Health inspection·January 29, 2026

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement interventions for a resident with a known history of elopement and exit-seeking behaviors to prevent elopement and failed to provide adequate supervision for one of one residents (R5) reviewed for elopement risk in the sample of six. These failures resulted in R5 exiting the facility on 1/5/26 without staff knowledge and being found at a local coffee shop two blocks away, near a busy highway, during cold weather conditions when a concerned citizen called 911, and emergency medical services responded.These failures resulted in an Immediate Jeopardy that began on 1/5/26. V1 (Administrator) was notified of the immediate jeopardy on 1/27/26 at 12:10 PM. While the Immediate Jeopardy was removed on 1/28/26, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and quality assurance.Findings include:The facility's Wandering & Elopement Assessment and Prevention policy revised 6/4/2024 documents all residents in this facility shall be assessed for elopement/unsafe wandering, to ensure their safety and prevention from elopement. Elopement is defined as a resident unable to protect themself, who departs the healthcare facility or enters a non-resident area unsupervised or undetected. An incident report will be completed by the Nursing Supervisor noting all investigative procedures, witness statements, and any other pertinent information.R5's census line documents R5 was admitted to the facility on [DATE].R5's Elopement Assessments dated 9/7/23 and 4/3/25 document R5 is at risk for elopement and has previously eloped from the facility. The 4/3/25 assessment also documents R5 exhibits exit-seeking behaviors.R5's Wandering/Elopement assessment dated [DATE] documents R5 has a history of leaving the facility.R5's care plan was updated on 1/6/26 to include wander guard placement, and physician orders dated 1/6/26 document a wander guard was placed on R5. R5's care plan further documents R5 has Alzheimer's/Dementia, Poor Safety Awareness, is at Risk for Falls and R5 walks with a walker and staff supervision.R5's Nurse Progress Note dated 1/7/26 at 11:47 AM documents R5 remains on 15-minute checks for safety and observation after a recent exit-seeking episode.R5's electronic record revealed no Nurse Progress Note or assessment regarding R5 eloping from the facility on 1/5/26.The National Weather Service report for Monmouth, Illinois, dated 1/1/26-1/24/26, documents that on 1/5/26 the outside temperature was a high of 49 F and a low of 28 F.On 1/26/26 at 9:45 AM, R5 was observed lying in bed with the call light attached to the blanket, watching television. R5 was only alert to self during conversation. A walker and manual wheelchair were at the foot of R5's bed.On 1/26/26 at 11:15 AM, V3 (R5's Friend) stated that on 1/5/26, V3 received a call from V1 (Administrator) informing her that R5 had exited the facility, possibly by following visitors out the door unnoticed. V3 stated V1 told her she was very upset and felt terrible that R5 had gotten out, but V1 had found R5 at a local coffee shop. V1 told V3 that R5 stated he had left to help someone fix their car. V3 stated she was notified only after R5 was found, not when he was missing. V3 further (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 01/29/2026 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)