Monmouth Rehab: Broken Hand Ignored After Fall - IL
A nurse looked at it and said it was probably just a sprain.
No X-ray was ordered that day. No emergency room visit. The medical director, who said he expects to be notified any time a resident has increased pain or a condition change, told inspectors he does not recall the facility calling him with updates on her condition after the fall.
He ordered the X-ray the next morning, when he saw her himself.
Federal inspectors cited Monmouth Rehab and Nursing following a complaint inspection completed September 11, 2025, finding the facility caused actual harm to the resident, identified in the report as R1, by failing to notify her physician of a condition that warranted immediate evaluation.
The two nursing assistants, identified in the report as V7 and V8, were both present when they found R1 on August 12. V7 told inspectors that R1's hand was visibly swollen and bruised and that R1 said it was hurting her very bad. V7 and V8 notified a nurse, though V7 said she could not recall which nurse was informed. V8 told inspectors that a second staff member, identified as V2, responded to the scene and said the hand would be fine, that it was probably just a sprain.
V8 said V4, another staff member present, appeared upset and felt R1 needed an X-ray.
Nobody ordered one.
The medical director, V9, told inspectors he remembers receiving a call on August 12 about R1's fall. He said he does not remember exactly what was said to him, but that if it had been conveyed to him that R1 was in a lot of pain or had swelling, he would have sent her to the emergency room to be evaluated. He said he does not recall the facility calling him with updates on her change of condition after that initial call.
When he saw R1 the following day, he ordered the X-ray.
The inspection report does not state what the X-ray found, but the federal citation carries a finding of actual harm, the agency's designation for violations where a resident suffered real injury or deterioration, not merely the risk of it.
The detail that cuts deepest in the inspection record is not the missed X-ray or the nurse who called it a sprain. It is what V8 told inspectors about the culture that produced that decision.
V8 stated that staff are often told by management to not report things.
That sentence appears without elaboration in the inspection report. Inspectors did not expand on it, did not name who in management said it or how many times, did not describe what category of things management discouraged staff from reporting. It sits in the record as a single statement from a nursing assistant who watched a colleague dismiss a visibly injured resident and felt compelled to tell a federal inspector that this was not unusual.
V7, for her part, told inspectors she was not even aware that R1 had refused to wear foot pedals on her wheelchair, a detail the facility apparently noted in connection with the fall. V7 said, "Sometimes she wears them and sometimes she doesn't," suggesting the foot pedal issue was known, inconsistently documented, and not resolved before R1 ended up on the ground with a hand she was begging staff not to touch.
The medical director told inspectors plainly what his standard is: he expects to be notified any time a resident has a condition change or increased pain. That standard was not met on August 12. A resident with a swollen, bruised hand sat in pain through the remainder of that day while the people around her had already decided, without an X-ray, without a physician's examination, without calling the doctor who said he would have sent her to the emergency room, that she was probably fine.
V8 saw it differently. V8 thought she needed an X-ray. V8 also thought, based on what management had communicated, that reporting it was not something staff were supposed to do.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monmouth Rehab and Nursing from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
MONMOUTH REHAB AND NURSING in MONMOUTH, IL was cited for violations during a health inspection on September 11, 2025.
A nurse looked at it and said it was probably just a sprain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.