Monticello Nursing & Rehab Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and chart the behaviors. Resident #2 doesn't have 1 on 1 supervision. We just try to keep track of her, the best we can do is redirect her. We lay her down and not a minute later she will be right back up. Sometimes activities will help but she doesn't sit still for them or anything else. On 10/30/25 at 9:15 AM Staff A, Licensed Practical Nurse (LPN) stated they were the nurse for the incident with Resident #1 and Resident #2 on 10/2/25. [Staff A] heard loud voices, walked in the room, and the residents were arguing. Resident #1 stated Resident #2 slapped her. Staff A explained Resident #2 was very confused, was declining, and was more agitated. She got irritated much faster.On 11/12/25 at 12:26 PM the Director of Nursing (DON) stated

they did have Resident #2 on 15 minute checks after each of the resident to resident incidents but they were discontinued after moving Resident #2 to a different hall. The DON explained felt that had separated

the residents and did not need the 15 minute checks any longer, resident interviews were done, and no one had concerns with safety issues for other residents. On 11/12/25 at 4:08 PM the Administrator stated had moved Resident #2 to the opposite side of the building after this incident with Resident #1. The plan was for

the residents involved to be separated. Resident #2 had not had any slapping incidents prior to the one with Resident #1, that was one of the reasons we are attempting to find alternate placement was her behaviors were progressing. Per the Administrator, did not think at that time Resident #2 needed one on one since it was the first slapping incident, we felt moving her room location would be sufficient. This was the first physical alteration and she had not had any issues prior to that. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2024. The policy directed in the section of Prevention of Abuse: The facility will identify, through ongoing assessment, high-risk situations where abuse, neglect or misappropriation of resident property may occur and provide appropriate intervention in such occasions. Situations that may indicate a higher risk for abuse to occur include, but are not limited to, verbally/physically/sexually aggressive behavior, wandering into other resident's rooms or rummaging through their property, the presence of history of aggressive/violent/self-injurious behaviors, communication deficits, or those residents most dependent upon staff for their care.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monticello Nursing & Rehab Center

500 Pinehaven Drive Monticello, IA 52310

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

room and watched television. Staff E, CNA sat in a recliner in room, he states Resident #8 was a 1:1 (one to one supervision) and they had been providing supervision. Resident stated he has been here for a while, and they were keeping an eye on his diabetes was the reason staff was with him. Staff E, CNA stated if the resident did get up and wanted to walk around the facility, he would go with him.On 11/12/25 at 10:00 AM Resident #6 stated the following regarding the incident from 11/7/25 with Resident #8: She did recall him putting his hand on her left knee and he was rubbing her knee and moving his hand up further on her thigh and she pushed him away and said stop it and he did. Staff did come and separate them. She did not like it and told him that. She did feel safe in the facility and staff removed him immediately. On 11/12/25 at 10:28 AM Staff D, Registered Nurse (RN) stated they was the nurse on duty on 11/7/25 for the incident with Resident #6 and Resident #8. [Staff D] was at the nurses station doing something and Resident #10 reported she had seen Resident #8 with his hand down Resident #6 pants. [Staff D] went out there immediately to separate them and he was not touching her. [Staff D] clarified it with Resident #10 and she verified his hand was on top of her pants and on her thigh. Then [Staff D] talked to Resident #8 and he got defensive and said he didn't do anything. [Staff D] then spoke to Resident #6 and asked her where his hands were. She said it was on top of pants and she said she brushed his hand away and he would not move his hand he started to move his hand up and I told him no and he would not listen. Resident #8 had been on 1:1 supervision since the incident happened. On 11/12/25 11:48 AM Resident #10 stated she did witness Resident #8 touch Resident #6 he had his hand on her thigh and was rubbing it. It was on top of her pants. It just did not seem appropriate. [Resident #10] went to the nurse and let her know and then she immediately went to the residents and staff assisted both of them back to their room. [Resident #10] had been a resident here for a while and had never seen anything like that. [Resident #10] felt safe in the facility.

On 11/12/25 at 2:49 PM Staff H, CNA explained worked on the night of 11/7/25 on the [redacted] hall and that was where Resident #8's room was located. Staff H explained at the beginning of the shift we let people know where residents are and [Staff H] did not hear anything about him having any particular incidents prior. He 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 at the time of the incident about 4:10 PM, got back at 4:40 PM, and they told [Staff H] had to do 1:1 with Resident #8 until 9:00 PM when another CNA took over. On 11/12/25 at 3:45 PM the Director of Nursing stated after the incident with Resident #9 and Resident #8 did not do 15 minute checks, they completed the sexual relationship tool, did that for any sort of relationship, would do it for both residents. Resident #8 answered appropriately and was able to give consent but Resident #9 was not. Then, notified the family and then kept those two residents separated. To prevent it from happening with other female residents facility educated the staff of what had happened and how to intervene, and discussed what they should be doing. On 11/12/25 at 3:59 PM the Administrator stated after the first incident with Resident #8 the residents were separated, staff did intervene, and educated staff to separate immediately. Facility had a policy for Sexual Relationship for cognitively impaired residents and staff should follow the policy.The facility provided a policy titled Sexual Relationships for Residents with Cognitive Impairment revised 10/24/22. It revealed the purpose to protect individuals with cognitive impairment who are unable to provide consent to an unwanted sexual relationship. The policy clarified the definition of cognitive impairment for purposes of this policy would consider residents with a BIMS score of 12 or below as cognitively impaired.

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