Inspection·December 10, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview and record review the facility failed to keep a resident free from sexual abuse. This applies to 1 of 6 residents (R1) reviewed for abuse. Residents Affected - Few The findings include: On December 3, 2024 at 11:15 AM, V10 (Cook) stated she had been coming out of the hallway bathroom on 11/15/2024, when she witnessed R2 patting R1 above her right breast on the outside of her clothing. V10 stated R2 then slipped his hand down the neckline of and underneath R1's shirt to her left breast. V10 stated she knew R2 could feel her presence because he stopped and left. V10 stated at first she thought R2 was just checking on her, then she saw him slip his hand down her shirt. V10 stated R1 is nonverbal and blind and regardless of if she reacted or not, R1 cannot defend herself. V10's written statement from the facility's 11/15/2024 investigation showed she .saw [R2] sitting in the hallway near the small dining room. I saw [R2] touch [R1] by her right side of her chest. I saw him put his hand under her shirt close to her left breast. Then when [R2] saw me he hurried up and moved his hand and moved out of the hallway . R1's Face Sheet showed her diagnoses include profound intellectual disabilities, aphasia, cerebral infarction, congenital malformations of lower limbs, and unspecified sequelae of nontraumatic intracerebral hemorrhage. R1's 11/26/2024 MDS (Minimum Data Set) showed staff determined her cognition was severely impaired. On 11/29/2024 at 1:20 PM, R1 was in her wheelchair in the hallway, sitting cross-legged. R1 continuously shook her head back and forth rhythmically from side to side. On 11/29/2025 at 1:25 PM, V5 LPN (Licensed Practical Nurse) stated R1 is vision-impaired and believes R1 has some vision, but only peripherally. On 12/5/2024, V9 (Nurse Practitioner) stated any groping that is not consensual would elicit a negative reaction. V9 stated if it were you or I, we would be upset, but humiliation would not come into play. R1's Abuse care plan (revised 4/18/2023) showed her comprehensive assessment reveals a possible [history] of suspected abuse, neglect, exploitation, possible past trauma and/or other factors that may increase my susceptibility to abuse/neglect (weakness, intellectual disability). [R1] demonstrates: Hearing/Vision Loss, Impaired Cognition/Communication, Difficulty in adjustment & generalized mood distress. Given her poor and compromised health status, cognitive issues, physical assistance needs and need for 24-hour care, the [Inter-Disciplinary Team] recognizes that [R1] is considered a (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 2 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 12/10/2024 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)