Montello Care Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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 (Resident R1) who had dementia. SGT-I reported that Resident R1 became violent when staff would not let Resident R1 leave the facility. SGT-I informed the writer that staff were holding Resident 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 Resident R1's increase in behaviors. NHA-A stated Resident 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 Resident R1 in a chair or the police report that indicated Resident R1 alleged that Resident R1 was attacked by numerous individuals. NHA-A acknowledged the allegations of abuse should have been reported to the SA.

Event ID:

Facility ID:

If continuation sheet

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

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Montello Care Center

251 Forest Lane Montello, WI 53949

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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 Resident R1 wanted to go home. CNA-G observed Resident R1 hitting CNA-E. When Resident R1 saw staff approaching, Resident R1 stopped hitting CNA-E and ran to an exit door. Resident R1 sought out the fire exits but staff blocked the doors. CNA-G indicated one staff was outside of the doors that Resident R1 tried to open. CNA-G asked CNA-F to hold the door shut in case Resident R1 got out. Resident R1 was swinging. Staff tried to stay out of Resident 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 Resident R1 space. Resident R1 stated Resident R1 didn't know anyone and was trying to get to Resident R1's spouse. Resident 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 Resident R1 on the evening of 9/25/25 when Resident R1 started to become agitated. CNA-E was injured by Resident 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 Resident R1 enter the dining room on 9/25/25. Resident R1 yelled at the CNAs and was followed by 2 to 4 CNAs to ensure Resident R1 did not elope. Resident R1 attempted to elope out the dining room door; however, CK-J stood between Resident R1 and the door. When Resident R1 left the dining room, multiple CNAs followed Resident R1 from door to door as Resident R1 attempted to leave the facility. CK-J stated one CNA stood between Resident R1 and the door to ensure Resident R1 did not elope. Resident R1 eventually sat in the lobby and CK-J stood behind Resident R1. CK-J's hands were on the back of Resident R1's chair as CK-J tried to calm Resident R1 down. When asked what Resident R1 yelled when Resident R1 entered the dining room, CK-J stated Resident 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 Resident 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 Resident 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.

Event ID:

Facility ID:

If continuation sheet

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

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Montello Care Center

251 Forest Lane Montello, WI 53949

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)

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.