MONTICELLO HEALTHCARE

1120 N MAIN ST, MONTICELLO, IN 47960 (574) 583-7073
Non profit - Corporation 116 Beds AMERICAN SENIOR COMMUNITIES Data: November 2025
Trust Grade
68/100
#271 of 505 in IN
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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Monticello Healthcare has a Trust Grade of C+, indicating that it is slightly above average but not exceptional. It ranks #271 out of 505 facilities in Indiana, placing it in the bottom half, but it is the second-best option in White County, with only one other facility available. The facility's trend is worsening, as it saw an increase in reported issues from 3 in 2024 to 6 in 2025. Staffing is a concern with a rating of 2 out of 5 stars, although the turnover rate is relatively low at 29%, which is better than the state average. While the facility has not incurred any fines, it has been noted for insufficient RN coverage compared to 75% of Indiana facilities, which could impact the quality of care. Specific incidents include a failure to properly prepare pureed food for residents, which could affect their nutrition, and medications were found improperly stored without necessary labeling, risking potential medication errors. Additionally, the facility's environment showed signs of neglect, with broken blinds and chipped paint in multiple units, indicating a need for maintenance. Overall, while Monticello Healthcare has some strengths, such as low turnover and no fines, there are significant areas of concern that families should consider.

Trust Score
C+
68/100
In Indiana
#271/505
Bottom 47%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
3 → 6 violations
Staff Stability
✓ Good
29% annual turnover. Excellent stability, 19 points below Indiana's 48% average. Staff who stay learn residents' needs.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Indiana facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Indiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
15 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 6 issues

The Good

  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Low Staff Turnover (29%) · Staff stability means consistent care
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover is low (29%)

    19 points below Indiana average of 48%

Facility shows strength in quality measures, staff retention, fire safety.

The Bad

3-Star Overall Rating

Near Indiana average (3.1)

Meets federal standards, typical of most facilities

Chain: AMERICAN SENIOR COMMUNITIES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 15 deficiencies on record

May 2025 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to insulin use for 1 of 18 MDS assessments reviewed. (Residen...

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Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to insulin use for 1 of 18 MDS assessments reviewed. (Resident 52). Finding includes: The record for Resident 52 was reviewed on 5/15/25 at 9:38 a.m. Diagnoses included, but were not limited to, Parkinson's disease, diabetes, and schizophrenia. The Quarterly Minimum Data Set (MDS) assessment, dated 3/14/25, indicated the resident received insulin. The Medication Administration Record (MAR) for March 2025 indicated the resident received Ozempic (semaglutide) (a medication for diabetes and weight loss) once a week. The record lacked documentation the resident received insulin during the MDS assessment period. During an interview on 5/15/25 at 11:30 a.m., the MDS Coordinator indicated she thought she should code that the resident received insulin because Ozempic lowers blood sugar. She indicated she would reach out to her consultant for supporting documentation/guidance. No further information was received. During an interview on 5/16/25 at 2:27 p.m., the Director of Nursing (DON) indicated Ozempic should be coded as an injected medication, but not as insulin. A policy titled, 5 Supportive Documentation Requirements Table, received as current on 5/16/25 at 3:31 p.m. from the Administrator, indicated, .Documentation must be consistent with physician orders and insulin administration records . 3.1-31(i)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discoloration...

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Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for 1 of 7 residents reviewed for non-pressure related skin conditions. (Resident B) Finding includes: On 5/13/25 at 11:12 a.m., Resident B was observed sitting in a wheelchair in the dining area. The wheelchair had padding on the arms. A large dark purple discoloration was observed to the resident's left elbow. On 5/14/25 at 10:26 a.m., Resident B was observed being wheeled out of her room in her wheelchair by her son. The dark purple discoloration was still observed to her left elbow. Record review for Resident B was completed on 5/14/25 at 10:42 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertension, dementia, diabetes mellitus, and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 2/14/25, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance for bathing, dressing, and transfers. The resident had a life expectancy of less than 6 months and was on hospice services. A Care Plan, dated 9/3/24 and revised 3/11/25, indicated the resident was at risk for skin breakdown or further skin breakdown due to impaired mobility with increased weakness. An intervention included to assess and document skin condition weekly and as needed and to notify the physician of abnormal findings. Another intervention included to have padded arm rests to the wheelchair. A Weekly Skin Assessment, dated 5/13/25, indicated the resident had no skin integrity alterations and bruising was not indicated. The record lacked any documentation to indicate the resident's discoloration had been assessed or was being monitored. During an interview on 5/14/25 at 10:50 a.m., LPN 1 indicated she was unaware of the resident's discoloration to her left elbow. During an interview on 5/16/25 at 3:00 p.m., the Director of Nursing (DON) indicated there was no prior documentation the resident's discoloration had been assessed or was being monitored. A facility policy, titled Skin Management Program, received as current, indicated .6. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported . This citation relates to Complaint IN00459697. 3.1-37(a)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to fully implement care-planned dietary interventions for a resident at risk for weight loss related to incomplete meal consumption logs and a...

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Based on record review and interview, the facility failed to fully implement care-planned dietary interventions for a resident at risk for weight loss related to incomplete meal consumption logs and a lack of supplement/substitute documentation for 1 of 18 records reviewed. (Resident C) Finding includes: Resident C's record was reviewed on 5/15/25 at 12:52 p.m. Diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 4/15/25, indicated the resident was severely cognitively impaired. The resident required setup help for eating. A Care Plan, dated 11/29/24, indicated the resident required assistance and/or monitoring for AM/PM care, nutrition, hydration, and elimination. Interventions included, but were not limited to, record breakfast, lunch, dinner, and fluid intake percentage. A Care Plan, dated 12/3/24, indicated the resident was at nutritional risk related to COPD, diabetes mellitus, dementia, and chronic kidney disease. Interventions included, but were not limited to, honor preferences, monitor weight, offer substitution if resident consumes less than 50% of a meal, and provide diet as ordered. A Registered Dietician Nutritional Review, dated 4/22/25 at 4:02 p.m., indicated the resident had an average meal consumption of 55% for three meals a day. The resident was able to communicate meal choices and feed himself. The resident weighed 145 pounds (lbs) on 4/22/25, 146 lbs on 4/14/25, and 148 lbs on 4/8/25. The resident's usual/desirable body weight range was 150-155 lbs. The Plan of Care/Interventions indicated the resident's weight had increased and he preferred to eat in his room but was encouraged to attend meals in the dining room. The Plan of Care was to be continued and to honor the resident's preferences. The Intake: Breakfast, Lunch, Dinner, and Supplements Point of Care from 4/19/25 to 5/19/25 indicated the resident consumed between 1-50% of the following meals: - breakfast: 4/19, 4/23, 4/24, 4/25, 4/29, 4/30, 5/9, 5/11, and 5/12/25 - lunch: 4/19, 4/20, 4/23, 4/24, 4/25, 4/26, 4/28, 4/29, 4/30, 5/2, 5/9, and 5/14/25 - dinner: 4/19, 4/22, 4/23, 4/24, 4/26, 4/27, 4/29, 4/30, 5/1, 5/2, 5/4, 5/5, 5/7, 5/9, and 5/14/25 There was no documentation of a supplement or substitute offered on the above dates. There was no documentation of any intake for dinner on 4/25/25, breakfast on 4/28/25, dinner on 5/6/25, and lunch on 5/10/25. During an interview on 5/19/25 at 3:30 p.m., the Director of Nursing (DON) indicated the staff were to document substitutes given with the Supplement Point of Care documentation under the Intake section. Substitutes were always available and offered, however it was not documented. The resident had been gaining weight. A policy titled, Delivery and Documentation of Meal Service and Between Meal Nourishments, indicated .Documentation The nursing Department will document foods/fluids consumed at each meal using percentage eaten and fluids consumed in ml's. The dining room assistant or licensed nurse offers a substitute in the event the resident's nutritional intake is 50% or less at any meal and document acceptance or refusal . This citation relates to Complaint IN00459697. 3.1-50(a)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure a resident who required respiratory care received oxygen as ordered by the physician for 1 of 2 residents reviewed for...

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Based on observation, record review, and interview, the facility failed to ensure a resident who required respiratory care received oxygen as ordered by the physician for 1 of 2 residents reviewed for respiratory care. (Resident B) Finding includes: On 5/13/25 at 10:58 a.m., Resident B was observed sitting in a wheelchair in the dining area. The resident was watching television with other residents. The resident had a portable oxygen attached to the back of her wheelchair. The oxygen was on the resident via a nasal cannula and set at 3 liters. On 5/14/25 at 10:26 a.m., Resident B was observed being wheeled out of her room in her wheelchair by her son. The resident was awake and had oxygen on via a nasal cannula and set at 3 liters. Record review for Resident B was completed on 5/14/25 at 10:42 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertension, dementia, diabetes mellitus, and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 2/14/25, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance for bathing, dressing, and transfers. The resident had a life expectancy of less than 6 months and was on hospice services. The resident received oxygen therapy. A Care Plan, dated 9/3/24 and revised 2/21/25, indicated the resident had potential for impaired gas exchange related to respiratory failure. The resident wore oxygen. An intervention included to administer oxygen as ordered by the physician. The May 2025 Physician's Order Summary (POS) indicated an order for oxygen at 3 liters per nasal cannula while sleeping or napping, every shift. During an interview on 5/14/25 at 10:50 a.m., LPN 1 indicated the resident needed to wear her oxygen at all times. She would have to clarify the order to only wear it while sleeping or napping with the physician. During an interview on 5/16/25 at 3:00 p.m., the Director of Nursing (DON) indicated the order for the oxygen had been changed to continuously at 3 liters. A facility policy, titled Oxygen-Liquid, received as current, indicated .Procedure 1. Verify physician orders. Know the flow rate and duration of use . 3.1-47(a)(6)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure there was adequate monitoring of vital signs per the physici...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure there was adequate monitoring of vital signs per the physician's orders prior to the administration of a medication that alters the rate/rhythm of the heart for 1 of 5 residents reviewed for unnecessary medications. (Resident 22) Finding includes: Resident 22's record was reviewed on 5/14/25 at 2:09 p.m. Diagnoses included, but were not limited to, dementia, Parkinson's disease, and atrial fibrillation (irregular heart beat). The Significant Change in Status Minimum Data Set (MDS) assessment, dated 4/20/25, indicated the resident was moderately cognitively impaired. A Care Plan, dated 9/20/22, indicated the resident received digoxin (medication that alters the rate and rhythm of the heart). Interventions included, but were not limited to, administer medications as ordered, check pulse prior to administering medications, and observe for symptoms of toxicity. A Physician's Order, dated 4/15/25, indicated digoxin 62.5 micrograms (mcg) one tablet at 6:00 a.m. daily. Hold the medication for pulse less than 60 beats per minute. The April and May 2025 Medication Administration Record lacked any documentation of the resident's heart rate being monitored at the time of digoxin administration. The medication was marked as administered daily. During an interview on 5/16/25 at 10:10 a.m., the Director of Nursing indicated the resident had been in the hospital and when she had readmitted on [DATE], the order was implemented, however it was not marked for the nursing staff to document the heart rate with each administration of the medication. 3.1-48(a)(3)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value related to not following instructions for puree food prepar...

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Based on observation, record review, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value related to not following instructions for puree food preparation. This had the potential to affect 5 residents who received a pureed diet from the kitchen. Finding includes: On 5/14/25 at 10:50 a.m., [NAME] 1 was observed preparing pureed food. She indicated she was going to puree chicken patties. She washed her hands and removed a pan of chicken patties from the oven. She placed 6 chicken patties in the blender and blended them. She stopped the blender, added two cups of water from the faucet, and blended again. She stopped the blender, stirred the contents with a spatula, added another cup of water, and blended longer. She stopped the blender, stirred the contents, added one scoop of thickener, and blended again. She stopped the blender, stirred the contents, checked the consistency using spoon tilt test (a test used to determine correct puree consistency), and resumed blending. She stopped the blender, stirred the contents, checked the consistency again, added one more scoop of thickener, and blended. She stopped the blender, stirred the contents, checked the consistency a final time, indicated she was done making the puree, and put the contents of the blender into a pan to be served. During an interview on 5/14/25 at 11:03 a.m., [NAME] 1 indicated the kitchen staff used to have a book of pureed recipes, but they no longer had it. During an interview on 5/14/25 at 11:04 a.m., the Dietary Manager indicated they no longer used pureed recipes. The corporation had gotten rid of the recipes, and they were now to follow the IDDSI (International Dysphagia Diet Standardization Initiative) guidelines. The pureed food just had to pass either the spoon tilt test or the fork drip test to be the correct consistency. There were no guidelines on how much liquid, what type of liquid, or how much thickener to add to a pureed food when preparing it. They started out by blending whatever food they were making and went from there to determine if they should add some liquid or thickener. They typically would not use water as the liquid but instead would use the broth of whatever item they were preparing, for example when preparing a chicken item they would use chicken broth. During an interview on 5/14/25 at 3:40 p.m., the Administrator was made aware of the concern with the pureed preparation and had no further information to provide. An IDDSI Notes document, undated and provided as current by the Administrator, indicated, .For pureed: Measure desired number of servings into food processor. Blend until smooth. Add broth or gravy with meats, and milk or water for other foods if product does not meet proper consistency per IDDSI guidelines. Commercial thickener should be added as necessary to achieve proper consistency . 3.1-21(a)(1)
Oct 2024 1 deficiency
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview, the facility failed to ensure medications were stored in accordance with professional standards related to medications for multiple residents stored...

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Based on observation, record review, and interview, the facility failed to ensure medications were stored in accordance with professional standards related to medications for multiple residents stored in the cabinet without the resident's name, medication name, prescribed dose, strength, and expiration date for 1 of 2 medication rooms observed. (Residents D, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, and Z) Finding includes: During an observation of the BCD Unit Medication room on 10/15/24 at 4:35 p.m., there were multiple paper medication cups stored with medication in the cups. The medication cups had another paper medication cup covering the medications. The medication cups used to cover the medications had initials and a 5, 6, or 7 written on them. During an interview at the time of the observation, LPN 1 indicated the medications in the medication cups were for the 5 p.m., 6 p.m., and 7 p.m. medication passes for Residents D, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, and Z. The medications should not have been set up and stored prior to the medication administration. During an interview on 10/15/24 at 4:40 p.m., the Director of Nursing indicated the medications were not to be set up and stored in the medication room prior to the medication administration times. A facility procedure for medication administration, dated 7/2023 and received as current from the Administrator, indicated medications were to be prepared for one resident at a time. A facility policy for storage of medications, dated 8/2024 and received from the Administrator as current, indicated the facility was to ensure the medications for each resident were stored in containers they were originally received in. This citation relates to Complaints IN00443901 and IN00444365. 3.1-25(j)
Mar 2024 2 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure assessment and monitoring of skin discolorations, for 1 of 2 residents reviewed for non-pressure skin conditions. (Res...

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Based on observation, record review, and interview, the facility failed to ensure assessment and monitoring of skin discolorations, for 1 of 2 residents reviewed for non-pressure skin conditions. (Resident 50) Finding includes: On 3/3/24 at 3:25 p.m. Resident 50 was observed lying in bed. There were multiple dark purple discolorations to his right arm and a white bandage in place to his right elbow. The resident was wearing a short sleeve shirt and there were no protective sleeves in place. On 3/5/24 at 10:21 a.m., Resident 50 was observed lying in bed. There were multiple dark purple discolorations to his right arm. The resident was wearing a short sleeve shirt and there were no protective sleeves in place. On 3/6/24 at 12:31 p.m., Resident 50 was observed sitting up in bed eating lunch. There were multiple dark purple discolorations to his right arm. The resident was wearing a short sleeve shirt and there were no protective sleeves in place. Record review for Resident 50 was completed on 3/4/24 at 12:57 p.m. Diagnoses included, but were not limited to, hypertension, vascular dementia, and cardiomyopathy. The Quarterly Minimum Data Set (MDS) assessment, dated 12/15/23, indicated the resident was moderately cognitively impaired, received antiplatelet medication, and required assistance from staff with ADLs (activities of daily living). A Care Plan, updated 1/2/24, indicated the resident was at risk for bleeding and bruising due to taking an antiplatelet medication. Interventions included to observe for increased bleeding or bruising. The Weekly Skin and Vital Sign Assessments, dated 2/20/24, 2/27/24, and 3/5/24, lacked any documentation of the discolored areas to the resident's right arm. The Physician's Order Summary, dated 3/2024, indicated the resident was to wear geri sleeves (protective sleeves) or long sleeves and to monitor the skin to the upper extremities every shift. There were also orders for aspirin 81 mg (milligrams) daily and clopidogrel (Plavix, an antiplatelet medication) 75 mg daily. The Medication Administration Record (MAR), dated 3/2024, indicated the resident received the aspirin and clopidogrel medications daily as ordered. The geri sleeves and skin monitoring were signed off every shift. There were no documented refusals or issues noted with the skin. During an interview with the Assistant Director of Nursing (ADON) on 3/6/24 at 2:53 p.m., she indicated she would complete a skin assessment for the resident and document any discolorations. A facility policy, titled Skin Management Program, received as current, indicated .6. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported .Procedure for alterations in skin integrity .4. All newly identified areas after admission will be documented on the New Skin Event. 5. The wound nurse/designee will be notified of alterations in skin integrity .b) .ii) Wound management entries will be completed for non-ulcers (bruises, skin tear, abrasion, rashes). If no signs of complications or worsening in condition of skin alteration and doesn't meet the guideline for IDT weekly wound review the wound management entry can be closed after 72 hours . 3.1-37(a)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the residents' environment was in good repair related to broke...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the residents' environment was in good repair related to broken and missing blind slats, chipped paint, marred walls, and loose stripping for 3 of 4 units observed. (Cottage, BCD, and [NAME] Units) Findings include: During the Environmental Tour, on 3/7/24 at 10:40 a.m., the following was observed: 1. Cottage room [ROOM NUMBER]- Stripping surrounding the air conditioner was loose and hanging. Two residents resided in the room. room [ROOM NUMBER]- Slats missing from window blind, peeling paint and caulk above the window and marred walls in the bathroom. Two residents resided in the room. 2. BCD room [ROOM NUMBER]- Slats were broken off the window blinds. One resident resided in the room. room [ROOM NUMBER]- Marred walls with chipped paint next to bed by the door. Two residents resided in the room. room [ROOM NUMBER]- Slats missing from window blind and chipped paint on the window trim. Two residents resided in the room. room [ROOM NUMBER]- Slats broken on window blinds and marred door frame to the bathroom. Two residents resided in the room. 3. West room [ROOM NUMBER]- Slats missing from the bathroom window blind. One resident resided in the room. During an interview with the Maintenance Director at that time, he indicated the items were in need of repair and he would fix them. 3.1-19(f)
May 2023 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

3. On 5/4/23 at 10:59 a.m., Resident 66 was observed seated in her wheelchair in the dining room. Her bilateral lower extremities were swollen and the ace wraps to her legs were loose and sliding down...

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3. On 5/4/23 at 10:59 a.m., Resident 66 was observed seated in her wheelchair in the dining room. Her bilateral lower extremities were swollen and the ace wraps to her legs were loose and sliding down. On 5/4/23 at 11:56 a.m., the resident was observed seated in her wheelchair in the dining room. Her bilateral lower extremities were swollen. There was no ace wrap in place to her right leg. The ace wrap to her left leg had fallen down around her ankle. Record review for Resident 66 was completed on 5/8/23 at 11:02 a.m. Diagnoses included, but were not limited to, lymphedema, hypertension, and fluid overload. A current care plan indicated the resident was at risk for skin breakdown due to increased edema to her bilateral lower extremities. She was also at risk for weight fluctuations related to lymphedema and a history of fluid overload. The Weekly Skin and Vital Sign Assessment, dated 5/2/23, indicated the resident had edema to the bilateral lower extremities. A Physician's Order, dated 4/18/23, indicated four-layer compression wraps to bilateral lower legs for lymphedema. Change every other day and as needed for dislodgement or soilage. The Medication and Treatment Administration Records, dated 5/2023, indicated the leg wraps had been changed on 5/4/23 and 5/6/23. They were due to be changed on 5/8/23 at 8 p.m. Interview with the DON on 5/8/23 at 3:32 p.m., indicated the wraps should have been in place as ordered. No further information was provided. 3.1-37(a) 2. On 5/3/23 at 11:23 a.m., Resident 36 was observed sitting in a recliner in her room. There were dark purple discolorations observed to the tops of both forearms, hands, and the top of the 3rd and 4th finger of her right hand. The resident indicated she bumped her arms and hands often on the wall and bed rail when she turned over in bed. On 5/5/23 at 2:17 p.m., Resident 36 was observed sitting in a recliner in her room. The same discolorations were still observed. Record review for Resident 36 was completed on 5/4/23 at 3:25 p.m. Diagnoses included, but were not limited to, heart failure, anemia, diabetes mellitus, and end stage renal disease. The Significant Change Minimum Data Set (MDS) assessment, dated 4/3/23, indicated the resident was cognitively intact. The resident required an extensive 2+ person assistance for bed mobility, transfers, and toilet use. A Care Plan, dated 8/1/22 and revised 4/7/23, indicated the resident was at risk for bleeding/bruising related to the use of antiplatelet medication. An intervention included to observe for increased bruising. A Skin Assessment, dated 5/2/23, indicated the resident had no areas of bruising. The record lacked any documentation to indicate the resident's discolorations had been assessed or were being monitored. Interview with the BCD Unit Manager on 5/5/23 at 2:22 p.m., indicated the discolorations on her forearms and the top of her left hand looked like her normal discolorations. The discolorations to the top of the right hand and fingers looked like bruising and the aides should have observed them with daily care and notified the nurse. Based on observation, record review, and interview, the facility failed to ensure a palm protector was in place for 1 of 1 residents reviewed for limited range of motion. The facility also failed to ensure an area of skin discoloration was assessed and monitored for 1 of 3 residents reviewed for skin conditions non pressure related, and leg wraps were in place for 1 of 2 residents reviewed for edema. (Residents 2, 36 and 66) Findings include: 1. On 5/3/23 at 2:01 p.m. and 5/4/23 at 1:49 p.m., Resident 2 was observed in bed. There was no palm protector (a splinting device used to prevent contractures) in place on his right hand. On 5/4/23 at 10:30 a.m., 5/5/23 at 10:39 a.m., and 5/5/23 at 12:46 p.m., the resident was observed seated in his reclining wheel chair and there was no palm protector in place on his right hand. The resident's record was reviewed on 5/5/23 at 10:41 a.m. Diagnoses included, but were not limited to, Cerebral Palsy and unspecified dementia. The Quarterly Minimum Data Set assessment, dated 3/16/23, indicated the resident had severe cognitive impairment and was dependent on staff assistance for transfers, eating and toileting. A Physician's Order, dated 3/23/23, indicated the resident was to have a palm protector in his right hand applied in the morning and removed at bedtime. The May 2023 Medication Administration Record indicated the palm protector was applied and removed every day. Interview with LPN 1 and QMA 1 on 5/5/23 at 12:50 p.m. in the resident's room, indicated the palm protector may have come off and was possibly in his clothing. They checked his blanket and clothing. The palm protector was located on the floor on the far side of his night table.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure a nutritional supplement was given as ordered for 1 of 4 residents reviewed for nutrition. (Resident 66) Finding inclu...

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Based on observation, record review, and interview, the facility failed to ensure a nutritional supplement was given as ordered for 1 of 4 residents reviewed for nutrition. (Resident 66) Finding includes: On 5/8/23 at 12:15 p.m., the resident was observed seated in her wheelchair in the dining room. The lunch trays were delivered to the unit and the staff started passing out the trays. At 12:20 p.m., the resident received her lunch and began eating. She received a fish sandwich, french fries, cantaloupe, and coleslaw. She had coffee and chocolate milk to drink. She had not received any fortified pudding. Record review for Resident 66 was completed on 5/8/23 at 11:02 a.m. Diagnoses included, but were not limited to, lymphedema, hypertension, and fluid overload. The admission Minimum Data Set (MDS) assessment, dated 3/8/23, indicated the resident was cognitively impaired and required extensive assistance of one with eating. A current Care Plan indicated the resident was at risk for weight fluctuations related to lymphedema and a history of fluid overload. The resident weighed 209 pounds on 4/3/23 and 199 pounds on 5/3/23. A Registered Dietician Note, dated 4/4/23, indicated the resident was not currently meeting her estimated nutrition needs with her oral intakes. The resident had a preference for pudding and fortified pudding at lunch was recommended. A Physician's Order, dated 4/5/23, indicated regular diet with fortified pudding at lunch. Interview with the DON on 5/8/23 at 3:32 p.m., indicated she was not sure why the resident hadn't received the fortified pudding. No further information was provided. 3.1-46(a)(1)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure a resident's pain medication was administered as ordered for 1 of 1 residents reviewed for pain. (Resident B) Finding ...

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Based on observation, record review, and interview, the facility failed to ensure a resident's pain medication was administered as ordered for 1 of 1 residents reviewed for pain. (Resident B) Finding includes: Interview with Resident B on 5/3/23 at 10:49 a.m., indicated her pain was controlled with the pain medications she received regularly. Resident B's record was reviewed on 5/5/23 at 10:25 a.m. Diagnoses included, but were not limited to, fibromyalgia, osteoarthritis, and Parkinson's Disease. The Quarterly Minimum Data Set assessment, dated 4/1/23, indicated the resident was cognitively intact, and received scheduled and as needed pain medications. The Physician's Order Summary, dated 5/2023, indicated the following pain medication orders: - Tylenol (acetaminophen) chewable 650 mg (milligrams) twice a day. Not to exceed 3 g (grams - 3000 mg) of acetaminophen from all sources in 24 hours. - Tylenol 650 mg every 6 hours PRN (as needed). Not to exceed 3 g of acetaminophen from all sources in 24 hours. - Hydrocodone-acetaminophen 5-325 mg four times a day. Not to exceed 3 g of acetaminophen from all sources in 24 hours. - Hydrocodone-acetaminophen 5-325 mg every four hours PRN. Not to exceed 3 g of acetaminophen from all sources in 24 hours. The Medication Administration Record, dated 5/2023, indicated the resident received the scheduled pain medications as well as the 650 mg PRN dose of acetaminophen on 5/2/23. The total dose of acetaminophen the resident received on 5/2/23 was 3250 mg, which was greater than 3 grams/ 3000 mg. The Medication Administration Record, dated 4/2023, indicated the resident received her scheduled pain medications as well as the 650 mg PRN dose of acetaminophen on 4/3/23, 4/5/23, 4/12/23, 4/15/23, 4/26/23 and 4/30/23. The total dose of acetaminophen the resident received on those dates was 3250 mg, which was greater than 3 grams/ 3000 mg. Interview with the DON on 5/8/23 at 3:32 p.m., indicated she would review the pain medication orders. No further information was provided. This Federal tag relates to Complaint IN00407457. 3.1-37(a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure a resident received routine and/ or emergency dental services related to lack of an oral assessment for a resident com...

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Based on observation, record review, and interview, the facility failed to ensure a resident received routine and/ or emergency dental services related to lack of an oral assessment for a resident complaining of mouth pain and swollen gums for 1 of 2 residents reviewed for dental services. (Resident 23) Finding includes: On 5/3/23 at 11:48 a.m., Resident 23 was observed in her room and her top dentures were removed. The upper gums were red and swollen and the resident indicated they were painful. She indicted this had been going on for 6 months. On 5/4/23 3:35 p.m., the resident was observed in her bed. She indicated she was unable to eat her lunch due to her mouth sensitivity and she was also unable to sleep due to the pain. The resident's record was reviewed on 5/4/23 2:19 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, anxiety, depression, and myalgia. The Quarterly Minimum Data Set (MDS) assessment, dated 3/21/23, indicated the resident was cognitively intact and had no dental issues. A Dental Care Plan, revised 4/4/23, indicated the resident had no natural teeth. Approaches were to observe and document for red/bleeding gums, lesions, symptoms of pain, to notify the physician, and obtain dental consult as needed. A Nursing Progress Note, dated 3/16/23, indicated that the resident was given Tylenol for mouth pain. A Nursing Progress Note, dated 3/21/2023, indicated the resident was given Tylenol at night for mouth pain. A Nursing Progress Note, dated 3/27/2023, indicted the resident had been receiving as needed Tylenol with 10 p.m. medications to help her mouth so she could sleep. A Nursing Progress Note, dated 4/14/23, indicated the resident requested ice cream or sherbet for her mouth. There was no documentation to indicate an oral assessment was completed, a dental consult was initiated, or the Physician had been notified. Interview with Social Services (SS) on 5/9/23 at 2:39 p.m., indicated she was not aware if the Nurse Practitioner (NP) had completed an oral assessment during her 2/13/23 appointment. The first time she was made aware the resident had mouth pain was by the Assistant Director of Nursing (ADON) on 5/1/23 or 5/2/23. SS was unable to provide any further documentation. Interview with the ADON on 5/9/23 at 2:39 p.m., indicated the resident complained about her gums somewhere between April 25th through 27th. She assessed the resident's gums and had not seen any concerns. The resident had told her she felt there was stuff coming out of her gums. She then told SS to set her up to see the dentist. She was unaware of any concerns the resident was having related to her gums prior to that. She was unable to provide any documentation related to completing an assessment of the resident's mouth. Interview with Director of Nursing (DON) on 5/9/23 at 3:00 p.m., indicated she was unable to provide any documentation the resident's gums had been assessed or that the NP was notified since 2/13/23. 3.1-24 (a)(2)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

Based on observation and interview, the facility failed to ensure food was prepared in a form to meet individual needs related to incorrectly made pureed food. This had the potential to affect 13 resi...

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Based on observation and interview, the facility failed to ensure food was prepared in a form to meet individual needs related to incorrectly made pureed food. This had the potential to affect 13 residents who received a pureed diet. (Main Kitchen, [NAME] 1) Findings include: On 5/3/23 at 11:00 a.m., [NAME] 1 was observed preparing pureed taco salad with chili. A recipe was used and the measured ingredients were prepared in advance. Two cycles were pureed through the blender to complete the taco salad puree portion of the recipe. The cook poured the pureed taco salad in to 13 bowls. The blender was washed and another cycle was performed to puree the chili. The chili was completed and the cook garnished the top of each 13 taco salad bowls with the chili. At 11:30 a.m., [NAME] 1 indicated that she was finished making the puree foods. The recipe was completed, besides adding sour cream, and the taco salad was ready to be served. At that time, the pureed food was observed to be watery and runny. At 11:32 a.m., interview with the Culinary Manager (CM) indicated there was too much water in the pureed taco salad and that they would not be serving them. The CM confirmed that the cook should have recognized the pureed salad was not the appropriate thickness and restarted the recipe sooner. The CM also indicated the cook would modify the recipe to add thickness and remake the 13 pureed taco salad dishes. 3.1-21 )(a)(3)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair relate...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to gouged walls, holes in bathroom walls, a cracked toilet riser, and chipped paint on 3 of 4 units. (BCD Unit, [NAME] Wing, and Cottage). Findings include: During the Environmental tour with the Directors of Maintenance and Housekeeping and the Administrator on 5/9/23 at 2:40 p.m., the following was observed: 1. BCD Unit a. In room [ROOM NUMBER], the window had chipped paint and the wall in the bathroom had holes underneath the soap dispenser. Two residents resided in the room. Four residents shared the bathroom. b. In room [ROOM NUMBER], the toilet riser handles were cracked, the bathroom sink was slow to drain, there was a film buildup in the sink, and the wall had holes underneath the soap dispenser. Four residents shared the bathroom. c. In room [ROOM NUMBER], the window had chipped paint, the bottom corner of the wall by the closet was gouged, and the wall in the bathroom had holes underneath the soap dispenser. Two residents resided in the room. Four residents shared the bathroom. d. In room [ROOM NUMBER], the wall had gouges by the bed closest to the door. Two residents resided in the room. 2. [NAME] Wing a. In room [ROOM NUMBER], the walls were marred next to the bed by the door. Two residents resided in the room. b. In room [ROOM NUMBER], the toilet booster seat was uncovered and sitting on the floor of the bathroom. One resident used the bathroom. 3. Cottage a. In room [ROOM NUMBER], the walls by the bathroom door were gouged. Two residents resided in the room. b. In room [ROOM NUMBER], the walls behind bed 2 were gouged. Two residents resided in the room. 3.1-19(f)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Indiana facilities.
  • • 29% annual turnover. Excellent stability, 19 points below Indiana's 48% average. Staff who stay learn residents' needs.
Concerns
  • • 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.

About This Facility

What is Monticello Healthcare's CMS Rating?

CMS assigns MONTICELLO HEALTHCARE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Indiana, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Monticello Healthcare Staffed?

CMS rates MONTICELLO HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 29%, compared to the Indiana average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Monticello Healthcare?

State health inspectors documented 15 deficiencies at MONTICELLO HEALTHCARE during 2023 to 2025. These included: 15 with potential for harm.

Who Owns and Operates Monticello Healthcare?

MONTICELLO HEALTHCARE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by AMERICAN SENIOR COMMUNITIES, a chain that manages multiple nursing homes. With 116 certified beds and approximately 71 residents (about 61% occupancy), it is a mid-sized facility located in MONTICELLO, Indiana.

How Does Monticello Healthcare Compare to Other Indiana Nursing Homes?

Compared to the 100 nursing homes in Indiana, MONTICELLO HEALTHCARE's overall rating (3 stars) is below the state average of 3.1, staff turnover (29%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Monticello Healthcare?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Monticello Healthcare Safe?

Based on CMS inspection data, MONTICELLO HEALTHCARE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Indiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Monticello Healthcare Stick Around?

Staff at MONTICELLO HEALTHCARE tend to stick around. With a turnover rate of 29%, the facility is 17 percentage points below the Indiana average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was Monticello Healthcare Ever Fined?

MONTICELLO HEALTHCARE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Monticello Healthcare on Any Federal Watch List?

MONTICELLO HEALTHCARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

MONTICELLO HEALTHCARE

1120 N MAIN ST, MONTICELLO, IN 47960 | (574) 583-7073

C+
Trust Grade (68/100)
3.0
CMS Rating
15
Deficiencies

Strengths

  • 4-star quality
  • Low turnover (29%)

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025