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Nursing HomeMedicaid Investigative

Monmouth Rehab and Nursing

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

117 South I Street, Monmouth, IL 6146258 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.5/5

based on 6 Google reviews

5
4
3
2
1
Monmouth Rehab and Nursing Nursing Home in Monmouth, IL — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (18 vs median 11.0)

Bottom 25% in IL · Worst in STERN CONSULTANTS chain · $195,115 in fines

Source: Medicare data

What this means for your family

This facility receives deeply conflicting reports, with some families finding comfort in the staff's end-of-life support, while others report life-threatening neglect. Given the serious allegations regarding medical oversight and hygiene, families should conduct an unannounced visit and specifically inquire about their protocols for medical emergencies and pest control.

Google Reviews

Google Reviews

6 reviews on Google
Monmouth Rehab and Nursing receives highly polarized feedback, with some families praising the compassionate end-of-life care and staff dedication, while others report severe concerns regarding patient neglect and hygiene. Critical reviews highlight life-threatening medical oversights and persistent pest control issues, while positive reviews emphasize the facility's small, loving environment.

Quality Themes

Tap a score for details
FoodN/AStaff4.0Clean1.0ActivitiesN/AMeds1.0MemoryN/AComms2.0ValueN/A

Strengths

  • Compassionate end-of-life care
  • Dedicated and caring staff
  • Small, intimate facility environment

Concerns

  • Severe patient neglect and failure to address medical emergencies (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2342.02017(1)1.02021(1)1.02024(2)5.02025(3)

Distribution · 7 analyzed

5
3
4
0
3
0
2
1
1
3

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the facility's intimate size of 58 residents, how do you ensure that each resident receives consistent, personalized attention throughout the day?
  • 2I noticed the CMS staffing rating is currently lower than average; what specific steps is the leadership team taking to improve staff retention and ensure consistent care coverage?
  • 3Could you walk me through your facility's specific protocols for responding to urgent medical changes, and how you ensure families are notified immediately during those moments?
  • 4I see that you have responded to some feedback online; how does the management team use family input to drive improvements in facility cleanliness and medication management?
  • 5With your focus on compassionate end-of-life care, how do you support families during those transitions while maintaining high standards of daily comfort for the resident?
  • 6What does a typical daily activity schedule look like for residents who are looking to stay engaged and social within the facility?

Personalized based on this facility's data


Key Review Excerpts

The staff provides the best care and are simply amazing They truly care about the residents. It's a small facility, but full of LOVE

Family member · 2025★★★★★

the compassion I endured at community care center In my mothers final days was amazing not only for my mom but for me as well!

Family member · 2025★★★★★

My Dad was in there for 5 days and almost died there because of neglect!! We filed a complaint and they were found to be guilty of improper nursing !!!

Family member · 2024☆☆☆☆
Source: 6 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.63hrs
84%
Registered nurses for medical care
Total Nursing
3.23hrs
79%
All nurses + aides combined
Staff Turnover
35%
Lower is better (< 30% = good)
RN Turnover
60%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
4/ 5
Better Than Avg

9

measures

Worse Than Avg

4

measures

Mixed Results

3

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility15.8%
Mixed vs Avgs
Here
15.8%
US
12.1%
IL
52.5%
Warren
17.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility10.1%
Better than Avg
Here
10.1%
US
15.5%
IL
21.8%
Warren
14.8%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility85.4%
Worse than Avg
Here
85.4%
US
95.5%
IL
91.8%
Warren
96.1%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
IL
90.0%
Warren
93.1%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility25.0%
Mixed vs Avgs
Here
25.0%
US
19.5%
IL
18.3%
Warren
25.8%
⚖️

Residents who lost too much weight

↓ Lower is better
This Facility1.7%
Better than Avg
Here
1.7%
US
5.3%
IL
6.6%
Warren
5.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility96.6%
Better than Avg
Here
96.6%
US
81.8%
IL
69.0%
Warren
83.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility5.7%
Worse than Avg
Here
5.7%
US
1.6%
IL
2.4%
Warren
1.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

26deficiencies
4penalties
Well above state avg (12.0)
18 complaint-triggered
$195,115 in fines

Families have filed 18 complaints triggering federal inspections, revealing recurring problems with accident prevention and safety, resident abuse/neglect protections, and care planning across multiple surveys from 2022-2026. The facility shows persistent issues with maintaining safe environments and preventing accidents, with safety deficiencies appearing in nearly every inspection period. While all violations show correction dates, the pattern of repeated problems in core care areas suggests ongoing systemic challenges that warrant careful consideration.

Mar 20, 2026Routine
22
0550Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0565Potential for harm · WidespreadCorrected

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0919Potential for harm · WidespreadCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0341Potential for harm · WidespreadCorrected

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0271Potential for harm · PatternCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0849Potential for harm · IsolatedCorrected

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Jan 29, 2026Complaint
2
0689Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Sep 11, 2025Complaint
1
0580Actual harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Jul 1, 2025Complaint
7
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Jun 18, 2025Complaint
2
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0700Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

Mar 17, 2025Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Federal Penalties

Fine

Sep 11, 2025

$19,115

Payment Denial

Jun 18, 2025

14-day denial

Fine

Oct 4, 2024

$110,975

Fine

Nov 29, 2023

$84,140

Ownership & Operations

Who Operates This Facility

Owner / Operator

Monmouth Rehab and Nursing

Organization Type

for profit

Chain Affiliation

Chain Name

Stern Consultants

Chain Size

23 facilities nationwide

Chain avg rating: 2.6/5 · Rank 22 of 22 (Worst)

Ownership & Management

Owners

Bsf Family Holdings LLC

Owner · Organization

15%

Etn Family Holdings LLC

Owner · Organization

Tlco Holdings LLC

Owner · Organization

Erblich, Avraham

Owner

Sheps, Boruch

Owner

Bsf 2025 Family Trust

Owner (parent company) · Organization

7%

Com Family Trust

Owner (parent company) · Organization

12%

Bf16 Family Trust

Owner (parent company) · Organization

E Newhouse Family Trust

Owner (parent company) · Organization

T Newhouse Family Trust

Owner (parent company) · Organization

Tlm Family Trust

Owner (parent company) · Organization

Friedman, Benjamin

Owner (parent company)

Key personnel

Friedman, BenjaminOfficer / DirectorEtn Family Holdings LLCManagerTlco Holdings LLCManagerAnderson, RebeccaManagerErblich, AvrahamManager
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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