Montello Care Center: Resident Physically Restrained - WI
The incident happened on the night of September 25, 2025. It began simply: a certified nursing assistant tried to change the resident's clothing at bedtime. The resident, identified in inspection records only as R1, told the aide that only their spouse did that. The aide backed off. But R1 wanted to go home.
What followed was documented in a state inspection complaint report dated October 22, 2025, and in a police report and county crisis records obtained by the surveyor during the investigation.
When R1 entered the dining room, R1 was yelling. One staff member, identified as CK-J, told the surveyor what R1 said: "I want to leave. Why won't you let me leave?" Multiple CNAs followed R1 from door to door as R1 tried to exit the building. At least one CNA stood physically between R1 and a door. CK-J stood behind R1 in the lobby with hands on the back of R1's chair, trying to calm the resident down.
R1 kicked, swung, struck, punched, and threw staff into door frames and walls.
When Sergeant I arrived, the facility's main area looked like the aftermath of a confrontation. Numerous staff were crying, out of breath, and disheveled. R1 was shirtless and seated. A person was standing directly behind R1, positioned, in the sergeant's assessment, to keep R1 in the chair. It was cool outside. R1 had no shirt on.
The sergeant tried to talk to R1. R1 could not formulate sentences and appeared confused. At one point, R1 indicated to the sergeant that R1 had been attacked by numerous individuals at the facility.
The county crisis documentation put it plainly: R1 became violent when staff would not let R1 leave.
CK-J, interviewed by the surveyor, had not been asked to give a statement about the incident at all and left the building when the police arrived. CK-J also told the surveyor something that made the facility's response harder to explain: after the incident, CK-J received training that if a resident wants to leave, staff should let them go, follow with a phone, and call emergency medical services.
That training came after. Not before.
The Director of Nursing, identified as DON-B, arrived at the facility after police. DON-B completed a skin check on R1's visible skin and found no injuries. DON-B did not collect staff statements, reasoning that the facility already had statements from the police investigation. DON-B told the surveyor that DON-B had heard multiple accounts of what happened but was not aware that staff had blocked doors or placed hands on R1. When told, DON-B was direct: staff should not have physically restrained R1 or held doors shut.
The nursing home administrator, NHA-A, also said they were unaware that staff had blocked doors or touched R1. NHA-A had not received the police report. NHA-A was not aware of the county crisis report. NHA-A initially believed DON-B had collected staff statements, then learned DON-B had not. When the surveyor spoke with NHA-A on October 13, the administrator confirmed staff were being trained on handling situations like this one, but said the facility had not finished its internal review.
The inspection cited the incident as causing actual harm.
R1 came to staff that night wanting something straightforward: to go home. R1 had dementia and could not be talked out of it, reasoned with, or redirected. What R1 got instead was a gauntlet of employees blocking every door while R1 fought through them, half-dressed, in a building R1 could not leave, until the police came and R1 tried to tell a stranger in uniform what had happened.
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: 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 7, 2026 · Our methodology
Montello Care Center in Montello, WI was cited for violations during a health inspection on October 22, 2025.
The incident happened on the night of September 25, 2025.
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.