Montello Care Center

blocked the doors. CNA-G indicated one staff was outside of the doors that R1 tried to open. CNA-G

similar situations and instructed staff to give R1 space. R1 stated R1 didn't know anyone and was

statements, however, facility staff did not ask CNA-G for a statement. CNA-G indicated CNA-G worked 3 or 4 days after the incident but did not receive education post incident or prior to working CNA-G's next shift.On 10/13/25 at 11:50 AM, Surveyor interviewed CNA-E who provided care to R1 on the evening of 9/25/25 when R1 started to become agitated. CNA-E was injured by R1 during the incident.

Surveyor noted a statement from CNA-E was not included in the police report or the facility's investigation.On 10/14/25 at 3:05 PM, Surveyor interviewed [NAME] (CK)-J via phone who indicated CK-J heard yelling and saw R1 enter the dining room on 9/25/25. R1 yelled at the CNAs and was followed by 2 to 4 CNAs to ensure R1 did not elope. R1 attempted to elope out the dining room door; however, CK-J stood between R1 and the door.

When R1 left the dining room, multiple CNAs followed R1 from door to door as R1 attempted to leave the facility. CK-J stated one CNA stood between R1 and the door to ensure R1 did not elope. R1 eventually sat in the lobby and CK-J stood behind R1.

CK-J's hands were on the back of R1's chair as CK-J tried to calm R1 down.

When asked what R1 yelled when R1 entered the dining room, CK-J stated R1 yelled, I want to leave.

Why won't you let me leave? CK-J stated CK-J left when law enforcement arrived because CK-J's shift had ended. CK-J was not asked for a statement regarding the incident.Surveyor also noted Licensed Practical Nurse (LPN)-L worked the evening of 9/25/25; however, a statement from LPN-L was not included in the police report or the facility's investigation.

Surveyor attempted to call LPN-L but did receive a return call. On 10/13/25 at 11:20 AM, Surveyor interviewed NHA-A who indicated NHA-A had been at the facility earlier in the day on 9/25/25 and R1 had no issues. NHA-A indicated NHA-A did not complete staff interviews post incident and thought DON-B had done so. On 10/13/25 at 1:10 PM, Surveyor interviewed DON-B who indicated DON-B did not obtain staff statements; however, the facility had copies of staff statements provided to law enforcement on the night of the incident.On 10/13/25 at 3:51 PM, Surveyor interviewed NHA-A who was unaware that staff had blocked exit doors or potentially put hands on R1. NHA-A indicated NHA-A had not obtained the police report or the county crisis report. NHA-A acknowledged the facility should have completed staff interviews. NHA-A confirmed the facility completed an internal investigation which included resident interviews and an updated process to ensure residents being admitted do not have a history of violence. NHA-A indicated the facility was in the process of completing staff education on the facility's updated Unmanageable Resident policy.

525657 10/22/2025

Montello Care Center 251 Forest Lane Montello, WI 53949

stood between R1 and the door.

When R1 left the dining room, multiple CNAs followed R1 from door to

ensure R1 did not elope. R1 eventually sat in the lobby and CK-J stood behind R1. CK-J's hands were

but did not witness it.

When asked what R1 yelled when R1 entered the dining room, CK-J stated R1 yelled, I want to leave.

Why won't you let me leave? CK-J stated R1 was half naked and it was dark.

CK-J received training post-incident that if a resident wants to leave, staff should let the resident leave, follow them with a phone, and contact emergency medical services (EMS). CK-J was not asked to provide a statement about the incident and left when the police arrived. A police report, dated 9/25/25, indicated Sergeant (SGT)-I entered the facility and was directed to the main area near the nurses' station in the central part of the building on the north side. SGT-I observed numerous staff crying, out of breath, and disheveled. R1 was shirtless and seated in a chair. A person standing behind R1 appeared to be there to ensure R1 did not leave the chair. SGT-I was told by multiple staff that R1 had dementia and attempted to elope; however, staff stopped R1 from leaving. R1 struck, kicked, punched, and threw staff into door frames and walls. SGT-I attempted to talk to R1, however, R1 could not formulate sentences and appeared confused. At one point, R1 indicated to SGT-I that R1 was attacked by numerous individuals at the facility. On 10/13/25, Surveyor obtained county crisis documentation related to the incident.

The documentation indicated SGT-I was called to the facility for a disorderly resident (R1) who had dementia. SGT-I reported that R1 became violent when staff would not let R1 leave the facility. SGT-I informed the writer that staff were holding R1 in a chair when SGT-I arrived citing safety concerns.On 10/13/25 at 3:41 PM, Surveyor interviewed SGT-I via phone. SGT-I was told staff put hands on R1 during the incident but were not holding R1 down when SGT-I arrived. SGT-I thought staff stated they had to block exits to prevent R1 from exiting the building. SGT-I indicated it was cool outside and R1 was not wearing a shirt. If R1 had eloped, SGT-I stated dogs or [NAME] may have been required to find R1. On 10/13/25 at 1:44 PM, Surveyor interviewed DON-B via phone. DON-B arrived at the facility after the police. DON-B indicated R1 was rocking in a chair in the lobby and appeared upset. R1 became upset when CNA-E attempted to change R1's clothing at bedtime and said only R1's spouse did that. CNA-E backed off, however, R1 wanted to go home. DON-B completed a skin check for R1's visible skin and observed no injuries.

DON-B did not obtain staff statements since the facility had staff statements from the police investigation. DON-B heard multiple accounts of what occurred but was not aware that staff blocked doors and put hands on R1. DON-B stated staff should not have physically restrained R1 or held doors shut. DON-B stated staff education was provided on what to do for an unmanageable resident and thought most nursing staff were trained. On 10/13/25 at 3:51 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware that staff blocked doors or placed hands on R1. NHA-A indicated the facility had staff statements from the police investigation but initially thought DON-B had obtained statements. NHA-A had not received the police report and was not aware of the County Crisis Line (APSA) report. NHA-A confirmed staff were being trained on how to handle unmanageable residents and stated the facility was completing internal things; however, NHA-A was not finished with everything yet.