Health inspection·October 15, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete intact and required partial assistance with transfer.R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, R3 stated shortly after she was admitted here, she was at the nurse's station when R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, R3 stated she told staff who were working at the time of this allegation but does not recall their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the Facility did not have any abuse investigations for R1 and R3. On 10/14/25 at 4:00 PM, V1 stated she does not understand how the incident between R1 and R3 could be considered sexual abuse, because there was no physical touching. R1 was just asking R3 if she would be interested and does not feel that would be upsetting to people.On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.The Facility's Abuse Prevention Program Policy revised 2/20/25 documents the Facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical). Abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Bottom of Form Event ID: Facility ID: 145581 If continuation sheet Page 2 of 6 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 145581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to implement its abuse policy through prevention, reporting and investigating abuse allegations in 2 of 3 residents (R2, R3) reviewed for abuse in the sample of 6. Top of FormFindings include:1.) R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired and ambulated by wheelchair.R1's Care Plan dated 8/5/25 documents R1 has a behavior problem of being sexually inappropriate. On 10/10/25 at 1:35 PM, V8 (Certified Nursing Assistant/CNA Supervisor) stated R1 has been on 15-minute checks since 8/22/25 for inappropriate behavior.On 10/14/25 at 9:10 AM, V14 (Nurse Practitioner) stated R1 has a history of sexual aggression and is monitored every shift.On 10/14/25 at 9:15 AM, V4 (Licensed Practical Nurse/LPN), stated R1 has inappropriately touched staff in the past and is on 15-minute checks for monitoring.On 10/14/25 at 9:53 AM, V16 (CNA) stated R1 has a history of inappropriately touching both staff and residents and requires redirection.2.) R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including intellectual disabilities.R2's MDS dated [DATE] documented R2 was moderately cognitively impaired and ambulated by wheelchair.R2's Care Plan dated 6/5/25 documents R2 is at risk of abuse due to impaired cognition. On 10/10/25 at 12:35 PM, R2 stated, (R1) touched me down there (pointed to genital area). That's not good for me. I don't like him touching me.The Facility's Initial Report sent to the state surveying agency on 10/5/25 documents R1 attempted to touch R2 on her private area at the nurse's station. R2's Progress Note by V7 (Licensed Practical Nurse/LPN), on 10/5/25 at 5:41 PM documents, Resident stated she was touched on her private area by a male resident in the hallway by nurse station.On 10/14/25 at 9:56 AM, V7 stated she was R2's nurse when R2 reported the allegation to her. V7 saw R2 next to the nurse's station while R1 was self-propelling his wheelchair down the hallway. V7 went to her medication cart, and a few minutes later R2 came and said R1 touched her. R1 was rolling himself back down the hallway at that time, and R2 was pretty shaken up. R2 was crying and pretty emotional. On 10/10/25 at 12:30 PM, V5 (Social Services Director/SSD), stated, I know it happened. We believe her when she tells us it happened and took it (the allegation) seriously. This is not the first time (R1) has had inappropriate behaviors.On 10/14/25 at 9:50 AM, V15 (Activities Director) stated she was about to take residents on an outing and R2 motioned for her to come over to her. R2 told V15 that R1 had touched her in the private area.The Facility's Investigation was provided on 10/10/25 at 12:36 PM. The investigation did not include any staff or resident interviews.On 10/10/25 at 1:37 PM, V1 (Administrator) provided an additional document that listed names of residents interviewed by V5 (Social Services Director) on 10/9/25. Residents listed included R3, R5, and R6. On 10/10/25 at 1:43 PM, R3 stated V5 just interviewed her about the incident between R1 and R2 earlier today.R3's MDS dated [DATE] documented R3 was cognitively intact.On 10/10/25 at 3:10 PM, R5 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility. R5's MDS dated [DATE] documented R5 was cognitively intact.On 10/10/25 at 3:11 PM, R6 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility.R6's MDS dated [DATE] documented R6 was cognitively intact.On 10/14/25 at 4:00 PM, V1 stated it is a problem if residents are saying they were not interviewed for this investigation.The Facility's Final Report and Conclusion of Incident documents V4 (LPN), reported R2's abuse allegation to V1. On 10/14/25 at 9:15 AM, V4 stated she was unaware of R2's allegation against R1 and did not report this to V1 because she had no knowledge of it.The Facility's Final Report and Conclusion of Incident also documents R2 reported R1 touched her private area while she was sitting at the nurse's station. When interviewed by V1, R2 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145581 If continuation sheet Page 3 of 6 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 145581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete asked what the Facility was doing about it. R1 was interviewed about the incident and replied, What is wrong with that?3.) R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two and muscle weakness.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was cognitively intact and required partial assistance with transfer.R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, R3 stated shortly after she was admitted here, she was at the nurse's station when R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, R3 stated she told staff who were working at the time of this allegation but does not recall their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the Facility did not have any abuse investigations for R1 and R3. V1 was notified that R3 alleged R1 grabbed her sweater and offered her money for sexual favors shortly after her admission to the Facility.On 10/14/25 at 10:25 AM, V1 stated she did not report the allegation made by R3 about R1 that was reported to her on 10/10/25. On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.On 10/14/25 at 4:00 PM, V1 stated she does not understand how the incident between R1 and R3 could be considered sexual abuse, because there was no physical touching. R1 was just asking R3 if she would be interested and does not feel that would be upsetting.The Facility's Abuse Prevention Program Policy revised 2/20/25 documents the Facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical). Abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. documents Facility staff will report and investigate any allegations of abuse within timeframes required by Federal law. The Facility will initiate external reports to the Department within 24 hours upon receipt of an allegation or upon the formation of a reasonable suspicion of abuse. Bottom of Form Event ID: Facility ID: 145581 If continuation sheet Page 4 of 6 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 145581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to report an allegation of abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 6.Findings include:1.) R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two and muscle weakness.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was cognitively intact and required partial assistance with transfer.R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, R3 stated shortly after she was admitted to the facility, she was at the nurse's station and R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, R3 stated she reported this incident to staff working at the time but could not remember their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the facility did not have any abuse investigations for R1 and R3. V1 was notified that R3 alleged R1 grabbed her sweater and offered her money for sexual favors shortly after her admission to the facility.On 10/14/25 at 10:25 AM, V1 stated she did not report the allegation made by R3 regarding R1. On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy. On 10/14/25 at 4:00 PM, V1 stated she did not understand how the incident with R1 and R3 could be considered abuse since there was no physical touching. R1 was just asking R3 if she would be interested.The Facility's Abuse Prevention Program Policy revised 2/2023 documents abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Facility staff will report any allegations of abuse within timeframes required by Federal law. The Facility will initiate external reports to the Department within 24 hours upon receipt of an allegation or upon the formation of a reasonable suspicion of abuse. Event ID: Facility ID: 145581 If continuation sheet Page 5 of 6 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 145581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Autumn Meadows of Cahokia 2 Annable Court Cahokia, IL 62206 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to thoroughly investigate abuse allegations from 1 of 3 residents (R2) reviewed for abuse in the sample of 6.Findings include:1.) R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired and ambulated by wheelchair.2.) R2's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including intellectual disabilities.R2's MDS dated [DATE] documented R1 was moderately cognitively impaired and ambulated by wheelchair.On 10/10/25 at 12:35 PM, R2 stated, (R1) touched me down there (pointed to genital area). The Facility's Initial Report sent to state surveying agency on 10/5/25 at 5:41 PM documents R1 attempted to touch female resident R2 on her private area at the nurse's station. The Facility's Investigation was provided on 10/10/25 at 12:36 PM. The investigation did not include any staff or resident interviews.On 10/10/25 at 1:37 PM, V1 (Administrator) provided an additional document that listed residents interviewed by V5 (Social Services Director)on 10/9/25. Residents listed included R3, R5, and R6.On 10/10/25 at 1:43 PM, R3 stated V5 just interviewed her about the incident between R1 and R2 earlier today.R3's MDS dated [DATE] documented R3 was cognitively intact.On 10/10/25 at 3:10 PM, R5 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility. R5's MDS dated [DATE] documented R5 was cognitively intact.On 10/10/25 at 3:11 PM, R6 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility.R6's MDS dated [DATE] documented R6 was cognitively intact.On 10/14/25 at 4:00 PM, V1 stated it is a problem if residents are saying they were not interviewed as part of the investigation.The Facility's Final Report documented V4 (Licensed Practical Nurse) reported the incident to V1 (Administrator).On 10/14/25 at 9:14 AM, V4 stated she had no knowledge of R2's allegation toward R1 and did not report this to V1 because she knew nothing about it.On 10/14 25 at 12:52 PM, V1 stated the investigation she provided was complete.On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.The Facility's Abuse Prevention Program Policy revised 2/2023 documents Facility staff will investigate any allegations of abuse within timeframes required by Federal law. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145581 If continuation sheet Page 6 of 6