Montello Care Center
Montello Care Center in Montello, WI — inspection on October 22, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
individuals at the facility.
The police report indicated SGT-I contacted the county crisis line.On 10/13/25, Surveyor obtained county crisis documentation for 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 3:51 PM, Surveyor interviewed NHA-A who indicated the incident was not reported to the SA because there were no resident injuries and the incident was related to R1's increase in behaviors. NHA-A stated R1 did not elope from the facility and there were no resident-to-resident altercations. NHA-A confirmed the facility did not complete interviews with staff who worked the night of the incident and only had statements that were obtained by law enforcement. NHA-A had not obtained the county crisis documentation that indicated staff held R1 in a chair or the police report that indicated R1 alleged that R1 was attacked by numerous individuals. NHA-A acknowledged the allegations of abuse should have been reported to the SA.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Montello Care Center
251 Forest Lane Montello, WI 53949
SUMMARY STATEMENT OF DEFICIENCIES
Assistant (CNA)-G who worked the 9/25/25 PM shift. CNA-G was working on the other side of the building when Licensed Practical Nurse (LPN)-L sprinted down the hall and asked for help. CNA-G indicated R1 wanted to go home. CNA-G observed R1 hitting CNA-E.
When R1 saw staff approaching, R1 stopped hitting CNA-E and ran to an exit door. R1 sought out the fire exits but staff blocked the doors. CNA-G indicated one staff was outside of the doors that R1 tried to open. CNA-G asked CNA-F to hold the door shut in case R1 got out. R1 was swinging.
Staff tried to stay out of R1's line of sight and moved residents into their rooms for protection. CNA-G had previous expeirence in similar situations and instructed staff to give R1 space. R1 stated R1 didn't know anyone and was trying to get to R1's spouse. R1 was calm when the police arrived. CNA-G indicated the police took 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Montello Care Center
251 Forest Lane Montello, WI 53949
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited MONTELLO CARE CENTER in MONTELLO, WI for a deficiency under regulatory tag F-F0744 during a complaint investigation conducted on 2025-10-22.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 3 deficiencies cited during this inspection of MONTELLO CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-10.