Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to prevent resident to resident abuse.
Residents Affected - Few
This applies to 2 of 5 residents (R2 and R3) reviewed for abuse in the sample of 10.
The findings include:
1. FRI (Facility Reported Incident) report documents an incident of April 14, 2025, alleging that R1 made
inappropriate contact with R2. The report indicates that immediate action taken: Residents were
immediately separated. Body and pain assessments completed on R1 and R2. Police was notified. R1 was
placed on 1:1 monitoring until sent out to the hospital for further evaluation. After interviewing staff and
residents, it was discovered that R1 and R2 were waiting in the hallway to go out for smoke break but staff
did not witness the incident.
R2's EMR included diagnoses of End Stage Renal Disease; Chronic Obstructive Pulmonary Disease; Major
Depressive Disorder, Recurrent; Unspecified Bipolar Disorder, Schizoaffective Disorder unspecified
R2's admission MDS dated [DATE], showed that R2 was cognitively intact.
R1's EMR (electronic medical records) included diagnoses of other Lack of Coordination; Hypothyroidism,
Unspecified; Dementia In Other Diseases Classified Elsewhere, Moderate, With Other Behavioral
Disturbance; Weakness; Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris.
R1's quarterly MDS (minimum data set) dated April 14, 2025 showed that R1 was moderately impaired
cognition.
On May 1, 2025 at 10:20 AM, R2 stated that she doesn't remember the date or time of the incident. R2
continued We were lining up for smoke break. He (R1) came out of his room and came by me and said Hi
and I said Hi. I have always said Hi (previously). This time he decided to touch me on my breast. He was
just rubbing across. Then he decided that he was going to move his hand down below on my vagina
through my clothes and I smacked is hand and said 'No.' He didn't stop. That was the end of it as they
(staff) were to open the door, and he stopped as he didn't want to get caught. I went to V7 (Activity Aide),
who opened the door and came to hand out the cigarettes. But she didn't see it. She told somebody who
was over her about it and I guess they send him to the hospital for a while .
On May 1, 2025 at 10:39 AM, V4 CNA (Certified Nursing Assistant) was seen seated outside R1's door
(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
05/05/2025
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and stated that R1 is on 1:1 monitoring since he got back from the hospital on April 19, 2025. V4 continued
He has had two or three incidents of inappropriate touching of other residents. It was R5 and another
resident who is no longer here. That resident did not report it until she was getting to leave at the door. I
don't know if those incidents happened. He (R1) has been on 1:1 monitoring after each incident
On May 1, 2025 at 11:36 AM, V1 stated that during investigation, R2 stated that while she was in line to go
for cigarette break, R1 touched her breasts and tried to touch her vagina area and that she pushed his
hand away. V1 stated that there were no more witnesses of the incident so it was not substantiated. V1
continued that R1 had had another allegation against him on November 15, 2024 alleging that he was
touching another resident on the breasts which was witnessed by a Dietary staff. V1 added that this was
investigated by IDPH and cited for the same. V1 stated that as a precautionary measure, R1 is placed on
1:1 monitoring until facility finds an alternate placement for him.
2. FRI (Facility Reported Incident) report included that R4 made physical contact with R3 on April 24, 2025.
The facility concluded afrer interviewing staff and residents, that R3 wandered into R4's room and tried to
remove some items from his table and R4 tried to stop her. The staff came into the room and removed R3
from the room. R3 and R4 were assessed and noted without pain or serious injury. R3 was noted to have a
small skin alteration to her left eyebrow.
R3's EMR included diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral
Disturbance, Psychotic Disturbance, Mood Disturbance, Generalized Anxiety Disorder. R3's quarterly MDS,
dated [DATE], showed that R3 was severely impaired in cognition.
R4's EMR included diagnoses of Hypothyroidism, Unspecified; essential (Primary) Hypertension;
hyperlipidemia, Unspecified; weakness; dementia in Other Diseases Classified Elsewhere, Mild, With Mood
Disturbance; and Anxiety Disorder, Unspecified. R4's quarterly MDS, dated [DATE], showed that R4 was
severely impaired in cognition.
On May 1, 2025 at 10:20 AM and 10:56 AM, R3 was seen wandering from hallway to hallway. R3 was also
seen walking about during activities eating pudding from a disposable container and going from table trying
to feed it to other residents or touching them and those residents appeared annoyed. V7 and V8 (both
activity aides) stated that R3 is a wanderer. V7 and stated that R3 just walks around and tries to touch
people. V8 stated that R3 touches people and some residents say, get away.'
On May 1, 2015, at 11:04 AM, R4 was resting in bed and when asked, stated that no residents bothered
him. V10 (LPN-Nurse) who was in the vicinity, stated that R4 is confused and not aware of any incidents
with other residents.
On May 1, 2025 at 12:45 PM, R10 stated that R4 is his roommate. [R4] and the other person [R3] who was
a female were fighting. I was sleeping and woke up and he was hitting her. They were both down on the
floor and were wrestling. He said that she took something of his, and he was trying to get it back. He hit her
right by the eye. I went to get V4 (CNA) who was standing by the front desk as I did not want to get involved
and everything.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 2 of 3
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
05/05/2025
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On May 1, 2025 at 11:46 AM, V1 stated that R3 had wandered into R4's room and was trying to get
something from his over the bed table and he was trying to stop her from getting into his stuff. V1 stated
that R4's roommate R10 woke up and ran to get help. V1 continued V4 (CNA) came in there and called for
more help and another V5 (CNA) came and got V6 (Licensed Practical Nurse) for more help. V6 took R3
out of the room and assessed her. V4 did not take her out of the room earlier as she was on the floor and
she did not want to move her. V6 did a head to toe assessment and R3 had a small scratch over her left
eyebrow. R3 has severe Dementia and wanders a lot and means no harm and tends to tap people as she is
walking
On May 5, 2025, at 3:35 PM, V6 confirmed the above and stated that when she entered the room, R3 was
sitting on the floor and R4 was on his bed. V6 stated that when she assessed R3 and observed a scratch
on her eyebrow that was bleeding a little bit
Facility provided other reportable's for R3 which showed R3's history of wandering and altercations.
November 25, 2024: R3 wandered into the dining room and tried to touch things on R9's table and R10
tried to push her away.
November 5, 2024 : R3 wandered into R8's room and touched her.
September 30, 2024: R3 wandered in the hallway and touched R7.
September 24, 2024: R3 wandered into R6's room and touched her.
Facility policy and procedure titled Abuse Prevention Program (last revised January 1, 2019) included as
follows:
Policy: It is the policy of this facility to prohibit and prevent resident abuse.
Abuse prevention program:
As part of the social history evaluation and MDS assessments, staff will identify residents with increased
vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might
lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches
which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals
and approaches regularly .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145713
If continuation sheet
Page 3 of 3
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation 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.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the May 5, 2025 survey of MOMENCE MEADOWS NURSING & REHAB?
This was a inspection survey of MOMENCE MEADOWS NURSING & REHAB on May 5, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MOMENCE MEADOWS NURSING & REHAB on May 5, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
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.