
"The facility should have completed staff interviews," NHA-A told the surveyor. She confirmed it had not.
The facility did complete some investigation. Resident interviews were conducted. A new process was put in place for screening incoming residents for histories of violence. Staff education on an updated policy for managing unmanageable residents was, at the time of the inspection, still in progress.
CNA-G, who directed the response on the floor that night, described the scene to the surveyor in detail: LPN-L sprinting down the hall, R1 swinging at staff, residents being moved into their rooms to get them out of the way. CNA-G drew on prior experience to make judgment calls in the moment. Then she went back to work, shift after shift, without a debrief, without a statement taken, without any formal acknowledgment that she had been part of something the facility was supposed to be investigating.
The surveyor cited Montello Care Center for failing to thoroughly investigate the incident, noting the missing statements from CNA-E, LPN-L, and CNA-G. CMS classified the violation as causing minimal harm or potential for actual harm.
CNA-E, who was hurt, was not asked what happened to her until a federal surveyor showed up three weeks later.
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 violations during a health inspection on October 22, 2025.
The incident began when a resident, identified in inspection records only as R1, became agitated and told staff she wanted to go home.
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.