Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to obtain physician orders for residents to have
medications at the bedside and failed to complete self-administration of medication assessments. This
applies to 3 of 3 residents (R18, R38, R58) reviewed for medications in a sample of 18.
Residents Affected - Few
The findings include:
1. On 11/13/24 at 11:34 AM, R58 was observed sleeping in her bed. Her Fluticasone Propionate nasal
spray 50 MG (Milligrams) was inside a box labeled with her name on the dresser that belonged to her
roommate (R18) behind her curtain. Surveyor asked (R18) if it was hers and if she ever used it. R18 just
stared at Surveyor and smiled. V6 (RN-Registered Nurse/Wound Nurse) who was in the room stated that
R18 was nonverbal.
On 11/13/24 at 2:18 PM, V2 (DON-Director of Nursing) said, I currently don't have any residents that can
self-administer any medications. Any meds (medications) at the bedside need an order from the doctor. The
nurse also must do a self-administration of medication assessment. It's important because we need the
resident to be competent and that they understand the dosage.
On 11/14/24 at 10:42 AM, R58's Fluticasone Propionate nasal spray was still on top of R18's (roommate)
dresser. Surveyor asked R58 if this was hers. She said, Yes and I've been looking for it. She said it's always
kept in her room. R58 said, No one taught me how to use it. I know how to do it. I use it at bedtime. R58
then put the box of Fluticasone Propionate in her basin which was on her bedside table.
R58's face sheet shows diagnoses of need for assistance with personal care and hemiplegia and
hemiparesis following cerebral infarction affecting left non-dominant side.
R58's MDS (Minimum Data Set) dated 10/18/24 shows she is cognitively intact. R58's POS (Physician
Order Sheet) shows an order for Fluticasone Propionate Nasal Suspension 50 MCG (Micrograms)/ACT-1
spray in both nostrils two times a day for antihistamine. There was no order for the nasal spray to be at the
bed side upon review of her POS. There was no self-administration of medication assessment uploaded
into her electronic medical record. There was no care plan stating she can self-administer.
R18's face sheet shows diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left
non-dominant side, aphasia following cerebral infarction, unspecified dementia, unspecified severity,
without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive
disorder recurrent, severe with psychotic symptoms, bipolar disorder, and anxiety disorder. Review of her
POS shows no order for Fluticasone Propionate nasal spray. R18's MDS dated
(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 12
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
11/15/2024
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)
F 0554
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
[DATE] shows a blank score for her mental status. R18's care plans do not state she can self-administer
any medications.
Facility's policy titled Self-Administration of Medications by Residents (Undated) shows: 2. If the resident
desires to self-administer medications, an assessment is conducted by an interdisciplinary team. This
assessment includes the resident's cognitive, physical, and visual ability to carry out this responsibility. 3.
An interdisciplinary team determines the resident's ability to self-administer medications by means of a skill
assessment as follows: b. The resident is instructed in the use of the package, purpose of the medication,
reading of the label, scheduling of medication doses and side effects. D. The resident is asked to
demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms,
e.g. inhaler, to verbalize the steps above involved in administration. e. If bedside storage is to be used, the
resident is asked to complete a bedside record indicating the administration of the medication. 4. If the
resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of
bedside medication storage is conducted. A. The storage does not present a risk to confused residents who
wander into the rooms of, or room with, residents who self-administer. B. The storage method prevents
access by other residents. 6. Once the order has been obtained, the procedure is explained to the resident.
2. On 11/12/24 at 11:59 AM, R38 was not in his room. R38 had two white pills on the bedside table next to
a medication cup. On 11/12/24 at 12:14 PM V2 (Director of Nursing) went to R38's room with the surveyor.
The two white pills remained on the bedside table.
R38's face sheet showed multiple diagnoses which included cerebral infarction, metabolic encephalopathy,
malignant neoplasm of the colon, need for assistance with personal care, cocaine abuse, weakness. R38's
MDS dated [DATE] showed R38 was cognitively intact. R38 had no self-administration of medication
assessment in the electronic medical record. R38's POS for November 2024 showed no orders for
medications to be left at the bedside. R38 did not have a care plan for self-administering medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 2 of 12
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
11/15/2024
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)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide a resident and/or his family/POA (Power of
Attorney) the reason of transfer to the hospital in writing. The facility also failed to notify the ombudsman of
the transfer.This applies to 4 of 4 residents (R7, R26, R38, R74) reviewed for discharge in a sample of 18.
The findings include:
1. On 11/13/24 at 2:27 PM, V2 (DON-Director of Nursing) stated, We don't notify the ombudsman about the
transfer to the hospital. We don't get the ombudsman involved in the discharge or transfer of a resident. We
only notify the ombudsman if the resident is non-compliant with something, or we can't reach an agreement
with the resident. We didn't give a written notice to (R74) and his POA at the time of discharge to the
hospital or afterwards. We notified the POA by phone. If we can't reach the POA, then social services
emails or gives them a written notice. There's nothing uploaded in the resident's chart regarding the written
notice of discharge to the hospital or notification that the ombudsman was notified.
R74's face sheet shows an admission date of 9/9/24 to the facility.
R74's progress notes document the following:
On 9/19/24 at 10:30 AM, (R74) observed on floor positioned on buttock with against door in bedroom. No
injuries, no skin alterations. Resident noted being verbally aggressive towards staff. MD (Medical Doctor)
notified. Received order to transfer to (Hospital) for CT (Computerized Tomography) scan and psych
evaluation. Order carried out. DON (Director of Nursing) and family POA made aware.
On 9/19/24 at 10:45 AM, Paramedics have arrived to transport resident to (Hospital) ER (Emergency
Room) via stretcher. Bed hold policy in place.
On 9/20/24 at 9:54 AM, (R74) admitted to hospital with a diagnosis of aggressive behavior.
On 10/11/24 at 12:10 PM, (R74) readmitted to facility A+O x 1-2 with confusion in stable condition. All
safety precautions in place. MD made aware of all orders verified.
Review of R74's electronic medical record shows nothing was uploaded regarding the discharge notice to
the resident/POA.
Facility's policy titled Discharge/Transfer of the Resident (1/1/2020) shows: Transfer: 3. Explain transfer and
reason to the resident and/or representative and give copy of signed transfer or discharge notice to the
resident and/or representative or persons (s) responsible for care. Note: If emergency transfer, Transfer or
Discharge Notice form may be completed later, but as soon as possible.
2. R7's face sheet showed R7 was admitted to the facility on [DATE]. R7 had multiple diagnoses which
included acute respiratory failure with hypoxia, weakness, atrial fibrillation, diabetes, dementia, muscle
wasting, and anxiety disorder. R7's MDS (MDS/Minimum Data Set) dated 09/20/24 showed R7 had
moderate cognitive impairment.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 3 of 12
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
11/15/2024
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)
F 0623
R7's progress notes showed the following:
Level of Harm - Minimal harm
or potential for actual harm
On 08/27/24 at 8:06 PM while doing rounds, (R7) observed lying on floor in front of his toilet. Skin alteration
to rt eye. Ice placed on rt eye. Tylenol given for pain. Resident transferred into bed. First aid rendered. BP
74/62, O2 79%, resp 20, pulse, 90 BS 134. MD notified with new orders to send to (Hospital), DON notified.
Family attempted to be reached x3. Unable to leave message. Will continue to try to reach family. On
08/28/24 at 6:31 AM called into (Hospital) for update. (R7) being admitted d/t low hemoglobin.
Residents Affected - Some
On 09/24/24 at 11:00 AM writer observed (R7) face to be drooping to left side, puffy face, swelling to right
hand/arm. Vitals 143/68, 97.6, 92, 18, 81% r/a, applied O2 n/c @ 2L, SPO2 now at 99%. MD notified
received order to transfer out to hospital, order carried out. 911 called to transport (R7) to hospital. Family,
DON and ADON made aware. On 09/24/24 at 11:25 AM Paramedics have arrived to transport (R7) to
(Hospital) via stretcher. On 09/25/24 (R7) admitted to (Hospital). Admitting dx DVT to rt arm.
On 09/29/24 at 8:30 AM While doing rounds (R7) observed with SOB, low O2, and diaphoretic. Vitals taken.
Increased O2. MD notified. Per MD ok to send to (Hospital) for eval and treat. On 09/29/24 at 3:24 PM
Called ER for update. (R7) being admitted for SOB and hypoxia.
R7's electronic medical record showed no uploaded information regarding the discharge letter to R7 or R7's
representative. The facility was unable to provide information regarding the discharge or notification of the
ombudsman of the discharge.
3. R26's face sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which
included multiple fractures of ribs, muscle wasting and atrophy, schizoaffective disorder, major depressive
disorder, epilepsy, post-traumatic stress disorder, and suicidal ideations. R26's MDS dated [DATE] showed
R26 was cognitively intact.
R26's progress notes showed the following:
On 05/08/24 at 9:00 PM 911 arrived to the facility stating that R26 had just placed a call to the suicide
hotline. Prior to R26 placing a call she was observed resting in her bed. When R26 was asked by the writer
and the police officers what was wrong, R26 stated that she was depressed and did not want to talk about
it. Ambulance arrived to facility and transported to (Hospital). MD made aware. On 05/09/24 at 3:11 AM
Writer placed a call to the hospital for an update on R26 status. R26 got admitted to (Hospital). Dx
depression.
On 07/22/24 at 6:15 PM R26 expressing suicidal ideations d/t not wanting to be at the facility anymore. R26
stated she wants to die and that she has a plan. She stated she could take a lot of pills to die. Contacted
NP and orders are to send out to be further evaluated. R26 placed on 1:1 until ambulance arrived. R26 is
her own responsible party. On 07/22/24 at 7:11 PM ambulance arrived to transport R26 to (Hospital) x 3
EMT via stretcher. R26 is her own responsible party. Report from off going nurse states all parties were
informed. On 07/23/24 at 5:12 AM Call placed to (Hospital) to get update on R26. Shift change is taking
place. Advised to call back. Will endorse to oncoming nurse.
R26's electronic medical record showed no uploaded information regarding the discharge letter to R26 or
R26's representative. The facility was unable to provide information regarding the discharge or notification
of the ombudsman of the discharge.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 4 of 12
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
11/15/2024
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)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
4. R38's face sheet showed R38 was admitted to the facility on [DATE]. R38 had multiple diagnoses which
included cerebral infarction due to embolism of right cerebellar artery, metabolic encephalopathy, asthma,
acute respiratory failure with hypoxia, malignant neoplasm of the colon, need for assistance with personal
care, and cocaine abuse. R38's MDS dated [DATE] showed R38 was cognitively intact.
Residents Affected - Some
R38's progress notes showed the following:
On 08/24/24 at 6:35 PM Altered mental status noted during rounding. V/S 98/64, 86, 16, 99.9, 83% on
room air (O2 applied), blood glucose 257, not responding to painful stimuli. MD was notified and said to
send R38 to the ER. 911 called and arrived shortly. R38's emergency contacts were called. Both of their
phone numbers were disconnected. The DON was contacted. On 08/24/24 at 10:54 PM per (Nurse) from
(Hospital) R38 was admitted for Pneumonia, Hypoxia, UTI, and Acute Kidney Injury.
On 09/16/24 at 6:28 PM R38 observed in bed not easily aroused. Sternum rub applied no response. Vitals
taken B/P 119/69, P 89, T98, R16, O2 90% room air. Blood sugar 161. Elevated head of bed applied 3L O2
NC O2 stats increased to 95%. Attempted to arouse, unable. Placed call to 911. MD, ADON notified.
Attempt to reach family no answer. On 09/16/24 at 6:35 PM EMT arrived to facility. Transferred resident onto
gurney. Exiting building to (Hospital) ER. Report called in to charge nurse. MD/DON aware. On 09/17/24 at
6:48 AM Called (Hospital) to get report. Shift change happening. (Hospital) will call back later. On 09/19/24
at 12:14 AM Spoke with RN at (Hospital). R38 admitted to IMCU with a dx of Acute Renal Failure. R38 is
expected to be discharged back to the facility within the next 48 hours.
On 09/25/24 at 12:15 PM R38 noted with change in condition. R38 unable to arouse. Checked vitals, B/P
83/53, P 74, R16, T97.9, O2 90% room air. Call placed to MD orders to send out to (Hospital) for further
evaluation and treatment. Call placed to 911 for transport. POA notified. On 09/25/24 at 12:28 PM EMT
arrived to facility, transferred onto gurney by EMT. Exiting the building. On 09/26/24 at 6:58 AM (Hospital)
called. R38 admitted for observation with dx of generalized weakness & altered mental status. Med list
faxed.
R38's electronic medical record showed no uploaded information regarding the discharge letter to R38 or
R38's representative. The facility was unable to provide information regarding the discharge or notification
of the ombudsman of the discharge.
On 11/14/24 at 3:22 PM, V1 (Administrator) stated the ombudsman should be notified each time a resident
is admitted to the hospital. I was not aware that we were supposed to send a written copy as to why a
discharge or transfer to the hospital was occurring to the residents/representative. The residents did not
receive written documentation notifying of the reason why they were transferring to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 5 of 12
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
11/15/2024
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)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide in writing to residents and their families/POA (Power
of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 4 of 4
residents (R7, R26, R38, R74)) reviewed for discharge in a sample of 18.
The findings include:
1. On 11/13/24 at 2:27 PM, V2 (DON-Director of Nursing) stated, We hold the bed for 10 days. That's
guaranteed to the patient. We don't typically keep a copy of the bed hold notice.
R74's face sheet shows an admission date of 9/9/24 to the facility.
R74's progress notes document the following:
On 9/19/24 at 10:30 AM, (R74) observed on floor positioned on buttock with against door in bedroom. No
injuries no skin alterations. Resident noted being verbally aggressive towards staff. MD (Medical Doctor)
notified. Received order to transfer to (Hospital) for CT (Computerized Tomography) scan and psych
evaluation. Order carried out. DON (Director of Nursing) and family POA made aware.
On 9/20/24 at 9:54 AM, (R74) admitted to hospital with a diagnosis of aggressive behavior.
Review of R74's electronic medical record shows nothing was uploaded regarding the bed hold provided to
the resident/POA.
The facility was unable to show proof the bed-hold policy was provided to R74.
2. R7's face sheet showed R7 was admitted to the facility on [DATE]. R7 had multiple diagnoses which
included acute respiratory failure with hypoxia, weakness, atrial fibrillation, diabetes, dementia, muscle
wasting, and anxiety disorder. R7's MDS (Minimum Data Set) dated 09/20/24 showed R7 had moderate
cognitive impairment.
R7's progress notes showed the following:
On 08/27/24 at 8:06 PM while doing rounds, (R7) observed lying on floor in front of his toilet. Skin alteration
to rt eye. Ice placed on rt eye. Tylenol given for pain. Resident transferred into bed. First aid rendered. BP
74/62, O2 79%, resp 20, pulse, 90 BS 134. MD notified with new orders to send to (Hospital), DON notified.
Family attempted to be reached x3. Unable to leave message. Will continue to try to reach family. On
08/28/24 at 6:31 AM called into (Hospital) for update. (R7) being admitted d/t low hemoglobin.
On 09/24/24 at 11:00 AM writer observed (R7) face to be drooping to left side, puffy face, swelling to right
hand/arm. Vitals 143/68, 97.6, 92, 18, 81% r/a, applied O2 n/c @ 2L, SPO2 now at 99%. MD notified
received order to transfer out to hospital, order carried out. 911 called to transport (R7) to hospital. Family,
DON and ADON made aware. On 09/24/24 at 11:25 AM Paramedics have arrived to transport (R7) to
(Hospital) via stretcher. On 09/25/24 (R7) admitted to (Hospital). Admitting dx DVT to rt arm.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 6 of 12
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
11/15/2024
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)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 09/29/24 at 8:30 AM While doing rounds (R7) observed with SOB, low O2, and diaphoretic. Vitals taken.
Increased O2. MD notified. Per MD ok to send to (Hospital) for eval and treat. On 09/29/24 at 3:24 PM
Called ER for update. (R7) being admitted for SOB and hypoxia.
R7's electronic medical record showed no uploaded information regarding provision of a bed hold policy for
each discharge to the hospital. The facility was unable to provide information regarding the bed hold policy
given R7 or his POA.
3. R26's face sheet showed R26 was admitted to the facility on [DATE]. R26 had multiple diagnoses which
included multiple fractures of ribs, muscle wasting and atrophy, schizoaffective disorder, major depressive
disorder, epilepsy, post-traumatic stress disorder, and suicidal ideations. R26's MDS dated [DATE] showed
R26 was cognitively intact.
R26's progress notes showed the following:
On 05/08/24 at 9:00 PM 911 arrived to the facility stating that R26 had just placed a call to the suicide
hotline. Prior to R26 placing a call she was observed resting in her bed. When R26 was asked by the writer
and the police officers what was wrong, R26 stated that she was depressed and did not want to talk about
it. Ambulance arrived to facility and transported to (Hospital). MD made aware. On 05/09/24 at 3:11 AM
Writer placed a call to the hospital for an update on R26 status. R26 got admitted to (Hospital). Dx
depression.
On 07/22/24 at 6:15 PM R26 expressing suicidal ideations d/t not wanting to be at the facility anymore. R26
stated she wants to die and that she has a plan. She stated she could take a lot of pills to die. Contacted
NP and orders are to send out to be further evaluated. R26 placed on 1:1 until ambulance arrived. R26 is
her own responsible party. On 07/22/24 at 7:11 PM ambulance arrived to transport R26 to (Hospital) x 3
EMT via stretcher. R26 is her own responsible party. Report from off going nurse states all parties were
informed. On 07/23/24 at 5:12 AM Call placed to (Hospital) to get update on R26. Shift change is taking
place. Advised to call back. Will endorse to oncoming nurse.
R26's electronic medical record showed no uploaded information regarding provision of a bed hold policy
for each discharge to the hospital. The facility was unable to provide information regarding the bed hold
policy given R26 or her POA.
4. R38's face sheet showed R38 was admitted to the facility on [DATE]. R38 had multiple diagnoses which
included cerebral infarction due to embolism of right cerebellar artery, metabolic encephalopathy, asthma,
acute respiratory failure with hypoxia, malignant neoplasm of the colon, need for assistance with personal
care, and cocaine abuse. R38's MDS dated [DATE] showed R38 was cognitively intact.
R38's progress notes showed the following:
On 08/24/24 at 6:35 PM Altered mental status noted during rounding. V/S 98/64, 86, 16, 99.9, 83% on
room air (O2 applied), blood glucose 257, not responding to painful stimuli. MD was notified and said to
send R38 to the ER. 911 called and arrived shortly. R38's emergency contacts were called. Both of their
phone numbers were disconnected. Bed hold policy in placement. The DON was contacted. On 08/24/24 at
10:54 PM per (Nurse) from (Hospital) R38 was admitted for Pneumonia, Hypoxia, UTI, and Acute Kidney
Injury.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 7 of 12
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
11/15/2024
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)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 09/16/24 at 6:28 PM R38 observed in bed not easily aroused. Sternum rub applied no response. Vitals
taken B/P 119/69, P 89, T98, R16, O2 90% room air. Blood sugar 161. Elevated head of bed applied 3L O2
NC O2 stats increased to 95%. Attempted to arouse, unable. Placed call to 911. MD, ADON notified.
Attempt to reach family no answer. On 09/16/24 at 6:35 PM EMT arrived to facility. Transferred resident onto
gurney. Exiting building to (Hospital) ER. Report called in to charge nurse. MD/DON aware. On 09/17/24 at
6:48 AM Called (Hospital) to get report. Shift change happening. (Hospital) will call back later. On 09/19/24
at 12:14 AM Spoke with RN at (Hospital). R38 admitted to IMCU with a dx of Acute Renal Failure. R38 is
expected to be discharged back to the facility within the next 48 hours.
On 09/25/24 at 12:15 PM R38 noted with change in condition. R38 unable to arouse. Checked vitals, B/P
83/53, P 74, R16, T97.9, O2 90% room air. Call placed to MD orders to send out to (Hospital) for further
evaluation and treatment. Call placed to 911 for transport. POA notified. On 09/25/24 at 12:28 PM EMT
arrived to facility, transferred onto gurney by EMT. Exiting the building. On 09/26/24 at 6:58 AM (Hospital)
called. R38 admitted for observation with dx of generalized weakness & altered mental status. Med list
faxed.
R38's electronic medical record showed no uploaded information regarding provision of a bed hold policy
for each discharge to the hospital. The facility was unable to provide information regarding the bed hold
policy given R38 or his POA.
On 11/14/24 at 3:22 PM, V1 (Administrator) stated residents and or family representatives should receive a
bed hold policy each time a resident is discharged from the facility or admitted to the hospital. The residents
did not receive a bed hold policy for the admissions to the hospital.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 8 of 12
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
11/15/2024
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)
F 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to change PICC (Peripherally Inserted Central
Catheter) dressings.This applies to 1 of 7 residents (R75) reviewed for infection control in a sample of 18.
Residents Affected - Few
Findings include:
R75's face sheet showed R75 admitted to the facility on [DATE] with diagnoses that includes cellulitis of the
right lower limb, diabetes mellitus, and cutaneous abscess of the foot. R75's MDS (Minimum Data Set)
dated 10/29/24 shows she is cognitively intact.
On 11/12/24 at 1:01 PM, R75 showed the surveyor the single lumen PICC line in her right upper arm. The
PICC had a border gauze dressing in place that had drainage in the center of it. R75 stated the dressing
had been in place 4 to 5 days and she had changed it herself. R75 stated the staff did not do the dressing
changes on her PICC line.
On 11/14/24 at 1:20 PM, R75 stated the dressing on her PICC line had not been changed. R75 showed the
surveyor her PICC line had the same stained border gauze dressing, with more soiling and rolled on the
sides, exposing the PICC insertion site.
On 11/14/24 at 1:41 PM, V3 ADON (Assistant Director of Nursing) stated PICC line dressings are changed
every seven days and as needed when a transparent dressing is in place. V3 was unsure the frequency of
PICC line dressing changes if a border gauze was in place.
On 11/14/24 at 1:51 PM, V2 DON (Director of Nursing) PICC lines and Central line dressings are done
every seven days and as needed if a transparent dressing is in place. A gauze type dressing should be
changed daily. The gauze has an increased risk of infection.
On 11/14/24 at 5:51 PM, V3 ADON stated there was no documentation for R75's PICC dressing changes in
her electronic medical record.
R75's physician orders document change transparent dressing on admission, then weekly and as needed
thereafter. Monitor site every shift for signs / symptoms of infection and or infiltration. R75's current care
plan for the PICC line includes monitoring for signs and symptoms of infection.
The facility policy Dressing Change, Midline Catheter dated April 2011 states gauze dressings are
changed: 24 hours post insertion or upon admission, every 48 hours or if the integrity of the dressing has
been compromised (wet loose or soiled). Assessment of venous access site is performed: during dressing
changes and at least once every shift when not in use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 9 of 12
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
11/15/2024
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review the facility failed to maintain the kitchen facility in a
manner to prevent foodborne illness.This applies to 74 residents in the facility receiving dietary services.
Residents Affected - Many
Findings include:
On 11/14/24 4:36 PM, V2 DON (Director of Nursing) stated 74 residents were served from dietary services
on 11/12/24.
On 11/12/24 at 10:45 AM, the dry storage contained:
A large bin of breadcrumbs with use by date of 7/28/24.
A large bin of oatmeal with use by date of 11/9/24.
A large bin of rice with use by date of 10/30/24.
A large bin of flour with use by date of 9/18/24.
A large bin of thickener with use by date of 7/9/24.
A clear plastic bag with dry penne pasta open to air.
Two clear plastic bags containing dry fettuccini pasta open to air.
Dented cans in rotation for use:
Diced beats 6lb (pounds) 8 oz (ounces).
Diced carrots 6lb 9 oz.
Three cans of diced potatoes 6lb 6oz.
Two cans of chunk tuna 4.16lb.
The facility policy Storge of Dry Foods / Supplies dated 9/18/23 states dry goods will be handled and stored
to maintain the integrity of the packaging until the item is ready to use. Dented cans will be stored
separately with a dented cans sign and marked for return or disposal.
On 11/12/24 at 10:58 AM, the milk cooler had a sour/spoiled odor.
The facility policy Storage of Refrigerated / Frozen foods dated 4/26/2024 states refrigeration units are
routinely cleaned and free from garbage and other waste.
On 11/12/24 at 11:00 AM, the walk-in cooler contained:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 10 of 12
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
11/15/2024
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)
F 0812
Corn in a clear plastic bag open to air.
Level of Harm - Minimal harm
or potential for actual harm
Pancakes in a clear plastic bag open to air.
Breakfast sausage patties in a clear plastic bag open to air.
Residents Affected - Many
On 11/12/24 at 11:03 AM, the walk-in cooler contained:
Yellow cheese slices partially wrapped in plastic with the exposed cheese hardened and open to air.
Bologna open to air without an open on or use by date.
A large bag of shredded yellow cheese open to air and falling out of the bag.
Large unsliced turkey meat wrapped in plastic stored above diced potatoes.
Plastic storage container of peeled boiled eggs with use by date of 11/9/24.
A 10lb box of hot dogs open to air dated 11/6/24.
Six bags of raw liquid eggs in a plastic container with use by date of 11/9/24.
The facility policy Receiving and Handling dated 4/2017 states All foods are wrapped in moisture proof
wrapping or placed in suitable containers to prevent freezer burn. Items are labeled and dated. Meats, fish,
and poultry will be stored on lower shelves below, fruits, vegetables or other ready to eat food to prevent
contamination. Food items will be arranged so that older items will be used first. Expiration dates will be
monitored.
On 11/12/24 at 11:14 AM, an oscillating fan located in the dish area was covered with dust and grease.
On 11/12/24 at 11:20 AM, the kitchen contained:
A storage bin containing flakes of corn cereal with a use by date of 9/25/24.
A storage bin containing crisped rice cereal with a use by date of 9/25/24.
A storage bin containing frosted flakes of corn cereal with a use by date of 9/25/24.
On 11/13/24 at 03:59 PM, V5 Dietary Manager stated we do not have a separate log for documenting the
sanitizer concentration for the red sanitizing buckets. V5 stated dented cans can spoil or become
contaminated and should be sent back to the distributor. V5 stated it's important to have the correct date of
when the food came in, when it was opened and use by, so we aren't serving outdated or spoiled food
items, and the food items should be properly wrapped / stored to prevent contamination and to make sure
the food quality remains fresh. V5 stated the turkey should not have been stored over the potatoes, you
don't want juice from the turkey getting in the potatoes and contaminating them.
V5 stated the cereal wouldn't spoil it would just be stale. I don't have a reference for how long dry goods are
good for. It should have been dated with the original expiration from the packaging or
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 11 of 12
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
11/15/2024
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)
F 0812
the delivery date. The pasta should be labeled dated and sealed.
Level of Harm - Minimal harm
or potential for actual harm
The policy Sanitizing Buckets dated 9/22/23 states sanitizer concentration will be checked using a test kit.
Concentration will be documented on the sanitizer solution log.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
16 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F926 - Establish policies, in accordance with applicable Federal, State, and
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
FAQ · About this visit
Common questions about this visit
What happened during the November 15, 2024 survey of MOMENCE MEADOWS NURSING & REHAB?
This was a inspection survey of MOMENCE MEADOWS NURSING & REHAB on November 15, 2024. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MOMENCE MEADOWS NURSING & REHAB on November 15, 2024?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install an approved automatic sprinkler system."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.