Inspection·August 27, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide care to a resident dependent on staff for ADL (activities of daily living). This applies to 1 of 3 (R5) residents reviewed for ADL care.The findings include:According to the Electronic Medical Record (EMR), R5 was admitted to the facility on [DATE], with multiple diagnoses including acquired absence of left leg above knee, cellulitis of groin, hidradenitis suppurativa, and pressure ulcer of sacral region, stage 3. R5's MDS (Minimum Data Set) dated June 5, 2025, showed R5 had mild cognitive impairment and required maximum assist with toileting hygiene, shower, and bathing. R5's Care Plan dated April 13, 2025, showed R5 has an ADL (Activity of Daily Living) self-care deficit and required staff assistance and showed that R5 is incontinent of bladder and bowel. Interventions include the CNA (Certified Nurse Aide) should check and change R5 every 2 hours and as needed.On August 25, 2025, at 12:40 PM, R5 was in bed with an empty urinal on his bedside dresser table. R5 stated that he uses the urinals and was incontinent of bowel. R5 also stated that he calls the CNA (Certified Nursing Assistant) when he needs to be cleaned up after a bowel movement and has had to wait up to 30 minutes sometimes. R5 also added that he has had chronic ulcers for about 20 years and developed a sore on his buttock at the facility about 3 months ago.On August 26, 2025, R5 was awake in bed with his urinal almost about half full of urine. R5's room was noted with a strong urine odor, and the bed linens and padding were stained and heavily soiled with urine. On August 26, 2025, at 9:33 AM V6 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) stated they are scheduled from 6 AM to 2 :00 PM and are both assigned to R5's room. V6 and V7 stated they were working in other rooms and giving bed baths. V6 and V7 stated they were getting ready to check in on R5. When V6 and V7 attempted to provide care to R5, a large area of R5's beddings, disposable pad and blanket were soiled with urine. On August 26, 2025, at 9:49 AM, V6 (Certified Nursing Assistant) and V7 (Certified Nursing Assistant) stated they typically complete their morning rounds during their shift around 10:30 AM. On August 26/2025 at 12:09 PM, V2 (Director of Nursing / DON) stated that CNAs (Certified Nursing Assistant) work from 6:00 AM to 2:00 PM and should complete their morning rounds which includes, checking on their residents, attending to their needs, and checking with the nurses to determine any specific needs for the resident such as an appointment or anything else. V2 also stated that the CNAs should prioritize attending to the residents who needs incontinence care right away unless another resident was experiencing an emergency. V2 added that CNAs are expected to complete incontinence care for all residents within the first 2 hours of their shift.R5's nurse practitioner progress note created by V4 dated August 22, 2025 documents R5 has a sacral wound, and a history of (IAD) incontinence associated dermatitis. On August 25, 2025, at 3:52 PM, V4 (Nurse Practitioner) stated she determined R5's skin irritation to be incontinence associated because R5 wears incontinence briefs, and it gets really moist from his incontinence episodes and also has leakage from having HS.The facility's Guidelines for A.M. Care policy dated March 21, 2023, Residents Affected - Few (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 08/27/2025 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)