Monmouth Rehab And Nursing
MONMOUTH REHAB AND NURSING in MONMOUTH, IL — inspection on January 29, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
aware they were looking for R5 and could not find him. V2 stated she immediately started searching
jeopardy to resident health or R5 was found. V2 stated she does not know why there is no documentation in R5's chart regarding the safety elopement and that it should have been documented in R5's electronic medical record. V2 further stated she assumed the documentation was there.On 1/26/26 at 12:20 PM, V1 (Administrator) stated
seen R5. V1 stated they began searching bathrooms and resident rooms, and when they realized R5 was not in the facility, they searched the perimeter. V1 stated she drove two blocks east, saw EMS (emergency medical services) lights at a local coffee shop, and found R5 there. V1 stated a concerned citizen had called 911 after seeing R5 walking with his walker. V1 stated she was not aware the incident was not documented in R5's chart.On 1/26/26 at 1:45 PM, V8 (Certified Nursing Assistant/CNA) stated R5 got out of the facility, and nobody knew he had left. V8 stated R5 has gotten out before, though V8 was not present during prior incidents. V8 stated R5 can ambulate with a walker or wheelchair depending on the day.On 1/26/26 at 1:48 PM, V6 (CNA) stated she saw R5 walking in the hallway with his walker between approximately 3:50 PM and 4:15 PM. V6 stated after assisting another aide, she was informed staff could not find R5. V6 stated she joined the search and drove with the activity director, locating EMS lights at a local coffee shop where R5 was found.On 1/26/26 at 1:53 PM, V7 (CNA) stated she was told R5 got out of the facility while she was working, but she was not involved in the search because she was assisting another resident.On 1/26/26 at 2:15 PM, V1 (Administrator) stated R5 did not have a wander guard prior to 1/5/26 because R5 refused to wear it, and this refusal was not documented. V1 confirmed R5 previously eloped in September 2023 and was found walking on a street.The facility submitted an abatement plan on 1/27/26 and was advised by the regional office to make revisions before it would be accepted.
The facility submitted the revised abatement plan on 1/28/26.
Again, the facility was advised to make revisions to the plan.
The final abatement plan was submitted on 1/29/26.On 1/29/26 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.All staff members present were in-serviced on 1/27/26 and 1/28/26 on the elopement policy and procedure.
All remaining staff members will be in-serviced via telephone prior to their next shift by administrator and/or designee.2.On 1/28/26, audit conducted by administrator and director of nurses by auditing medical chart to ensure interventions are in place and documentation of event with all action taken is recorded.3. On 1/28/26 all nurses were in serviced on incident charting and completion by Director of Nursing.4. On 1/27/26 all residents had an updated wandering/elopement assessment completed by Director of Nursing and Assistant Director of Nursing.
Care plans were reviewed for accuracy by Director of Nursing on 1/28/26.
146057 01/29/2026
Monmouth Rehab and Nursing 117 South I Street Monmouth, IL 61462
in accordance with accepted professional standards.
records for two residents (R3, R5) of three reviewed for documentation out of a sample list of
of this policy is to maintain a medical record to serve as a legal document that details the services provided to the residents, or any changes in the residents' medical or mental condition, through charting and documentation.
Documentation will include information on assessment, notifications, interventions and evaluation including but not limited to: Incidents/ Accidents, Change in Condition, Physician Notification and Responsible party, education provided to resident and or responsible party.1. R5's electronic medical record contained no Nurse Progress Note or assessment regarding R5's elopement from the facility on 1/5/26.R5's care plan was updated on 1/6/26 for wander guard placement, and physician orders dated 1/6/26 documented the wander guard was placed.
However, there was no documentation of the elopement event, staff response, or resident condition after returning to the facility.On 1/26/26 at 12:05 PM, V2 (Director of Nursing) stated she assumed documentation was completed but confirmed it was missing from R5's chart.On 1/26/26 at 12:20 PM, V1 (Administrator) stated she was not aware the incident was not documented in R5's chart.2. R3's Medical Diagnosis list documents R3 has Alzheimer's Disease and Dementia.R3's current care plan documents R3 is at risk for Falls and Elopement/Wandering and a wonder guard was placed on R3 on 1/28/26.R3's Nurse Progress Note dated 12/31/25 documents R3 has a bruise under her left eye that is healing.
There is no documentation in R3's chart explaining how the bruise occurred, nor any follow-up assessment or investigation.On 1/28/26 at 1:30 PM, V2 (Director of Nursing) stated all incident/accident documentation has been recorded in the facility's internal Risk Management system, which does not carry over into the resident's electronic medical record. V2 stated any assessments related to an incident would not be found in the residents' chart for this reason. V2 further stated she is in-servicing nurses on how to ensure assessments and incident documentation are entered into the resident's medical record.