Inspection·June 18, 2025

F 0689 Level of Harm - Actual harm R1's Nurse Progress Note dated 5/30/25 documents R1 was seen sitting on the floor by the side of the bed. R1 stated R1 slid off the bed. R1 was sitting with her back supported by the side of the bed and R1's bilateral lower extremities were extended in front of R1. R1 was assisted back to bed by two staff members, R1 was instructed to turn on call light on when wanting to go to bathroom. Residents Affected - Few R1's electronic medical chart does not contain documentation of a therapy evaluation after R1's falls on 5/6/25, 5/20/25, and 5/30/25. On 6/17/25 at 9:30 AM, R1 was lying in R1's bed with R1's eyes closed. Metal half rails were up on the side of the bed. On 6/17/25 at 9:15 AM, V1 (Administrator) stated that R1 is confused and rolled out of bed onto the floor. R1 was inching to the side of the bed and rolled out. R1 had not been evaluated by therapy since admission to the facility. On 6/17/25 at 10:00 AM, V2 (Director of Nursing) stated R1's falls are usually at night when R1 gets up to go to the bathroom. V2 is unsure when R1 was last screened for a therapy evaluation. V2 further stated that some of R1's safety interventions are not appropriate because R1 takes off R1's gripper socks and will not leave them on. V2 also stated R1 would not remember to use a call light for assistance. V2 confirms R1 does not have very good memory recall especially at night R1 becomes more confused. V2 confirmed R1 should have been evaluated by therapy to ensure it was safe for R1 to be toileting and ambulating in R1's room independently. On 6/17/25 at 9:35 AM, V3 Certified Nursing Assistant (CNA) stated V3 was unaware of R1's fall with a fracture to left foot. R1 gets up on her own and does her own thing in her room. We push R1 in a wheelchair to the dining room because R1 cannot walk very far and R1 is confused and disoriented. On 6/17/25 at 1:31 PM, V6 (R1's Family Member) stated R1 has dementia and was placed in the facility after a fall at home. R1 is unable to care for herself and is very forgetful and does not recognize her family anymore. V6 stated R1 would need help with toileting and ambulating as R1 has had past falls and is very forgetful and unsteady. 2.) On 6/17/25 at 12:50 PM, R2 was lying in bed with eyes closed. R2 was not responsive to voice. R2's family was at the bedside. R2 had half rails on each side of the bed. R2's Fall assessment dated [DATE] documents R2 is at moderate risk for falls. On 6/17/25 at 1:00 PM, V6 (R2's Family Member) stated when R2 admitted to the facility approximately four weeks ago R2 was alert and oriented and had been doing things on her own at home. R2 sustained a fall at home and was admitted to the facility for rehab. V6 further stated R2 had a diagnosis of Cancer but had been doing well health wise. V6 stated R2 has fallen approximately four times since being admitted to the facility and has continued to decline each time. V6 stated R2 had an unwitnessed fall on 5/29/25 and sustained a fractured elbow, rib and shoulder. R2 was admitted to hospice after the fall per recommendation of the facility. There is not enough staff here to provide care, R2's call light doesn't show when it is on at the nurse's station because the panel is broken. V6 further stated V6 regrets bringing R2 to this facility and feels if he had not, R2 would not currently be in the condition she is in. R2's admission Nurse Progress Note dated 5/7/25 documents R2 was admitted to the facility for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 2 of 4 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 06/18/2025 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 therapy. R2 was cognitively intact and required assistance of one staff member and a walker for ambulation and transfers. Level of Harm - Actual harm Residents Affected - Few R2's Social Services Note documents R2 is alert and oriented and was admitted to the facility on [DATE] for short term therapy with plans to discharge home after therapy in completed. R2's Nurse Progress Note dated 5/13/25 documents R2 was found on the floor of R2s room crawling on her hands and knees stating R2 thought there was water on the floor coming from the hallway. R2 stated she did hit her head and touched her right-side temple. With the help of staff R2 was helped up and into her wheelchair. R2 was reeducated to use the call light system, location and how and when to use it. R2 was encouraged to call for help when needed. R2 states I thought there was water all over the floor. R2's Nurse Progress Note dated 5/20/25 documents R2 was observed on her bottom in front of R2's recliner with her knees bent. R2 had a small skin tear on her left elbow. Educated R2 on the importance of calling for assistance when she needs to use the bathroom to ensure her safety so R2 does not fall and harm herself. R2 was helped into her recliner. R2's Nurse Progress Note dated 5/21/25 documents R2 was observed on her hands and knees on the floor looking under her bed. When asked if she needed help R2 stated she was looking for something she had dropped. No signs of injury, R2 is alert and oriented, no abnormalities to head or back or discoloration. R2 was assisted back to bed. R2's Nurse Progress Note dated 5/29/25 documents R2 had an unwitnessed fall and was observed sitting in R2's wheelchair inside her room. R2 apparently was outside of her room trying to go home. A head-to-toe assessment completed. R2 was able to move all extremities and was unable to raise her right arm all the way but was able to elevate her left all the way up. R2 has large abrasion on her right side back. R2 is complaining of inability to catch her breath although she says it is due to her lung cancer. R2's Nurse Progress Note dated 5/29/25 documents R2 is complaining of pain on right side and right arm from the fall. R2's physician was notified and ordered a mobile x-ray to be performed at the facility. R2's X-Ray results dated 5/30/25 documents R2 has a displaced rib fracture to the eighth rib and a right radial neck fracture. R2's Census documents R2 was admitted to Hospice on 6/1/25. On 6/17/25 at 10:00 AM, V6 (Certified Nursing Assistant) stated when R2 admitted to the facility R2 was alert/oriented and walked with a walker and was an assist of one. R2 was often unsteady and slowly became worse to where two staff had to help R2. R2 was not confused until around the end of May. After R2 fell on 5/29/25 R2 did not get out of bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 3 of 4 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 06/18/2025 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an entrapment assessment for bedrails prior to bedrails being applied to a bed as a fall intervention for one (R1) of three residents reviewed for bed rail assessments out of a sample list of three. Findings include: The facility's Side Rail Assessment Policy revised 11/5/24 documents bedrails are considered restraints; this includes full and half bed rails. The only time a bed rail can be used in the facility is after an evaluation for appropriateness and a Side rail assessment has been completed prior to applying bedrails. Consideration for the resident's cognitive ability to understand the use of bed rails also needs assessed. If determined side rails are appropriate the maintenance needs to determine prior to application that side rails are compatible with the bed and that safety is not compromised. On 6/17/25 at 9:30 AM, R1 was lying in R1's bed with R1's eyes closed. Metal half rails are up on side of the bed. R1's current care plan documents on 5/30/25 an intervention of half side rails was added to R1's care plan after R1's unwitnessed fall on 5/30/25. This same care plan documents R1 has poor safety awareness and is at risk for falls. R1's Entrapment assessment was not initiated until 6/2/25 and was not completed as of 6/17/25. R1's current Minimum Data Set (MDS) dated [DATE] documents R1 does not have bed rails. This same MDS documents R1 is cognitively impaired. On 6/17/25 at 11:00 AM, V2 stated she normally completes the medical entrapment assessment when bed rails are put on a bed. V2 stated R1's entrapment assessment wasn't started until 6/2/25 and was never completed. V2 stated she was not aware assessment needed completed prior to rails being put on the bed. The facility's Quarterly Bed Entrapment Prevention Checklist dated 6/3/25 documents a bed rail assessment completed by V5 (Maintenance Director). On 6/17/25 at 11:15 AM, V5 stated V5 completes an Entrapment Prevention Checklist assessment quarterly on residents with bedrails. V5 stated that he does not complete a new assessment when bed rails are applied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146057 If continuation sheet Page 4 of 4