Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure complete and timely physician
notification following a resident accident and subsequent change in condition for one of three residents (R1)
reviewed for notification of change out of a sample list of three. This failure resulted in R1 experiencing
excruciating pain to her right hand due to a delay in notifying the physician and ultimately leading to a
diagnosis of a fracture.Findings include:The facility's Physician Notification Policy revised 11/5/2022
documents a facility will immediately inform the resident; consult with the resident's physician; and notify, of
a significant change in condition in a resident's physical, mental, or psychosocial status or a need to alter
treatment significantly.The facility's Change in Condition Procedure revised 9/21/2022 documents a change
in condition requires notification of Medical Doctor of change and resident assessment information. R1's
Nurse Progress Note dated 8/12/25 documents R1, who utilizes a wheelchair was on a supervised outing
with facility staff. While navigating a grassy area, R1 slid forward out of her wheelchair, landing on her
knees and both hands. Staff immediately assessed the resident on-site. R1 voiced she was fine and
attempted to reposition herself independently. Staff assisted her back into the wheelchair without issue and
returned R1 to the facility. R1 was assessed upon return to facility and Physician, Director of Nursing
(DON), and Administrator were notified, and an intervention was initiated for foot supports to be added to
R1's wheelchair to prevent future sliding incidents.R1's Medical Diagnoses revealed R1 has Myasthenia
Gravis and Cerebellar Ataxia, both of which affect muscle strength, coordination, and mobility.R1's
Minimum Data Set (MDS) dated [DATE] documents that R1 is cognitively intact and requires
substantial/maximal assistance with standing and transfers. R1's Nurse Progress Note dated 8/12/25 at
3:50 PM, documents R1 reported minimal pain in the right hand following a fall earlier that day. R1's right
hand had mild edema and scant discoloration observed on the 3rd, 4th, and 5th fingers. Ice was applied to
the right hand. R1 stated It does not hurt really unless she moves her fingers.R1's Nurse Progress Note
dated 8/13/25 at 12:30 AM documents R1 was complaining of discomfort right hand, right hand is very
swollen and bruised, unable to grip with hand. R1's right great toe is painful and bruised. Ice offered for
hand, resident declined, the pressure causes discomfort. R1 states she injured her hand on outing in
wheelchair.R1's Nurse Progress Note dated 8/13/25 at 10:30 AM documents R1 was up in her recliner
chair with right lower extremity (RLE) elevated due to swelling on the top of right foot area from the previous
incident on 8/12/25. Bruising continues to R1's right great toe between toe and top of right foot. R1's right
hand remains swollen with bruising. Will continue to monitor.R1's Nurse Progress Note dated 8/13/25 at
11:30 AM documents Ordered through portable X-Ray two view Xray of right hand due to moderate
swelling and moderate bruising with pain, per V9 (Medical Director).R1's Nurse Progress Note dated
8/14/25 at 10:45 AM documents R1's X-ray results of right hand reveal prominent displaced fractures
involving the base of the proximal
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
146057
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
09/11/2025
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 0580
Level of Harm - Actual harm
Residents Affected - Few
phalanges of the third through fifth digits.On 9/10/2025 at 8:50 AM, R1 was seated in a wheelchair and had
a hard cast on her right wrist. R1 was pleasant and alert during the interview. When asked about the injury,
R1 stated, (R1) was with (V3/Activity Director) on my way to the store. (V3) was pushing me in my
wheelchair, and we hit a curb or something on the ground, and (R1) fell out into the grass and broke her
hand. R1 stated they had her foot in a boot as well because of her toe, but it's doing better. R1 stated she
normally wears foot pedals outside of facility but forgot them that day. R1 stated if she had foot pedals on
the chair she would not have fallen out. R1 further stated that she immediately felt excruciating pain in her
right hand shortly after her fall and that she made the staff aware of the pain as soon as staff arrived to help
R1 up from the ground. On 9/10/25 at 9:54 AM, V3 (Activity Director) stated that the facility regularly takes
residents on outings to a local store, located one block from the facility. V3 reported, We take side streets
when we walk because it's less busy. There's a three-four-foot patch of grass off the sidewalk. V3 explained
that during the outing on 8/12/2025, she remained with R1 while other residents and staff returned to the
facility. V3 stated, I told her hold on, I'll put my bags down and help you. V3 reported that R1 self-propels
using her arms and feet, and that as V3 attempted to assist R1 through the grassy area, which was uneven,
then it happened so fast that R1's wheelchair's front wheels were in the grass and the rear wheels
remained on concrete. V3 stated, (R1) slipped out of wheelchair going forward and I think R1 put her feet
down to break the fall and was on her knees, put her hands down on the ground to break her fall. (R1) then
rolled over in the grass. V3 noted that R1 was not wearing foot pedals at the time, adding, She never does
wear them. V3 acknowledged, It was swollen very quickly. I should've done things differently-I probably
should have had foot pedals on, or pulled her backwards, or taken her another way. V3 contacted the facility
immediately, and two Certified Nursing Assistants (CNAs) were sent to assist, as V3 is not a CNA or
nurse.On 9/10/25 at 10:30 AM, V4 (Licensed Practical Nurse/LPN) stated that she was made aware of the
fall by V2 (Director of Nursing) and was unsure who assisted R1 at the scene. V4 reported, I don't
remember any CNAs leaving the floor to go help. V4 stated that R1 did complain of pain during her
assessment upon returning to the facility. However, V2 directed staff to wait a day or two before determining
whether R1 needed an X-ray or further evaluation. V4 also stated she was told that V3 was pushing R1 in
her wheelchair when they hit something, causing R1 to fall forward. V4 added, I was told that (R1) stopped
her fall using her hands on the ground.On 9/10/25 at 12:00 PM, V2 (DON) stated that on 8/12/2025, she
received a call from V3 (Activity Director) reporting that R1 had slid out of her wheelchair while outside the
facility at a local store and was on the ground. V2 stated she sent two CNAs to assist because V3 was not
certified to lift or transfer residents. Upon R1's return to the facility, V2 assisted V4 (LPN) with the
assessment. V2 reported that R1 did not complain of pain, swelling, or bruising at that time, so they decided
to monitor her condition. V2 stated that on 8/13/2025 at 12:30 AM, V5 documented increased pain,
swelling, and discoloration to R1's hand. V2 acknowledged that V5 should have reported this change in
condition to the physician. V2 also stated that V6 (RN) documented continued pain and swelling on 8/13/25
without notifying the physician.On 9/10/25 at 1:05 PM, V8 (CNA) stated on 8/12/2025, she and V7 (CNA)
were passing lunch trays when V2 (DON) informed them that R1 had fallen outside of a local store and
needed assistance. V8 reported that when they arrived, R1 was sitting on the ground. V7 and V8 used a
gait belt to assist R1 back into her wheelchair. V8 stated, (R1's) right hand was very swollen, and (R1) was
complaining that it hurt. V8 observed that R1's hand became more swollen and bruised over the next few
hours. V8 stated she provided care for R1 again on 08/13/2025, and R1 continued to complain of pain in
her right hand and foot. V8 reported that she notified V4 (LPN), and that
(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
09/11/2025
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 0580
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
V2 responded, (R1) hand will be fine-it's probably just a sprain. V8 stated that V4 appeared upset and felt
R1 needed an X-ray. V8 further stated we are often told by management to not report things.On 9/10/25 at
1:30 PM, V7 (CNA) stated that when she and V8 arrived at the scene on 8/12/2025, R1 was sitting on the
ground with her legs extended and hands on the ground. V7 reported that R1 stated her hand was very
sore and asked staff to be careful with it. V7 observed that R1's hand was swollen, bruised, and stated, Her
hand was hurting her very bad. V7 stated that she and V8 notified a nurse but could not recall which nurse
was informed. V7 also stated she was not aware of R1 refusing to wear foot pedals, noting, Sometimes she
wears them and sometimes she doesn't.On 9/10/25 at 8:30 AM, V9 (Medical Director) stated he
remembers receiving the call on 8/12/25 regarding R1's fall. V9 stated he does not remember exactly what
was said to him at that time, but if it was conveyed to him that R1 was in a lot of pain or had swelling V9
would have sent R1 to the emergency room to be evaluated. V9 stated when he saw R1 the next day he
ordered an Xray. V9 stated he expects to be notified any time a resident has a condition change or
increased pain. V9 stated he does not recall the facility calling him with updates on R1's change of
condition.
Event ID:
Facility ID:
146057
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FAQ · About this visit
Common questions about this visit
What happened during the September 11, 2025 survey of MONMOUTH REHAB AND NURSING?
This was a inspection survey of MONMOUTH REHAB AND NURSING on September 11, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MONMOUTH REHAB AND NURSING on September 11, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.