Cura of Monticello

1104 EAST RIVER STREET, MONTICELLO, MN 55362 (763) 271-2333
Non profit - Other 67 Beds Independent Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
56/100
#105 of 337 in MN
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Last Inspection: April 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Cura of Monticello has received a Trust Grade of C, which means it is average and positioned in the middle of the pack among nursing homes. It ranks #105 out of 337 facilities in Minnesota, placing it in the top half, but only #6 of 7 in Wright County, indicating limited local competition. Unfortunately, the facility is worsening, with issues increasing from 1 in 2024 to 2 in 2025. Staffing is a concern, as it has a turnover rate of 60%, significantly higher than the state average of 42%, suggesting challenges in retaining employees. The facility has faced $13,022 in fines, which is average, yet it is important to note that it has experienced serious incidents, including a failure to provide necessary oxygen therapy that led to a resident's death and insufficient assessment of pressure ulcers, indicating potential areas of risk for residents. While Cura of Monticello has good overall ratings in health inspections and quality measures, families should weigh these strengths against the concerning staffing turnover and critical incidents reported.

Trust Score
C
56/100
In Minnesota
#105/337
Top 31%
Safety Record
High Risk
Review needed
Inspections
Getting Worse
1 → 2 violations
Staff Stability
⚠ Watch
60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
○ Average
$13,022 in fines. Higher than 72% of Minnesota facilities. Some compliance issues.
Skilled Nurses
✓ Good
Each resident gets 66 minutes of Registered Nurse (RN) attention daily — more than 97% of Minnesota nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
✓ Good
Only 5 deficiencies on record. Cleaner than most facilities. Minor issues only.
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 2 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • 4-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Staff Turnover: 60%

14pts above Minnesota avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $13,022

Below median ($33,413)

Minor penalties assessed

Staff turnover is elevated (60%)

12 points above Minnesota average of 48%

The Ugly 5 deficiencies on record

1 life-threatening 1 actual harm
Apr 2025 2 deficiencies 1 Harm
SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, that facility failed to comprehensively assess and implement interventions ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, that facility failed to comprehensively assess and implement interventions for 1 of 2 residents (R26) reviewed for pressure ulcers. R26 developed pressure ulcers after splint placement for ankle fracture resulting in actual harm when the facility did not clarify orders for monitoring or when to remove the splint. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively intact and received extensive assistance to complete activities of daily living (ADL's) including dressing, grooming and bathing, R26 required extensive assistance of two staff with transfers and toileting. R26's care plan, also indicated a self-care deficit related to weakness, unsteady balance, impaired cognition, tends to fatigue easily, and history of knee buckling. The care plan dated 2/5/25, directed staff to provide extensive assistance of two staff with transfers and toileting. Progress note dated 3/12/2025 at 5:59 p.m., indicated at 5:15 p.m. R26 was lowered to the ground after twisting ankle during assisted transfer. R26 was transferred by ambulance to the emergency room (ER) due to right ankle pain, swelling and decreased ability to move the ankle. Progress note dated 3/12/2025 at 11:43 p.m., R26 returned from the hospital with no new medication orders. R26 rated pain eight out of 10, ice was applied to right ankle. After Visit Summary dated 3/12/25, identified R26 was diagnosed with sprain of right ankle with instructions to wear air splint for comfort and stability, elevate, ice and rest, take pain medication as needed, return to the emergency room if symptoms worsen. Progress noted dated 3/20/2025 at 11:00 p.m., indicated R26's ankle was noted to be weepy, had been wearing a splint since the fall on 3/12/25. R26 had increased pain and swelling, when splint was removed to assess, was noted to have open areas on both sides of the ankle. R26 had a temperature of 99.4. Orders were obtained from the nurse practitioner (NP) to send R26 to the ER. Progress note dated 3/21/2025 2:37 a.m., indicated R26 was admitted to the hospital with cellulitis (bacteria infection of the skin and underlying tissue), pressure injury, and closed fracture of the right ankle. Review of R26's progress notes, physician orders and care plan, identified an order to wear air splint for comfort and stability. However, R26's electronic medical record failed to identify any indication or physician order to assess/monitor right ankle and splint between placement of splint on 3/12/25 and 3/20/25 when facility removed the splint after R26 had increased pain and swelling. Emergency Department note encounter date 3/20/25, indicated R26 was last in the ER on [DATE], after twisting her ankle. R26 was advised symptomatic treatment and ankle brace. it appears that the ankle brace had not been removed since then. Today when brace removed, R26 noted to have redness and ulcer on both medial aspect (inner) and lateral aspect (outside) of right ankle. Progress note dated 3/24/2025 at 3:05 p.m., R26 readmitted from hospital with diagnosis of ankle fracture, open area on right ankle When observed on 4/14/25 at 6:58 p.m., R26 had a cast on right foot, when asked R26 stated I fractured my ankle. When interviewed on 4/16/2025 at 10:57 a.m., licensed practical nurse (LPN)-B stated if an order was not clear or parts were missing, the nurse needed to call the provider to clarify the orders. When interviewed on 4/16/25 10:59 a.m., LPN-A stated orders from a hospital return are entered by the health unit coordinator (HUC) and checked by two nurses or entered by a nurse and checked by another nurse. If an order does not make sense or is missing information, the nurse is responsible to contact the provider to get directions. LPN-A confirmed the order for R26's splint should have been clarified for specific instructions. When interviewed on 4/16/25 at 12:45 p.m., nurse practitioner (NP) stated the air splint should have been removed to provide cares, however, NP did not clarify how often the splint should have been removed for cares. If the staff had any questions about the splint they should have called and asked for clarification. Based on what was on the ER note the cause of the cellulitis and pressure sores resulted from the air splint not being removed. When interviewed on 4/16/25 at 2:52 p.m. the director of nursing (DON) stated no order was entered to remove the splint and check the skin. DON stated she expected when a resident returned with a removable device the nurses should get parameters/orders to remove and check the skin underneath, this was not done for R26. DON was unable to locate any procedure or process changes that were made to ensure that this did not occur again. Facility provided policy Transcription Processing Provider Orders - Long Term Care dated 1/2025, indicated transcribe order to the electronic medication administration record (EMAR)/electronic treatment administration record (ETAR). However the policy did not address clarifying orders.
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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively investigate a fall for 1 of 3 reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively investigate a fall for 1 of 3 residents (R26), who had a fall while being transferred. Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], indicated R26 was cognitively intact and received extensive assistance to complete activities of daily living (ADL's) including dressing, grooming and bathing, R26 required extensive assistance to 2 staff with transfers and toileting. R26's care plan, also indicated a self-care deficit related to weakness, unsteady balance, impaired cognition, tends to fatigue easily, and history of knee buckling. The care plan dated 2/5/25, directed staff to provide extensive assitance of two staff with transfers and toileting. Progress note dated 3/12/2025 at 5:15 p.m., indicated R26 had a staff assisted fall at 1715 (5:15 p.m.) resident was lowered to the ground after twisting ankle during assisted pivot transfer with two staff. Injuries: right ankle pain and swelling after twisting it during transfer. R26 did not have full range of motion in right foot. R26 transferred to the hospital. R26's post-fall investigation form indicated R26 had a fall on 3/12/25 at 5:15 p.m., while being assisted to the bathroom, when ankle twisted during the transfer and R26 was lowered to the floor. The provided recap of the incident indicated R26 was lowered to the ground after twisting ankle during assisted pivot transfer with two staff. R26 was transferred to the hospital emergency room. However, there was no interviews with the staff involved during the transfer included with the investigation. Progress note dated 3/20/2025, at 11:00 p.m. Indicated R26 had increased pain and swelling in ankle, R26 was transferred to the hospital emergency room for evaluation. Progress note dated 3/21/2025, 2:37 a.m. indicated R26 was admitted to the hospital with cellulitis (bacteria infection of the skin and underlying tissue), pressure injury, and closed fracture of the right ankle. Facility reported incident to state agency 3/21/25, facility then completed investigation into R26's fall which occurred 3/12/25. During facility investigation was found during transfer on 3/12/25, R26 received assistance of one staff during pivot transfer resulting in R26 twisting ankle requiring being lowered to the floor. During interview on 4/16/25 at 10:58 a.m., trained medication aid (TMA)-A stated R26 needed assistance of two staff during transfers prior to her fall when she broke her ankle. During Interview on 4/16/25 at 10:59 a.m., licensed practical nurse (LPN)-A stated before R26 had the fall R26 required assistance of two staff with transferring and toileting. During interview on 4/16/25 12:27 p.m., nursing assistant (NA)-A stated she was transferring the resident herself, during the transfer R26 was unable to move her foot when she attempted to assist R26 to the wheelchair. NA-A stated R26 was then lowered to the floor, NA-A then called for assistance. During interview on 4/16/25 2:52 p.m., director of nursing (DON) stated at the time of the fall R26 required assist of two with transfers and toileting needs. When DON initially was informed of the fall, she was told there were two staff when R26 was transferred. DON stated she did not ask staff that were there what happened until after R26 had been admitted to the hospital with an ankle fracture. During the investigation at that time it was discovered R26's care plan was not followed and had been transferred by one person. Facility policy Fall Management - Long Term Care dated 2/2025, indicated responding to a resident fall obtain information from the resident and/or any witnesses's pertaining to the circumstances of the fall, obtain information from the staff on the unit/within the area prior to or during the fall.
Feb 2024 1 deficiency
CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to assess the resident and determine safety for 1 of 1 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to assess the resident and determine safety for 1 of 1 resdients (R1) reviewed for self-administration of medications (SAM). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact. R1's admission record printed 2/29/24, included diagnoses of chronic pain, depression, end stage renal disease, and dependance on renal dialysis (kidneys are no longer able to function properly). R1's medication review report printed 2/29/24, included orders for self-administration of eye drops and self-administration of oral medications after nurse set up. Medication review report did not include Orajel or generic equivalent. On 2/26/24 at 3:24 p.m., a red box of generic topical oral pain medication was observed on R1's bedside table. R1 stated she self-administers gel for tooth pain. On 2/28/24 at 2:16 p.m., a red box of generic topical oral pain medication was noted on R1's bedside table. R1 left the facility three times per week for dialysis. These appointments kept her out of the facility for a few hours each time, leaving room unattended. Interview on 2/28/24 at 10:29 a.m., trained medication assistant (TMA)-A stated she would immediately inform a nurse on duty when she found a medication in a resident's room that was not on the medication list. TMA-A stated residents needed to have a self-administration order that specifically noted it was safe for resident to store the medication in their room. Interview on 2/29/24 at 10:42 a.m., director of nursing (DON) stated when someone wanted to self-administer medications, the facility completed an assessment to ensure safety. The resident was assessed yearly or with a change in condition that may have affected their ability to self-administer medication. The facility would have obtained an order from the provider indicating the resident was allowed to self-administer the specific medication. The medication would have needed to be stored in a locked drawer or box in the resident's room. DON stated it was important to complete the assessment to ensure the resident was able to safely administer the medication. It was important for the medication to be kept in a secure area to ensure other residents did not have access to the medication. Facility policy titled Medication Self Administration by residents- Long Term Care dated February 2024, included residents would have been evaluated by an intradisciplinary team to determine ability, cognitive status and the resident's understanding of medication. Residents were to demonstrate understanding of when to take the medication and potential side effects before they would be approved to self-administer. Facility policy included medication would be stored in a locked drawer or compartment. A physician order was necessary if the resident wanted to keep their medication at the bedside.
Jul 2023 1 deficiency 1 IJ
CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Respiratory Care (Tag F0695)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure oxygen therapy was provided per physician orders for 1 of ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure oxygen therapy was provided per physician orders for 1 of 3 residents (R1) when R1, who required continuous oxygen (O2), had her oxygen removed by a nursing assistant (NA). This resulted in an immediate jeopardy (IJ). The immediate jeopardy began on [DATE], when R1's O2 was removed by a nursing assistant (NA). R1 went limp and unresponsive after approximately 9 minutes in the bathroom. R1 subsequently died. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 3:39 p.m. on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore issued at Past Noncompliance. Findings include: R1's Face Sheet printed [DATE], identified R1 was admitted to the facility on hospice care [DATE] with diagnoses which included: chronic respiratory failure with hypoxia (a condition in which the body or region of the body is deprived of adequate oxygen supply at the tissue level, causing restlessness, confusion, anxiety, shortness of breath, rapid breathing and rapid heartbeat), pulmonary fibrosis, malignant neoplasm of right upper lobe of lung, and dependence on supplemental oxygen. On [DATE], a progress note indicated R1 had moderately impaired cognition. R1's [NAME] printed [DATE], directed staff to notify the nurse prior to transfers so her oxygen level could be increased per orders. R1's Physician Orders dated [DATE] directed oxygen 5 liters (L) per minute at rest, and 1-15 L per minute at exertion, titrate for comfort. R1's Physician Orders dated [DATE] directed 5 L per minute at rest, and 10-15 L per minute with exertion. Titrate for comfort via high flow rate nasal cannula. On [DATE], R1's Weight and Vitals Summary indicated at 11:57 a.m. R1's O2 saturation (O2 sats, the level of oxygen in one's bloodstream. Normal is 95-100%) was 88%. At 2:07 p.m. R1's O2 sats was 85%. At 4:09 p.m. R1's O2 sats was 90%. On [DATE] at 5:30 p.m., a progress note indicated at 4:55 p.m. R1 was noted to be unresponsive on the floor, and she did not have oxygen (O2) on. R1 was immediately placed on O2 at 15 L, and slow shallow breaths were noted. R1 was assisted to bed. R1's vital signs ceased at 5:02 p.m. The facility investigation indicated on [DATE] at 4:44 p.m., NA-A went into R1's room. At 4:46 p.m. NA-A exited R1's room. At 4:47 p.m. R1's bathroom call light went on. NA-B answered the call light seconds later. R1's call light went off, and NA-B exited R1's room at 4:48 p.m. At 4:49 p.m. R1's call light went on, and seconds later NA-B went into R1's room. At 4:52 p.m. NA-B exited R1's room partially running. At 4:53 p.m. RN-A entered R1's room. On [DATE] at 10:58 a.m., registered nurse (RN)-D indicated R1 required continuous O2 otherwise her oxygen saturation level would drop. In addition, RN-D stated R1 required an increase in O2 whenever R1 was going to do any activity, and NA's were expected to notify a licensed nurse prior to moving R1. On [DATE] at 11:45 a.m., RN-A stated R1's oxygen order indicated R1 required O2 via nasal cannula at 5 L when resting and required an increase in O2 to maintain O2 saturation levels when transferring or doing an activity. RN-A stated on [DATE], a NA alerted him R1 was on the floor. RN-A entered R1's bathroom and observed her on the floor, unconscious, without O2. R1 was transferred to her bed. RN-A listened to R1's heart and lung sounds and stated there was nothing there. RN-A confirmed he was not made aware R1 was going to be transferred to the toilet, so he did not increase R1's oxygen, nor ensure it was on. On [DATE] at 12:12 p.m., NA-A stated [DATE] was the first day she had assisted R1. NA-A stated at approximately 4:50 p.m. she answered R1's call light. She observed R1 sitting in her wheelchair, holding the call light, and her nasal cannula was on, hooked up to the room concentrator. NA-A stated she observed R1 being shaky, jumpy, and sweating a lot, and she appeared to be very anxious. NA-A stated she asked R1 if she could remove her O2 and R1 replied yes. NA-A removed R1's O2 and brought R1 into the bathroom using her wheelchair. When R1 was assisted to the toilet, R1 had a loose bowel movement. NA-A directed R1 to place the call light on when she finished, and NA-A left the bathroom. NA-A stated a few minutes later, NA-B came and reported R1 had fallen. NA-A stated when she entered R1's bathroom, R1 was on the floor unconscious, with both calves and feet tucked under her thighs. NA-A stated RN-A entered the bathroom and immediately questioned where R1's O2 was, and placed her nasal cannula on. NA-A stated R1 was placed into bed and took 2-3 spaced out breaths. R1 would not respond, and RN-A stated R1 had passed. NA-A confirmed she did not review R1's [NAME] prior to assisting R1, and stated staff never explained the importance of that oxygen. NA-A stated she did not inform RN-A of R1's condition prior to assisting her to the bathroom, and was not aware R1 required an increase in O2 prior to transfers. On [DATE] at 12:38 p.m., NA-C indicated R1 required oxygen use which was very important due to R1's diagnoses. NA-C indicated on [DATE], she had transferred R1's source of O2 from the portable to the room concentrator. NA-C indicated she would compare flow rate of the source they are removing the resident from and ensure the flow rate matched on the next source. Further, NA-C confirmed she was unaware NA's could not apply or remove O2 or notifying a licensed nurse to increase R1's O2 prior to transferring R1. On [DATE] at 1:00 p.m., RN-C indicated R1 required continuous O2, and confirmed she was not aware R1 required an increase in O2 while transferring or completing any activity. On [DATE] at 1:26 p.m., NA-D stated R1 required continuous O2 and staff were expected to move R1's O2 room concentrator with her when she would use the bathroom, but NA's were not allowed to remove a resident's O2 or change source of O2. On [DATE] at 2:56 p.m., NA-B stated R1 was a new admit and [DATE] was the first time NA-B had assisted R1. NA-B stated he answered R1's bathroom call light at approximately 4:55 p.m., and observed R1 sitting on the toilet without O2. NA-B stated he was unaware R1 required the use of continuous O2 at that time. NA-B stated R1 was not finished at that time and did not notice anything different with R1 at that time. NA-B stated he returned approximately a minute later to assist R1 with transferring off the toilet and back into her wheelchair. NA-B stated when R1 stood up she went limp, and he assisted R1 to the floor. R1 was unresponsive. NA-B stated he exited R1's bathroom to find RN-A. NA-B stated he did not review R1's [NAME] prior to assisting R1. On [DATE] at 3:41 p.m., hospice RN-E stated facility staff had reported on [DATE], R1 was in the bathroom without O2 on and went unresponsive. Staff assisted R1 into bed where she took a few breaths and then passed. Further, RN-E indicated R1 required continuous O2 5 L at rest and with any exertion or activity such as transferring or toileting, R1 required an increase in O2 above 5 L. In addition, RN-E confirmed R1 not having O2 applied could have contributed to R1's death. On [DATE] at 4:14 p.m., RN-B indicated R1 required continuous O2 and with any activity R1 would require an increase in O2. RN-B stated on [DATE], she was called to R1's room along with RN-A. Upon arrival to R1's bathroom, RN-B state R1 was observed on the floor, with no O2 on, and R1 appeared pale but breathing. RN-B stated O2 was applied and increased O2 to 15 L, R1 was assisted into bed and passed away. RN-B inquired why R1's O2 was not on to which NA-A stated she took R1 to the bathroom, approximately 9 minutes prior to incident, and was unaware R1 couldn't have the O2 off. On [DATE] at 4:45 p.m., the director of nursing (DON) stated on [DATE], NA-A removed R1's nasal cannula prior to assisting her with toileting and transferring. The DON stated NA-A did not notify RN-A prior to transferring R1, as R1's [NAME] directed. The DON stated NA-B assisted R1 to transfer off the toilet and did not notify RN-A prior to transfer as R1's [NAME] directed, as well as NA-B did not recognize or was not aware R1 required continuous oxygen. Further, DON staff were expected to review each resident's [NAME] prior to start of their shift. On [DATE] at 10:13 a.m., the DON was interviewed again. The DON stated by not receiving O2, R1 could sustain hypoxia, restlessness, lethargy, cyanosis, sweating, elevated heart rate, loss of consciousness and death. On [DATE] at 11:24 p.m., the hospice medical director stated by not receiving O2, R1 was put at increased risk of loss of consciousness and/or death. On [DATE] at 11:35 a.m., the DON stated majority of all staff education regarding oxygen monitoring and hypoxia was completed by [DATE]. On [DATE] at 1:47 p.m., the facility medical director stated by R1's O2 not being applied put her at risk for an adverse outcome such as death due to R1's number of different pulmonary diagnoses. The Oxygen Administration-Long Term Care policy dated 6/23, identified licensed nurses and trained medication aids (TMA) may only regulate liter flow rates according to provider orders. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: NA-A was removed from the facility pending investigation and was provided immediate education on reviewing each resident's [NAME] prior to start of shift. All nursing staff were educated on the facility policy related to oxygen monitoring which included identifying licensed nurses and trained medication assistants only can adjust oxygen rate and source as well as reviewing each residents [NAME] prior to the beginning of the shift; and orientation for both licensed nurses and nursing assistants have been revised to include facility specific policy related to oxygen monitoring.
Jan 2023 1 deficiency
CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to complete a drug regimen review for residents ordered psychotropic ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to complete a drug regimen review for residents ordered psychotropic drugs to receive gradual dose reductions for 1 of 5 residents (R9) who were reviewed for unnecessary medications. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had intact cognition, a Patient Health Questionnaire score of 1 suggesting minimal depression which may not require treatment, a diagnosis of depression and was receiving an antidepressant. R9's diagnosis list dated 1/6/23, indicated Major Depressive Disorder, single episode, unspecified. R9's order summary report dated 1/6/23, listed an order for Citalopram tablet 10 milligrams one time per day related to Major Depressive Disorder, Single episode, unspecified with a start date of 9/8/21. R9's care plan dated 12/20/22, indicated a potential for drug interactions and adverse affects related to the use of multiple medications including the use of an antidepressant secondary to diagnosis of depression and directed staff that a monthly medication regimen review by the facility pharmacy consultant was to be completed and any recommendations were to be forwarded to the resident provider for review. R9 had documentation of pharmacy consultant reviews being completed every month over the past 13 months with no recommendation for a dose reduction of R9's Citalopram. When interviewed on 1/6/22, at 8:21 a.m. the director of nursing (DON) stated she was unable to identify a recommendation for a reduction in R9's Citalopram dose or a rationale as to why not. The DON also stated that there had been no attempts by the facility to reach out to the pharmacy consultant or R9's provider for a gradual dose reduction of her Citalopram dose or to obtain the rationale as to why not. When interviewed on 1/6/23, at 8:52 a.m. the facility Pharmacy Consultant (Pharm D) stated the recommendation for a dose reduction of R9's Citalopram was something they had missed in their monthly medication regimen reviews and they would have recommended R9's provider think about a reduction/discontinuation or provide rationale as to why not. The facility policy Psychotropic Medication Management dated February of 2022, identified that each resident's drug/medication regimen is managed and monitored which includes the implementation of gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medications in an effort to discontinue these drugs. The policy defined a gradual dose reduction as the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. The policy also indicated that within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practioner has initiated a psychotropic medication, the facility must attempt a gradual dose reduction in two separate quarters (with at least one month between attempts), unless clinically contraindicated. After the first year, a gradual dose reduction must be attempted annually, unless clinically contraindicated.
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

  • "What changes have you made since the serious inspection findings?"
  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Licensed and certified facility. Meets minimum state requirements.
Concerns
  • • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), Payment denial on record. Review inspection reports carefully.
  • • 5 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • $13,022 in fines. Above average for Minnesota. Some compliance problems on record.
  • • Grade C (56/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 56/100. Visit in person and ask pointed questions.

About This Facility

What is Cura Of Monticello's CMS Rating?

CMS assigns Cura of Monticello an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Minnesota, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Cura Of Monticello Staffed?

CMS rates Cura of Monticello's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Minnesota average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Cura Of Monticello?

State health inspectors documented 5 deficiencies at Cura of Monticello during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 3 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Cura Of Monticello?

Cura of Monticello is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 67 certified beds and approximately 61 residents (about 91% occupancy), it is a smaller facility located in MONTICELLO, Minnesota.

How Does Cura Of Monticello Compare to Other Minnesota Nursing Homes?

Compared to the 100 nursing homes in Minnesota, Cura of Monticello's overall rating (4 stars) is above the state average of 3.2, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Cura Of Monticello?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Cura Of Monticello Safe?

Based on CMS inspection data, Cura of Monticello has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Minnesota. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Cura Of Monticello Stick Around?

Staff turnover at Cura of Monticello is high. At 60%, the facility is 14 percentage points above the Minnesota average of 46%. Registered Nurse turnover is particularly concerning at 62%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Cura Of Monticello Ever Fined?

Cura of Monticello has been fined $13,022 across 1 penalty action. This is below the Minnesota average of $33,209. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Cura Of Monticello on Any Federal Watch List?

Cura of Monticello 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.

Cura of Monticello

1104 EAST RIVER STREET, MONTICELLO, MN 55362 | (763) 271-2333

C
Trust Grade (56/100)
4.0
CMS Rating
5
Deficiencies

Strengths

  • 4-star staffing
  • 4-star quality

Concerns

  • 1 Immediate Jeopardy citation

Ask about: Inspection Response, Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025