Health inspection·May 23, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the menu plan and serve residents with alternatives for food items refused. This applies to 11 of 11 (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R14) residents reviwed for meal service. The findings include: The facility's lunch meal for 5/15/24 listed Cuban style pork chop, red beans and rice, chocolate mousse, corn bread, margarine, and beverage. Their menu for lunch, or the substitute menu was not posted for the residents on the notice board in the hallway. After checking the temperature V4 (Cook) began to plate the food for the residents. During Lunch instead of chocolate mousse they served Banana Cream Pie. Corn bread was not available during lunch. By the end of serving R4 and R15 did not get, red beans and rice, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R14 did not receive Banana Cream Pie instead they were given [NAME] Crackers for dessert. On 5/21/24 dietary staff did not post the breakfast or lunch menu until 10:00AM and the menu in the kitchen and the menu posted in the hallway for the residents were not the same. Residents were noted to get glazed ham, broccoli, herb stuffing, dinner roll with margarine and pears with whipped topping. R1 was interviewed on 5/21/24 and stated that the menu served on 5/21/24 for lunch was not the planned menu and so R1 requested a vegetable salad in place. According to R1, dietary staff refused to provide the salad since she did not order it the previous day. R1 added that most days the menu is not posted for residents. R2 and R4 were also interviewed and stated that the menu is not posted and that food service often changes the menu and so residents cannot order the substitute the day before. Both residents claimed that the facility runs out of food items and they just, give us what they have. V3 (Dietary Manager) was interviewed on 5/15/24 at 12:20PM and stated that the food order is not always correct. V3 added that there was a mix up with the new system. V1 (Administrator) confirmed on 5/21/24 at 10:09AM that the facility should not run out of food. Facility 's grievances and concern forms were reviewed from February until May of 2024 and the resident council minutes were also reviewed. On 4/5/24 the Resident council minutes indicated that the kitchen keeps running out of hot dog and hamburger buns and alternative selections continue to not be followed. The residents also complained that food portions have gotten smaller. On 4/24/24 Resident (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: 145713 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 145713 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Momence Meadows Nursing & Rehab 500 South Walnut Momence, IL 60954 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)