Inspection·March 17, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm going off. I came in and (V13/CNA/Certified Nursing Assistant) was out front with (R4). I went outside and saw (R4's) wheelchair at the end of the ramp and (R4) was in the grass on her back. (R4) did not have any injuries except for a slightly reddened area to her right leg. The reddened area disappeared thirty minutes later. (R4) goes to the front door frequently and exit-seeks but has never gotten outside before. No other residents have gotten outside before. Residents Affected - Few On 3-15-25 at 1:00 PM V13 (CNA) stated, On 2-28-25 around 7:00 PM I heard the front door alarm going off. I went outside and saw (R4) on the ground in front of her wheelchair. (R4) had gone down the ramp and it looked like (R4's) wheelchair hit the grass and (R4) slid out of the wheelchair onto the ground. (R4) only had a small red mark to her right leg. (R4) wanders around the facility and is confused. 2. R7's MDS dated [DATE] documents R7 is severely cognitively impaired R7's admission Record documents R7 has the diagnoses of Dementia and Behavioral Disturbance. R7's Health Status Note dated 3-13-25 at 5:50 AM and signed by V16 (LPN) documents, (V16) heard front door alarm go off. Upon approaching the door (V16) observed (R7) standing in the road with no coat on and holding her purse. (R7) had her oxygen tubing off and was holding it in her hand. As soon as (V16) reached out to help (R7), she had swung the oxygen tubing at (V16) attempting to make contact. (V16) and 2 other staff members were able to walk along side of (R7) and get (R7) back into the building. (V16) called (V2/Director of Nursing) and (V1/Administrator). (R7) was placed on 15-minute checks. (R7) does not have wander guard (electronic monitoring bracelet) on. On 3-16-25 at (V16) stated, On 3-13-25 as soon as I heard the front door alarm go off, I went to see what set the alarm off. When I went outside, (R7) was just getting to the edge of the sidewalk, into the parking lot of the facility. (R7) was in the parking lot and not in the actual road. (R7) was confused. (R7) had no injuries. B. The facility's Falls Clinical Protocol dated 09/2012 documents, Based on assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls to address risks of serious consequences of falling. If interventions have been successful in preventing falling, the staff will continue with current approaches. R2's MDS dated [DATE] documents R2 was cognitively impaired. R2's Incident Note dated 12-4-24 at 9:47 AM and signed by V15 (LPN) documents, This nurse was called into (R2's) room by (V14/Agency CNA) who states she lowered (R2) to the floor while transferring (R2) from the bed to the wheelchair. (V14) states (R2's) feet slid out from under her causing (V14) to lower (R2) to the floor. (R2's) legs hit the wheelchair causing a 1.6 x (by) 0.1 x 0.1 cm (centimeter) skin tear to RLE (Right Lower Extremity), a 2.5 x 0.7 x 0.1 cm skin tear to left medial shin, and a 2.0 x 0.7 x 0.1 skin tear to the left knee. Skin tears were cleansed. Steri-strips and dressings applied. (R2) was stood up by two assists with gait belt and placed into her wheelchair. Resident denies any pain. R2's Care Plan dated 1-4-24 documents, Focus: (R2) is at risk for falls related to mental status. Goal: (R2) will be free of falls through the next review date 3-11-25. Interventions: 9-4-24 Two staff for all transfers with a gait belt. 12-4-24 Staff was re-educated on two staff with gait belt for all transfers for (R2). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 2 of 3 Printed: 05/15/2026 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 146057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462 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 0689 Level of Harm - Minimal harm or potential for actual harm On 3-15-25 at 10:30 AM V2 (Director of Nursing) stated, (V14/Agency CNA) transferred (R2) on 12-4-24 by herself which caused (V14) to have to lower (R2) to the floor. (R2) was supposed to have two staff to always assist (R2) with transfers. (V14) was an agency CNA. We (facility staff) had to educate (V14) on ensuring two staff were being used to transfer (R2) at all times. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 3 of 3