Resident #6 told federal inspectors that Resident #8 put his hand on her left knee, rubbing and moving upward on her thigh until she pushed him away. "I told him no and he would not listen," she said.
Another resident witnessed the inappropriate touching and immediately reported it to nursing staff. Resident #10 told inspectors she saw Resident #8 with "his hand on her thigh and was rubbing it" on top of the woman's pants. "It just did not seem appropriate," she said.
Staff D, the registered nurse on duty, was at the nurses station when Resident #10 initially reported seeing Resident #8 with "his hand down Resident #6 pants." The nurse went immediately to separate them, though by then he was no longer touching her.
When Staff D questioned Resident #8 about the incident, "he got defensive and said he didn't do anything." The female resident confirmed to the nurse that his hands were on top of her pants on her thigh, and that "she brushed his hand away and he would not move his hand he started to move his hand up."
The facility placed Resident #8 on one-to-one supervision following the incident. Staff E, a certified nursing assistant, was assigned to sit in a recliner in the resident's room and provide constant supervision. The CNA told inspectors that if Resident #8 wanted to walk around the facility, staff would accompany him.
Resident #6 told inspectors she felt safe in the facility because "staff removed him immediately." Resident #10, who had been at the facility for an extended period, said she "had never seen anything like that" but also felt safe.
This was not Resident #8's first inappropriate incident. The Director of Nursing referenced a previous incident involving Resident #8 and Resident #9, though details of that encounter were not provided in the inspection report.
After the earlier incident, facility staff completed a "sexual relationship tool" assessment for both residents involved. Resident #8 "answered appropriately and was able to give consent," but Resident #9 was not able to consent, according to the Director of Nursing.
The facility's policy on Sexual Relationships for Residents with Cognitive Impairment, revised in October 2022, defines residents with BIMS cognitive assessment scores of 12 or below as cognitively impaired and unable to provide consent to sexual relationships.
Staff H, a CNA working on Resident #8's hall the night of November 7, said supervisors typically communicate information about residents with behavioral issues at shift change. However, Staff H "did not hear anything about him having any particular incidents prior" to being assigned one-to-one supervision duties that evening.
The CNA noted that Resident #8 would "occasionally walk down the hall and hold hands but not that he had an incident of touching any residents inappropriately." Staff H was on break from 4:10 PM to 4:40 PM when the incident occurred and was assigned to provide one-to-one supervision until 9:00 PM.
Following the November 7 incident, the facility administrator said staff were educated about how to intervene and what they should be doing to prevent similar situations. The Director of Nursing said they notified family members and kept the two residents separated.
The facility's response included educating staff about the incident and intervention procedures, though the inspection found violations in the facility's handling of resident protection protocols.
Federal inspectors cited the facility for failing to ensure residents were free from sexual abuse and for not implementing adequate supervision measures to prevent the inappropriate contact. The violation was classified as causing minimal harm or potential for actual harm to some residents.
Resident #8 remains under constant supervision, with staff required to accompany him if he leaves his room. The facility policy requires staff to immediately separate residents when inappropriate sexual contact occurs and follow established protocols for cognitively impaired residents.
The November 12 complaint inspection revealed gaps in the facility's prevention and response systems, despite having written policies addressing sexual relationships among residents with cognitive impairments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monticello Nursing & Rehab Center from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Monticello Nursing & Rehab Center
- Browse all IA nursing home inspections